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Equity must be embedded in Ahpra’s registration fee systems if it is to achieve its intended aims and promote a safe and flexible health workforce.
“Equity in health is not only a matter of fairness and social justice; it is also a prerequisite for the achievement of health for all and sustainable development.”
Dr Margaret Chan, former Director–General of the World Health Organization (WHO)
Throughout 2024, Australian Medical Association (AMA) Victoria has advocated for equitable Ahpra (Australian Health Practitioner Regulation Agency) fees for all health care practitioners, seeking to achieve systems change that will increase equity in our health care system for the benefit of patients and practitioners. We have been joined by unions and professional groups across Australia in these efforts, reflecting a widespread understanding that equity must be embedded in Ahpra’s systems if it is to achieve its intended aims and promote a safe and flexible health workforce.
Our national health practitioner regulator funds 16 national regulatory schemes by imposing fees on practitioners, fully covering its costs. Understandably, it wants to keep its fees and finances simple, but the way Ahpra currently sets its fees is inconsistent with its stated values. It fails to recognise important differences between practitioners and results in inequity, unequal outcomes and a loss of talent to the medical and other regulated professions.
The principles of equity
Ahpra says it sets fees with consideration of “principles of equity” in mind. It is not entirely clear what it thinks this means. But, in the fee setting agreements it reaches with the National Boards, it uses the term “equity” in a financial sense; not share capital, but cash. Equity, to Ahpra, is what it has in the bank for each profession.
This means that when Ahpra says a particular profession has “greater equity”, it imposes smaller fee increases in subsequent years. This interpretation raises questions: Is this the same principle of equity referenced in its fee policy? Perhaps Ahpra might tell us one day. Or, a plain language consultant might suggest saying “we collected more than we ended up needing to spend, so we’ll give it back”.
In the meantime, health care professionals will keep talking about equity in the way it is universally understood – as a process that leads to more equal outcomes. The WHO definition is straightforward:
Equity is the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (eg, sex, gender, ethnicity, disability, or sexual orientation). Health is a fundamental human right. Health equity is achieved when everyone can attain their full potential for health and wellbeing.
Equity is why we treat some patients differently, or provide additional resources to some individuals, communities or geographic areas. If we treated everyone as if their circumstances were the same, we would overservice those with the most, underservice those with the least and waste precious resources. If this seems simple, it is because it is.
At a macro level, Ahpra gets this. Doctors pay much higher fees than other practitioners, because their risk is higher and so (in general) are their incomes. At a micro level, Ahpra ignores this – each National Board requires registered practitioners to pay the same fee, so a Year 2 hospital medical officer who takes parental leave pays the same annual registration fee as Australia’s highest earning surgeon.
Flexible fees for a flexible workforce
In an ideal world, fees might fully reflect individual needs, risks and earning capacity. Perhaps the complexity of this is why Ahpra is reluctant to countenance ever treating different practitioners differently. But there are some basic steps it could take to improve equity in our profession, and perfect should not be the enemy of better (or fairer).
Right now, Ahpra and the Medical Board do not offer reduced registration fees during periods of extended or parental leave. There is no reduction in registration fees for practitioners who work part-time, or for those who are on reduced incomes or under significant financial hardship. This is not simply unjust (because only those who can afford to pay will stay registered, while others drop out), but inefficient. A practitioner who is not seeing patients poses a much lower risk and consequently much lower costs to regulate.
Ahpra’s approach is also inconsistent with one of the key objectives of the Act, “to enable the continuous development of a flexible, responsive and sustainable Australian health workforce”. A practitioner who could work part-time if registration costs matched their hours would cover shifts that otherwise would go unfilled. This objective has never been as important as it is today, as Australia grapples to find staff and fill roles.
Ahpra does provide “non-practising registration” for practitioners on extended leave. However, this is not fit-for-purpose for those on parental leave, due to a restrictive and complex re-registration process. Non-practising registration removes practitioners’ ability to engage in any work activities — such as locum shifts or “keeping in touch” days. It also burdens practitioners with significant re-registration delays of weeks to months.
This all or nothing approach ignores every development or improvement in parental, carer or other extended leave for the last 40 years. It breaks links between health workers and their employers. It forces health workers — disproportionately women, carers and the disadvantaged — to either fund full fees or disconnect from their profession. It denies patients access to practitioners who are ready and willing to work, now or in the future.
State and federal AMAs and state health ministers have raised the issue repeatedly with Ahpra. May it listen and act.
Dr Jill Tomlinson is a plastic and hand surgeon, gender equity advocate and President of the Australian Medical Association of Victoria.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Another aspect of flexible working arrangements is well-being, reduced burnout, reduced likelihood of impairment and enhanced performance . Health professionals have demanding roles and often will benefit from reduced hours of work to ensure career longevity, improve performance and reduce impairment. Ultimately this will increase workforce retention and access to better performing health professionals with consequent benefits to the broader community. It is Ahpra’s interest to offer a more flexible approach to registration fees as t will benefit the public.
Thank you Dr Jill Tomlinson for a great article. Like many other medical practitioners with a varied and sometimes part time work practice, the setting of the same fees across the board creates unintended inequity. And as rightly pointed out, the approach has not evolved to reflect the diverse reality of modern work lives. Hopefully change is on the horizon but it may take a decent nudge .
The primary aim of AHPRA is to protect the public from inappropriate practice, and thus considering risk, part time practitioners, older practitioners and other categories may present more risk. A valid argument could be presented that higher risk groups should pay a higher fee, as the registrants fees are used by boards to administer the functions of boards to protect the public. As such full-time practitioners may be subsidising higher risk practitioners’ fees. i.e. apparently, we have a “community rated insurance model”, like private health insurance,
I have heard similar arguments from practitioners re “pro-rating” of CPD hours based on hours worked. Another risk issue. Is anyone arguing that part timers should do less CPD?
This is one of the many serious issues AHPRA fails to address; well done for publishing this.
The current fee is about $1000 per doctor. Just where does this money go? Let’s sit back and work this out, noting there are over 100000 doctors in Australia.
AHPRA and the Medical Board only accept Visa and MasterCard when renewing our registration. What happened to legal tender? And why force doctors to adopt one of two brands of credit card?
Systems issues such as these need to be dismantled to promote flexibility and support the medical workforce to support better health for Australians. This is not difficult – given the highly disproportionate parenting burden for Australian women and the prevailing gender pay gap in medicine, this is a matter of equity. Medical insurance costs are graded by income, hence simple systems are in place to address this disparity.
One wonders whether this could in fact be discrimination. According to the Australian Human Rights Commission., “Discrimination happens when a person is treated less favourably than another person in the same or similar circumstances, because that person has family responsibilities”, whereby less favourably is the payment of a far higher proportion of salary during carers leave, regardless of gender.
Consideration for reduced fees for those who avail parental leave, maternity leave and also carers especially affects female doctors as they are integral to bear children .