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National registration and accreditation scheme for doctors and other health care workers

CHAIR —Welcome. Do you have any comments on the capacity in which you appear today?

Dr Field —I am a registered osteopath.

Mr Brownbill —I am also of George Brownbill Consulting Pty Ltd.

CHAIR —Thank you very much. You have information on parliamentary privilege and the protection of witnesses, and more can be obtained from the secretariat if you choose. We have your submission, and yours was one of the very first submissions we received, so we thank you for that. I invite all or any of you to make an opening statement—Mr Brownbill, you’ve got that gig—and then we will go into questions from the senators.

Mr Brownbill —Thank you, Madam Chair. We thank the committee for its invitation to appear. I will just note that Dr Field practises osteopathy here in Civic. He is also the chair of the ACT chiropractors and osteopathic registration board as well as national president of what I will call AOA from now on.

Osteopathy is one of the 10 healthcare professions selected for inclusion in the national registration and accreditation scheme, so we have a vital interest in how it will work. The scheme, as I would respectfully point out to senators, will cover many of the professions—indeed, the vast bulk of what might be thought to be the mainstream ones—which are responsible for the delivery of health care of the Australian people. Thus it is essential not only in people’s interests but also in the interests of the economic functioning of this country that these people who are to be registered adhere to the highest standards, first of all, and, secondly, that these people are properly regulated as members of a very significant workforce. Thirdly, it is important that people’s rights as workers and as professionals should be recognised. For all those reasons and for reasons that will appear as we proceed, we would submit that people’s rights are more important than states’ rights. There is at least some suggestion that the latter have prevailed in some respects over the former.

I will say a few words about the osteopathic profession, its place in Australian health care and the contribution made to the Australian economy and the healthcare sector of that economy. First of all, osteopaths treat the whole person, concentrating on the musculoskeletal system. Our people are highly trained. They need a five-year master’s degree to practise, and that five-year degree largely covers the same area that, for example, medical practitioners follow in their training on matters of anatomy, physiology and so forth. I say again that a master’s degree is the standard. Although osteopathy is sometimes linked with chiropractic, the two modalities are quite different. Finally, our professional indemnity insurers have confirmed that osteopaths have very low rates of claim, whether in respect of professional misfeasance or in respect of improper conduct in patient relationships. Considering that osteopaths must be in close physical contact with patients, this latter is noteworthy.

In the Australian healthcare scene there are about 1,500 osteopaths practising in Australia. More than half of them are women, and the great majority are under 35. The main mode of service delivery is the small business clinic, although osteopaths believe they have much to contribute to public health and so-called superclinics—for example, by obtaining the right to practise in public hospitals.

About 85 per cent of all patients are self-referred. They walk in off the street. No doctor, nor anybody else, sends them there. It is word-of-mouth and, as will appear later, they come ready to pay full fee. About the same proportion come to our clinics complaining of back pain or pain in the arm or the leg. Several come to us on the rebound from other modalities, and that does not exclude medical practitioners.

I would, if I may, table an article that appeared in this week’s Medical Journal of Australia, which discusses the issue of whether back pain should be a national health priority area in Australia and comes to the conclusion that it probably should. That puts the profession in perspective.

Financially, in 2007 those 1,500 osteopaths earned gross fees of about $200 million. Of this, no more than $10 million came from Medicare, with another $10 million to $15 million perhaps from private health insurance or workers compensation. The rest, we would like to point out, people paid for themselves. What this tells us—and what, I respectfully suggest, it tells this committee—is that the market is working. People freely seek osteopathic treatment and are prepared to pay for it. If I may, I will table a copy of a consulting report which we obtained a little while ago and which details the economic contribution that the osteopathic profession makes to the Australian economy.

CHAIR —Mr Brownbill, are you going to be tabling some more documents?

Mr Brownbill —That is the end of my requests.

CHAIR —You saw the secretariat disappear to go and photocopy them; I just wondered if you were tabling more documents.

Mr Brownbill —No, that is the end of my requests. We will not abuse—

CHAIR —Not at all; it is the way we get information, so that is very useful.

Mr Brownbill —I will now turn to the specific subject of the committee’s inquiry. AOA supports a national scheme. Secondly, we do appreciate the significant efforts officials are making to keep us informed. I would respectfully point out, however, having listened to the previous witness, that there are more questions than there are answers on the precise interplay of the legislative dispositions that are going to affect the lives of thousands of very important contributors to the health care of Australia. We do feel that the Senate committee has does very well indeed to have concerned itself with those precise questions. We do await publication of so-called ‘bill B’, which may provide detailed responses to some of our and others’ concerns. Mr Nicholas is going to outline to the committee, if that is agreeable to you, the conditions under which AOA offers its support for the national registration and accreditation scheme.

Mr Nicholas —As George said, the Australian Osteopathic Association thinks a principle of national registration is one that is worthy of pursuing. However, it does need some conditions attached to it that we do not think currently are clear to us. One, it needs to be properly designed rather than something that perhaps is rushed through to get it across a time line. It needs to be more cost-effective than the current models, and we have some concerns that it may not be. And not only must it be cost-effective; it must be more efficient than the current model and maintain safety for the public. After all, that is the main reason a registration scheme is in place. It needs to be a truly national model, and having states who may not participate or a split of power across various states will weaken the scheme and lead to some of the circumstances that we currently get in the state based system where practitioners may move from one state to another and certain conditions do not follow them. It is also important to notice that the key role of the scheme is to benefit patient safety and that proper safeguards need to be in place to prevent political interference in workforce professional standards or educational standards and of course that it has full and proper administrative appeals processes for those who are in it.

We have some key concerns. To start off with, obviously the name of the scheme is ‘for doctors and other healthcare workers’, which I think is rather dismissive of the 300,000 to 400,000 health workers. We believe that it should be ‘for health practitioners’, which we all are. Secondly, currently under the structure the national boards will not have power over the funds they collect to operate. The agency will control those funds. As we know, in some states that has been an issue for state based registration boards, and in fact they have to argue to get funds to carry out work which they believe is in the best interests of the safety of the public. Again, we think that the national registration boards should have control of their money.

Obviously, the scheme has to have reasonable costs. The whole picture of the scheme as put to us was to increase efficiency but also to reduce costs because of that efficiency. If in the long run we end up with additional layers of bureaucracy, obviously that burden of payment will be carried by the practitioners. There must be reasonable costs, and those costs should be attached to registration, not to the collection of data for workforce planning or a range of other issues. There are other agencies that should be finding that, not practitioners through registration schemes. As I said, those reasonable costs have to be across the different professions. For instance, as we know, in some professions there are 350,000 participants. In our profession there are 1,500. If that cost is, for instance, a $10 million IT system, if that is just split evenly across professions rather than per capita, that could be a huge impost on our members. Most importantly—and I am sure that your other witnesses today will probably spend far more time on this than we will—governments and government officials must not have a role in setting educational or professional standards. That is the role of registration boards or the professions.

Finally, there are a couple of other things. Dr Field will talk a bit more about this first one. We have grave concerns that in some of the consultations there is a discussion around removing certain health practices that are currently restricted by title. The main one we have concerns about, although there are discussions about others, is the removal of spinal manipulation. Spinal manipulation carried out by skilled practitioners is incredibly safe, as our indemnity insurance shows. However, in the hands of an unskilled practitioner it can lead to a stroke, death or serious injury. The removal of spinal manipulation as a protected title for, currently, osteopaths, physiotherapists, chiropractors and medical practitioners would have a huge impact on the safety of the public. If, ultimately, this is the role of this scheme, we have grave concerns about what is going to occur.

There have also been a range of other conditions that have come up in consultations. We are still blind because we will not know whether they are following one model or another until we see drafts or get some feedback on decisions which ministers have made. At this stage, all these comments are made prefacing the fact that they may or may not be covered in bill B or that there may be decisions made on them but 400,000 health practitioners are still waiting to see what those decisions are.

Finally, I would like to say that the AOA does support some of the things that have been talked about around mandatory reporting of inappropriate behaviours or practices, criminal record checks, the need for health and impairment programs and support for practitioners rather than just punishing them. We support the introduction of student registration to make sure that students in the final stages of clinical practice have an understanding of what registration means for them and the safety of the public. But, ultimately, the scheme must have an appropriate means for appeal and it must be more efficient than current models, while maintaining proper patient safety.

Dr Field —In relation to national registration, if this really is about public safety, I cannot emphasise enough the importance of maintaining restricted title and that being related to specific practices such as spinal manipulation. We have a fantastic safety record in our country with this procedure and this is predominantly because those who perform it are highly trained. If this were not to continue, it would be most dangerous for the general public.

Mr Brownbill —It is no good just going anywhere to get your neck cracked. I turn now to the administrative law issues, which are of grave concern to us. I find it extraordinary, after so long a development by this Senate of the parliamentary control of administrative action, that a scheme like this, which is close to devoid of any such control, can be countenanced. We do not consider it acceptable in 2009 for a new legislative scheme to be set up without the following things.

Firstly, we do not consider it acceptable for the scheme to be set up without legislative instruments being open to parliamentary disallowance. That is extraordinary. All these standards, rules of conduct and goodness knows what are clearly of legislative character—that is, they would be legislative instruments if made by a Commonwealth agency. I believe, and we put it to you, that the parliament—‘the’ parliament, which means this parliament—should, if it countenances a scheme like this by legislation, have the capacity to disallow. That leads to a proper control, by the body elected by the people, of administrative discretion.

Secondly, we do not consider it acceptable for the scheme to be set up without a proper freedom of information and privacy legislative regime which is uniform throughout Australia. How can you be uniform if you do not know whether you can find out something in one state but not another?

Thirdly, we do not consider it acceptable for the scheme to be set up without access by aggrieved persons to administrative review on the merits—that is, to something like the AAT—or to judicial review—that is, under ADJR, or the judiciary act, or both. I would submit to this committee that it is not beyond the wit of those designing this scheme to overcome so-called state objections. For example, each state’s legislation could easily confer the relevant jurisdictions on the AAT and the Federal Court. I would put it to this committee that there are serious issues here of the rights of professional people. Officials, no matter how dedicated or well-trained, do not always get it right. Just look at the history of the department of immigration and the High Court cases, from Teo on, if you want a case in point. Osteopaths, no less than nurses, podiatrists or dentists, deserve the comfort and assurance of proper merits and judicial review processes which are uniform in any part of Australia. Now we simply do not know, from the legislation and the expressions of goodwill in the various discussion documents, how any of that will work. How could an osteopath comfortably submit to being registered under a scheme where he or she has no idea, at this point, as to how a decision adverse to their interests can be appealed or reviewed? I think these are very fundamental issues and I would submit to the Senate committee that it has a very significant role in assuring a better approach on these matters.

Senator HUMPHRIES —Thank you, gentlemen, for appearing today and giving us your evidence. You have suggested a national scheme, one that is run by the national parliament. Now what we are going to get, apparently, is a national scheme, but it is not going to be one that is run by the national parliament. The reason is that the power to register and regulate health professions is constitutionally a matter for the state governments.

Mr Brownbill —Sole traders.

Senator HUMPHRIES —That is right.

Mr Brownbill —Corporations, not—

Senator HUMPHRIES —Indeed. There might well be some advantages in having that all referred to the Commonwealth parliament but it is not going to happen under these arrangements. We are interested in whether there should be equivalent protections, the sorts that you have spoken about, Mr Brownbill, with respect to disallowance arrangements, for example, built into the state parliaments as they are now. Some regulations can be disallowed in state parliaments and, as I think we understand the scheme that is being put forward, that is possible with some existing standards that are set by state or territory governments, and it may be possible for that arrangement to be preserved in this new structure as well even though it is a national scheme.

With the proviso that I do not think we can deliver regulation or disallowance by the national parliament—it is not going to happen—I will just ask you about the arrangements for protection of the independence of the profession to regulate itself through the structure of the new board that will be set up for osteopaths. You would have heard today that there are a number of details about these arrangements yet to be agreed upon so unfortunately we cannot answer the questions yet about what is going to happen, but based on what we have been told so far, there will be a national board. It will be replicated, presumably at least in most states, by a state committee that will deal with the issue of registration of osteopaths and disciplinary and regulatory procedures governing them. The board will consist mostly of osteopaths with some community representatives on it as well. It will not be possible for the ministers to direct the board to do certain things with respect to the standards. The best they could do is to reject standards that are presented to them by the boards.

Your submission makes the comment that you have a no confidence in ministers having that power and you say that they will be tempted to interfere with draft standards for what they may regard as workforce planning reasons. If we are going to have a national scheme, is there a better way of doing it than the one that is being presented, in that it seems to preserve a large measure of independence for the national boards consisting mainly of members of that particular occupational group, or is there an improvement you can suggest we can make to preserve that independence?

Mr Nicholas —Osteopathic boards are concerned about the accreditation of university courses affecting their independence. That is their biggest concern. There is an international standard for osteopathy so it has not as much consequence for us as it has for other professions. But certainly we can understand that for many of the other professions this is a ‘die in the ditch’ matter in that under the proposed scheme now they will lose their international standards because accreditation must be independent of government. This scheme is not independent of government. It is basically under ministerial approval. So schools of medicine and a range of courses are looking at losing international standing, because no longer will accreditation be independent.

Certainly around registration issues I think that the model is not dissimilar from what currently exists for osteopathy in most states on registration and standards. But I think that a lot of professional standards have previously been produced by the professions and may or may not have been endorsed by boards. They certainly have not been legislative issues; they have actually been around education and training issues, standards of expectation and accreditation of courses. Now if ministers are going to set standards that the registration boards have to meet—as in standards of operations or standards for having standards—then there is the possibility that some of those standards may be set in ways that reduce the standard for some professions, and that is the main concern. There may be a dumbing down of professions to increase workforce capacity and that means a reduction in professional standards or educational quality to meet that need.

Senator HUMPHRIES —How could this proposal be restructured to avoid that happening?

Mr Nicholas —I would suggest the actual complete separation of accreditation bodies so that there are national accreditation bodies for educational standards and that the assessment of overseas applicants needs to be independent of the scheme.

Mr Brownbill —They could, for example, be incorporated under companies law or similar rather than endowed with functions by statute. The incorporated bodies could be taken as giving advice, if you like, to the registration board, which it could not depart from other than for a clear cause shown. The other thing that I would observe with regard to Senator Humphries’s observation that certain things are not going to happen is that it would be a very strange uniform scheme if the administrative law structure, which supports the rights of people and the oversight of the institution of parliament, were not uniform. That I find to be counterintuitive, to put it mildly. One wonders whether all the effort is worth it. All you need is one unhappy osteopath who has been pinged by a board for something she did not do but the patient said she did—I need not be more particular than that—and you are all the way to the High Court, with goodness knows what outcome. So I do believe that this issue of uniformity has to be resolved not just as to the subject matters but as to the process of management and review and adjudication—somehow. I do not think it is beyond the wit of state jurisdictions and the Commonwealth to do that. It has been done in many other areas; companies law is perhaps the leading case.

Senator HUMPHRIES —I might focus on this issue of registration for a minute. What seems to be proposed for the national scheme looks very much like what was in operation for the state schemes but just elevated to a different level—it is a bit different, but really it looks much the same. At the moment, who performs the role of accrediting osteopaths who might, say, move from overseas? Is that state board based as well?

Mr Nicholas —Currently there is the Australian Osteopathic Council, which is a national accreditation body, but that effectively was only formed last year. Prior to that it was a subcommittee made up of various members of the registration boards who took on that role, and it was either outsourced to one of the universities, who undertook the accreditation under the process outlined, or handled in Western Australia by a contractor, who carried out a similar process that, because of Western Australian legislation, has to be done in WA. So certainly within osteopathy that model currently is very intrinsically linked to registration—and probably for good reason: you want people of a certain standard to be entering the country.

Senator HUMPHRIES —Isn’t there a risk, then, in separating, as you are proposing, registration from accreditation and having them done by different bodies?

Mr Nicholas —The accreditation bodies will become the holder of knowledge of current educational and professional standards, so they are probably best placed to say, ‘This is what we would expect somebody coming in from overseas to be capable of doing based on what Australian registration and education would require.’ Really, the accreditation bodies are almost the house of standards within health care, and that is where that assessment should sit. Yes, obviously they are going to be making recommendations to registration boards and registration boards may make further requests, but I think it really should sit within bodies that have good skill and knowledge about current educational and training standards, not a body that is based around maintaining a database and ensuring people do not behave inappropriately.

Senator HUMPHRIES —Mightn’t that result in either a higher or a lower standard being adopted for people who enter the profession in Australia from overseas than for those who are trained here and registered under the national registration scheme?

Mr Nicholas —Currently, the scheme that assesses overseas applicants looks at making sure that they have the capacity to be the equivalent of a new graduate in Australia.

Senator HUMPHRIES —But that is because, as you said, the scheme now is tied in with the registration boards.

Mr Nicholas —Yes.

Senator HUMPHRIES —But if you are separating the two—you are saying that one should be done by an independent body—then why wouldn’t the standards end up being on different planes?

Mr Nicholas —I think because that body is also responsible for saying, ‘This is the educational standard for graduating as an osteopath in Australia,’ so they have a good understanding of what the current standard is for Australia. Obviously, all the accreditation bodies then make a recommendation to the registration board that graduates from said course are qualified to be registered. So with these independent bodies there is always that link back to a registration board, but I think the fact that the accreditation body would be completely independent and free of any possible interference generally makes it stronger. We are not seeing a reduction in healthcare standards in Australia under this current model; in fact, we have probably got some of the best trained health practitioners in the world. So the current independent model is its own proof. With a different model, we would have to see—especially when this is a registration scheme, which should be based around safety and therefore standards. But what we have constantly seen discussed and in the recording of the data that will go on the registration board is workforce issues, workforce issues, workforce issues. Well, registration is not about workforce issues. Registration is about registration and safety of patients and standards of care, not workforce issues.

Senator HUMPHRIES —Given that, clearly, a separate accreditation body is not part of the national scheme and we around this table do not have the power to change that—as you noted, it is not national parliament legislation—you are going to end up with that separation from the international standard. What will the profession do in those circumstances?

Mr Nicholas —For osteopathy that is not a concern because there currently is not. But, certainly, from our colleagues, we know that will mean that a graduate from Australia will not be seen in as high standing elsewhere as they currently are.

Senator HUMPHRIES —Right.

Mr Brownbill —There are two Commonwealth legislative precedents that my past experience reminds me of. One is in the Office of National Assessments Act and the other is in the ASIO Act, and they explicitly require that the minister administering the legislation may not direct either of those agencies as to the precise content of the findings or information they provide by way of national assessments or security assessments. It would not be difficult to devise a somewhat similar process, and I thought I heard Dr Morauta say that there was to be such a provision. We are yet of course to assess the drafting of that.

Senator HUMPHRIES —Yes, she made it clear that the ministers collectively could reject standards that were thought up and presented by the board. It is an interesting question. So, given the Commonwealth parliament cannot do this, you would like to see preserved the power of the state parliaments to disallow instruments made by the boards or by the ministers to set standards?

Mr Nicholas —Yes.

Senator HUMPHRIES —As long as they are consistent.

Mr Brownbill —How can the Tasmanian parliament disallow a legislative instrument which is national in scope without its jurisdiction going beyond the boundaries of Tasmania, for example—or the ACT or wherever? And what happens in the rest of Australia in the meantime?

Senator HUMPHRIES —Presumably, a state under that arrangement could disallow the regulations in its own jurisdiction. You would then have variations between the different jurisdictions.

Mr Brownbill —Not if the law of, as it were, mutual takeover of each other’s legal rights and responsibilities continues.

Senator HUMPHRIES —I think this is more a case of all the states individually signing up to a national scheme, with the power, at the same time, to pull back from that national scheme, in whole or in part, if they want to. It is not like the referral of powers to the Commonwealth parliament where the Commonwealth parliament effectively runs the whole scheme and imposes a rule on every jurisdiction.

Senator FURNER —With regard to your last dot point, where you recommend that the scheme be truly national in scope, with states and territories taking part, is that similar to the discussion we have just had with Senator Humphries in regard to your belief that it is a scheme where the national government will take control of all the state bodies?

Mr Brownbill —That would be possible. There are a variety of precedents for national legislation in fields that are thought not to be the province of the parliament of the Commonwealth under section 51 et cetera. I would have thought that the concept of an overarching Commonwealth statute which, so to speak, blessed the state structures and established a uniform process of legislative and administrative review exercisable on the instance of one of the jurisdictions including the Commonwealth was entirely feasible and possible to be conceived of. My concern is that no-one is prepared even to countenance it. Instead, we have a situation where we have nine ministers who are responsible to nobody in respect of their actions, in a ministerial council which is not even incorporated, oversighting bodies that make what are in effect legislative instruments, but which are not so described, prescribing the operations of bodies whose actions in respect to the rights of people are in no way, it appears so far, open to any kind of merit or judicial review. With great respect, I cannot see that that is an advance on our present situation.

Senator FURNER —Would you be able to explain how many international osteopaths might be coming in to assist Australians in specialised fields like the back and those sort of areas? You have identified back pain as a national health priority. I am just wondering whether you can identify specialists in each field that are being utilised in the country.

Mr Nicholas —Globally, osteopathy is quite diverse. In Australia it has been registered for 30 years; in the UK it has only been registered for 10 years; in the US it has been actually transformed into a medical practice, so all American osteopaths are actually medical physicians. So it is very varied, which is why there is not an international standard. There are about 6,000 osteopaths in the UK, which is probably the largest of the other jurisdictions where they are registered. All through Europe, many of the countries do not have any regulation or registration attached to osteopathy, so they can be practitioners whose qualifications range from a three-week course to a university degree. Naturally, that raises some concerns for us if entrance into Australia is weakened. Currently, there are about 40 to 60 osteopaths who apply every couple of years to enter Australia through the exam process, either through Victoria or WA. We are not expecting that there will be a huge influx to fill a gap, although osteopathic graduates walk straight into employment—literally 100 per cent. Certainly, in the vast majority of Australia, there is in fact a shortage of osteopaths. Apart from probably Victoria and New South Wales, there are only 20 or 30 practitioners per state.

Senator FURNER —Out of that 40 to 60 applicants, how many will be successful in being granted approval?

Mr Nicholas —I am not sure. The registration boards could probably apply for that. I would say a significant amount do not get through the first stage, which is just noting whether their qualifications are of the required Australian standard, which is effectively almost the equivalent of a four-year university degree.

Mr Brownbill —Australian standards for osteopathic practise are, relative to the rest of the world, very high. One would hesitate to say they are the highest, but they are certainly in the top fifth decile of standards. The profession in Australia, home grown, is growing more rapidly than any other healthcare profession—from a low base, but very rapidly.

Senator FURNER —Mr Nicholas, you spoke about an appeal process for the scheme. How do you consider that would work?

Mr Nicholas —We are not sure. A range of parliamentary secretaries who are the great minds of parliamentary law have been working on bill B now for several months. I am sure that we would be happy to take their advice on the best way to ensure that the safety of practitioners’ and patients’ rights is covered clearly in this scheme. Bill B was due to be tabled in March this year but it was stalled by Queensland going to an election. Clearly, many decisions have been made or at least put forward for an exposure draft, so many of these questions could possibly be answered by the sections that ministers have made decisions on. They would at least give us some idea of the areas where they have decided to go one way or the other from consultations. There must be significant information about what is in bill B, considering it was supposed to be going out for consultation in March and only ceased because of the election in Queensland. I assume that there is a fairly final draft sitting somewhere and I dare say most of the associations would be very keen to have a longer period of time to review it than a few weeks.

Senator HUMPHRIES —One of you mentioned that you want this new scheme to be more cost-effective than the current model of registration. Although we have lots of gaps in our knowledge of how this is going to work, do you expect or feel that it will be or it will not be, given that you must have some economies of scale if you are registering at a national level?

Mr Nicholas —Certainly in the big picture of the scheme we would expect that economy of scale and the standardising of standards or procedures across the country to lead to some economies of scale in ITS systems, staffing, HR et cetera. Osteopathy is one of the professions that have several contractors as registrars in Tasmania, South Australia and WA. You can imagine that, in those states where there are only 20 or 30 registrants, the cost may be higher because they are supporting an entire system of registration for 20 or 30 people. When they are attached to a scheme, it will just depend on how those funding agreements with the agency play out. If we have to pay for a 10th of the scheme, it is going to be very expensive for osteopaths. If we are paying per capita of registrants then it may not be. But we have no details of that. We have been given no advice on how the funding of the scheme will be carried out. What we have said in our submissions is that if it is going to be more expensive then perhaps governments do need to think about funding this supposedly more efficient scheme rather than relying on practitioners to fund it.

Mr Brownbill —If I may add to that, it is now customary in the area of cost recovery arrangements for a CRIS, a cost recovery impact statement, to be prepared and to be the subject of consultation and for that consultation to be certified to the parliament when the relevant regulation or statute is brought in. We see none of that in these arrangements. We do not know if there will be a CRIS or some document purporting to go through the cost recovery steps. As Antony says, it is of vital interest to us little guys whether this is per capita, per profession or some mix of that and, if it is a mix, what the ingredients are. We do not know.

CHAIR —I only have one question, to do with your concern about the back adjustments that you put in your submission and you mentioned particularly in your evidence. What have you seen in the legislation and in the consultation processes in which the organisation has been involved that leads you to think this could happen?

Dr Field —In most states and territories there are different definitions or descriptions which restrict this practice. From what has been presented to us, there was to be a restriction in said titles having specific techniques or medical procedures related to them. That is a very serious concern—that our title does not necessarily protect that practice.

CHAIR —Is it protected in every state and territory now?

Dr Field —Most.

Mr Nicholas —One, I think: Victoria.

CHAIR —So Victoria does not. What has been the impact in Victoria of it not being protected?

Dr Field —The process is then confused because, if there are procedures that cause injury or death, they do not necessarily go through the registration board; they end up in litigation.

Mr Nicholas —We would have to see data from who has gone to litigation because they have nobody to go and complain to other than perhaps the Health Care Complaints Commission.

CHAIR —So you are concerned that the current system, with which you are not happy, in Victoria could become the national law?

Mr Nicholas —Yes. In one of the consultation documents there was a question asked about whether it should be excluded from the national model.

CHAIR —And the answer?

Mr Nicholas —We do not know. We assume that will come out in bill B, but that is an assumption.

CHAIR —It just seemed from the original evidence from Doctor Morauta that the states are going to maintain very similar processes within the national scheme, so it could well be that your issues in Victoria continue in Victoria but not anywhere else. Thank you very much, gentlemen. If you have any further comments or things you wish to add, this committee is due to report on this particular process at the end of June. We will still wait to see what is happening with the second bill. Thank you.

Proceedings suspended from 10.52 am to 11.05 am