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Regulation, Scope of Practice & Leadership: A Conversation With Dr Anne-Louise Carlton

Dr. Anne-Louise Carlton has been closely involved with health workforce regulation and policy for the last 35 years, with a professional journey commencing with direct service as a social worker and which led, through a range of policy and other roles, to co-designing regulatory reform within Australia as well as internationally.

Anne-Louise played a pivotal role in establishing the Australian Health Practitioner Regulation Agency (Ahpra), the 15 National Boards that govern different health professions, and the National Registration and Accreditation Scheme. She has actively contributed to various international health workforce regulation initiatives.

In 2022, she joined HealthWork International as Senior Policy Advisor, and has since covered a range of projects including helping AHANA to establish its systems for credentialing allied health assistants, working with World Health Organization (WHO) Malaysian Country Office and the Ministry of Health Malaysia on credentialing policy for Malaysia’s allied health workforce, and helping to draft a code of conduct for the health workforce in Somalia.

Recently, Anne-Louise was part of a multi-national research team that carried out an extensive review of the global literature on health practitioner regulation, commissioned by WHO Geneva.

We were very pleased to speak with Anne-Louise to tease out her opinions on a wide range of topics, including allied health leadership, the Commonwealth Health Minister’s Scope of Practice Review, and some of the biggest challenges to health workforce regulation.

Is there a project that you’ve been involved in throughout your career that you’re most proud of? Is there one that stands out?

There’s a couple.

The National Registration and Accreditation Scheme—although no scheme is perfect and it’s only as good as the people who are implementing it, and there’s always room for improvement—it’s taken about ten years, but I’m pretty pleased to see how that scheme has reached maturity.

It hit its straps during the pandemic and I think Australia’s health workforce regulation system held up very well in comparison with some other countries, in terms of the speed with which regulators were able to adapt and make changes to support governments to implement a surge workforce. The other area is in traditional medicine, where I think Australia’s been a world leader in the sort of work that we’ve done to register and regulate the Chinese medicine profession.

Then more recently, the work that we’re doing in Malaysia I think is very exciting, with Susan Nancarrow, Nicki Atkinson, Jenny Care and Lee Ridoutt, where we are pulling ideas from the UK, Canada and New Zealand to try and design an integrated careers capabilities and credentialing framework for Malaysia’s allied health workforce—pretty innovative and exciting work.

Did you also have a role in developing the Disability Service Safeguards Act for the Victorian Department of Health?

I did much of the regulatory policy work with a team from the Department of Premier and Cabinet, to develop the Disability Service Safeguards Act, which was the first registration regime for disability support workers, which is now up and running. While I’ve not been involved in its implementation, I worked to develop the legislation and was in Parliament when the legislation was debated and passed. I’m a keen observer of how implementation is going with that act, because it was an Australian first—no other state or territory has actually tried to register and regulate the disability workforce under an occupational regulation umbrella.

In the research that we did, we also didn’t find any similar schemes in other countries. We find occupational regulation of specific  professions or providers and we find regulation generally of drugs and poisons, public health, radiation safety, facilities, licensing, all of that. But I’ve never found anywhere in my travels a scheme to register and regulate disability support workers, one that combines both positive and negative licensing. So it’s certainly a world first.

It must be pretty gratifying to do that work and then be able to see it being implemented

Yeah, it is. I enjoy the process of law reform. I enjoy that it’s deadline driven and creative.

So this week, for example, I’ve been helping the National Health Professional Council (NHPS) in Somalia develop its first strategic plan. I’ve helped them draft their first a code of conduct for the health workforce in Somalia, and I’ve also worked with them to develop a regulation to register and regulate their health professions. So that is very rewarding because you get to see something that you’ve helped develop being implemented in a country that really struggles with resourcing and security and all of those things.

When you say “health workforce”, does that mean something different depending on the country you’re working in?

It does, because every country has its own history in terms of its division of labour in healthcare, and who does what. The suite of professions that exist in Australia and the subset of those that are registered or licensed is different to the suite of professions that are registered and regulated or constitute the broader health workforce in Somalia or the UK, or Malaysia or anywhere else. So that depends on history and how their health occupations have developed over time.

And what are some of the biggest challenges you’ve faced in your career working in regulation and policy?

You can design the best laws in the country or in the world, but unless they’re well-implemented, they don’t work—I’ve worked in many countries where they have a law that’s not a bad law, it gives them the basis to do the job that they need to do, but they don’t have the resources or the regulatory workforce to be able to implement it properly.

And they can be undermined by political processes and corruption. We think we’ve got a hard time making change in our country, but I’ll tell you what, it’s a lot harder in a lot of other places!

Using the example of your work in Malaysia for the WHO, is it reasonable to draw a line from the implementation of that project to quality of care outcomes?

Well, it’s always about outcomes for patients, and that’s foremost in everyone’s minds when we do this work, and that’s the joy of working in a team of people who have that orientation and that commitment.

All of the work that I’m involved in is about ensuring the quality and safety of the health workforce in any country that I’m working in; if you don’t have a high quality and safe health workforce then you don’t get good patient outcomes. Of course it’s not automatic, but there’s definitely a link.

That’s what it’s about: quality and safety, patient-centred care, and the need to do it efficiently and effectively with the least resources possible, because resources are always scarce and there’s always unmet need—and ensuring that it’s equitable, addressing disadvantage, inequality –how to make sure that those who are in most need are getting the services that they need.

What would be the most challenging environment to work in politically?

I think every environment has its own challenges, because wherever you work, you’ve got to understand the context within which you’re operating, and that means understanding the nature of government, the structure of government, the way policy decisions are taken, who has the power to do what. In Australia, one of the challenges is working under a federal system of government where the responsibilities are split between a federal government and multiple state and territory governments.

Working within that environment—particularly when you’re working on national policy—can be quite challenging. The number of players that you have to involve, and the number of the processes that you have to go through to get decisions taken, is really challenging. So I see the policy-making process as a dynamic interplay of context, institutions, individuals, ideas, all interacting together, and if you can actually make them all work together to get a result, it’s a real high, it can be a really exciting thing to do.

What are your thoughts on the Scope of Practice Review and what do you hope to see come out of it later this year?

I hope they move away from this idea of the professions working “to full scope of practice” because I think our system is much more dynamic than that, and what constitutes full scope of practice today is going to be looking different in two years or five years.

Governments have to get a lot better at leading health workforce reform, and I think I’ve mentioned in that interview that I came across a US study—it’s a bit old now—where they compared scopes of practice of about four or five professions across their fifty or so states, and found vast differences in the scopes of practice—well that hasn’t changed. The literature still shows us that there are big differences in a federated system of government in the scopes of practice across states. What governments have got to get better at is leading workforce reform and managing the contests between professions, managing the demarcation disputes, to drive workforce reform.

For example, in the US armed services they have a command-and-control hierarchy. This study I mentioned showed they could identify an unmet health need, identify a workforce that requires additional skills, establish the competencies, establish the training, up-skill the workers, and roll out the changes, all over a period of about two years. Now that’s what we’ve got to get better at: identifying where there’s a gap in health services; what competencies are required; which profession/s might be able to step up; do they need additional training, and if so, should the training be rolled out statewide or nationwide; upskilling all or part of a workforce; and then rolling out that extended scope of practice.

We have the experience—that sort of workforce reform on a statewide or a national basis has been going on for years, with the development of the nurse practitioner role, with the implementation of prescribing rights for nurses, nurse practitioners, midwives and optometrists, that workforce reform has been happening since the early 1990s. It’s just not happening quickly enough.

Do you think there’s much anxiety on the part of medical practitioners about the implications of the Scope of Practice Review?

It depends on who you talk to. Organised medicine, meaning the medical professional associations. colleges and unions, their default position is generally to maintain the status quo, and they rarely support expansions to the scopes of practice of the allied health professions, in particular nurses and allied health professions and pharmacists and others. Their default position has been the same for as long as I can remember, and I have seen governments take that into account and press ahead with  workforce reform anyway—pharmacists doing vaccinations, nurse practitioners prescribing medicines, ordering tests, etc.

Governments have just got to get better at managing in a more interventionist way those demarcation disputes, recognising them for what they are, and managing the resistance to change, to achieve reform. We would never have got prescribing rights for optometrists up if governments had accepted the official view of the ophthalmologists, we would never have got prescribing rights for podiatrists or midwives if governments had accepted the views of organised medicine.

But there are many, many medical practitioners in many different settings who support expanded scopes of practice in nursing and allied health and pharmacy, because they know that the needs are huge, and the medical profession alone cannot meet those needs. They’ve got to work as members of teams in multidisciplinary settings, sharing roles and responsibilities, including at the risky end, which involves, you know, prescribing, referring to specialists; those things that require resources and cost money. Because ultimately it leads to better patient care. The international research confirms this.

What does leadership in allied health mean to you?

I’m a fan of distributed leadership. Allied health leadership isn’t necessarily restricted to people who hold positions of power in organisations. I’m a great believer that anybody can be a leader, anybody can develop leadership competencies and can lead change, and a lot of workforce reform is initiated at the local level, and that’s leadership.

There are leaders that we know and aspire to be like, but I really think that anybody can. I know in my early career as a newly minted social worker, or even as a social work student, I was leading change processes back then and I didn’t have any official leadership position, so I would encourage people to think in those terms: leadership is a distributed and shared attribute.

Follow Anne-Louise on Linkedin, or view her bio. AHP Workforce provides allied health workforce planning, strategy and consulting for employers, managers and stakeholders. Contact us today to learn more about our service offerings.

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