The Australian aged care and disability support workforces include more than 500,000 workers, and of these approximately 280,000 identify as personal care workers or support workers.

These unregistered and unregulated workers cater to some of our most vulnerable citizens. Recent investigations and media reports, such as The Royal Commission into Aged Care Quality and Safety (2021), The Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (2023), NDIS Review: Working together to deliver the NDIS (2023)  and the ABC’s Four Corners episode about abusive practices at Irabina Autism Services (Sept, 2023), highlight challenges in maintaining standards across this workforce, and the adverse outcomes of not doing so.

The Royal Commissions focusing on Aged Care and Disability, along with the NDIS Review, recommended mandatory registration for the aged care and disability support workforces. Additionally, the NDIS review recommended “a graduated risk-proportionate regulatory model, as well as a new provider risk framework, to improve the visibility and regulation of NDIS providers and workers.”

Registration is designed to enhance public safety by setting higher occupational standards, thereby elevating the quality and professionalism of these essential services.

Resistance to registration of disability service workers

Some disability advocacy and service user groups have been vocal in their resistance to worker registration on the basis that they perceive it will erode the options for self-management and personalised arrangements (under the NDIS, particularly). Participants are concerned about the importance of maintaining autonomy in choosing their service providers, and emphasise the right to determine who enters their personal spaces.

User groups advocate for direct employment or engagement of support staff without third-party interference, enhancing understanding of self-management risks and responsibilities, and establishing a supportive risk framework with an independent appeals process. Furthermore, they propose development of a tailored ecosystem for quality and safeguarding to ensure client safety.

At the heart of this, is the concern is that mandatory registration will reduce the pool of workers and therefore their choice of provider. These concerns are not unfounded as there are various ways this could happen:

• Registration standards are set too high, forcing workers without formal qualifications from the workforce
• Worker registration costs are set too high
• The registration process is too complex or time-consuming for workers, and
• Workers who work in multiple sectors (e.g., aged care and disability) are forced to register for multiple schemes, leading to workers choosing to work in one sector only.

What is self-regulation in the health context?

Self-regulation through certification is the regulatory mechanism adopted by allied health disciplines not registered under Health Practitioner Regulation National Law (more than 30 different occupational groups).

Through self-regulation, a non-government body (the peak body for the profession) sets minimum standards for initial and ongoing certification. For the allied health professions, this includes completion of certain qualifications, as well as compliance with a code of conduct, continuing professional development requirements and requiring that a practitioner take certain steps before returning to practice after a break from working. These standards are set by the profession to ensure that certified members maintain their skills and knowledge, and provide safe and ethical services. Each certification framework is fleshed out by disciplinary and complaints procedures, and noncompliance can result in termination or suspension of certification.

The majority of allied health professionals are regulated this way—speech pathologists, social workers, dietitians, exercise physiologists, audiologists (to mention only a few). Fewer than half of the professions recognised by Allied Health Professions Australia (AHPA), the peak body representing allied health professions in Australia are regulated under national legislation (AHPRA), instead, most are self-regulated.

Certification often operates in synergy with ‘co-regulatory’ approaches from the government. This involves a partnership between government and the peak body. The peak body ensures that standards are in place for the professions, and have a framework for ensuring certified professionals comply with those standards, thereby supporting the safety and quality of services delivered by workers who meet those standards. In return, government incentivises certified professionals with exclusive benefits such as access to funding streams that are not available to uncertified workers (examples include Medicare DVA, and some NDIS funding). These privileges given to certified members then encourage other members of the workforce to become certified, and adhere to the standards enforced by the peak body.

The example of self-regulation of allied health assistants (AHAs)

AHAs are important members of the care and support workforce in the disability and aged care sectors. They perform low-risk therapeutic tasks under the supervision and delegation of an allied health professional (e.g., physiotherapist, speech pathologist). AHAs are like other members of the care and support workforce in the sense that they are a heterogenous workforce, with no minimum qualifications mandated nationally to work, have heterogenous roles and often deliver services across diverse sectors.

The Allied Health Assistants’ National Association Ltd (AHANA) developed a certification framework in 2023 that recognises these workforce complexities. The AHANA certification framework allows anyone currently practising as an AHA to be certified, regardless of whether they have a formal qualification, provided they meet other standards set by AHANA. AHANA membership contains tiered certification levels that recognises different levels of experience and qualifications to encourage formalisation of qualifications.

AHANA’s certification framework incorporate key elements proposed for inclusion in the national support worker registration schemes recommended by the Royal Commissions for Aged Care and Disability, i.e., mandatory adherence to a code of conduct, police checks, ongoing professional development requirements, and a publicly accessible workforce register. Detailed information about AHANA can be found on the website.

This certification scheme aligns with global best practices of health practitioner self-regulation, the principles of the Australian Government Health Regulatory Policy Framework (2020), and the self-regulation approaches stipulated by the National Alliance of Self-Regulating Health Professions (the governance body that oversees the self-regulated allied health professions in Australia).

How self-regulation can support increased consumer choice, while also raising the safety and quality of services

Certification of care and support workers – disability, and aged care – provides an opportunity to raise safety and quality standards for this large, unregulated workforce while reducing the risk of worker loss and reduced choice for service users. The benefits for consumers, government and employers of a certification scheme include:

Rapid, effective regulation of workers for enhanced safety: with self-regulation, the potential inconsistencies of state-based systems and/or delays in developing and implementing national occupation regulation policy, are reduced (or avoided, if the degree of take-up is such that national regulation is deemed not to be required). By supporting the scheme with co-regulation, the government can improve standards quickly by incentivising certification.

Nationally consistent, high-quality care and quality assurance for service-users and employers: Certification promotes uniform standards and supports across the country, benefiting all service users regardless of their location or the sector from which they receive services, and reduces risk for employers.

Enhanced consumer choice: A publicly accessible register of certified workers who are quality assured through the certification process. Registers can specific areas of worker interest/skill, and qualifications, for more informed choice.

Single scheme for multiple sectors: Like AHAs, many disability support workers and aged care workers work across multiple sectors. The government can outsource the quality controls to the peak body through the certification process and recognise certified workers automatically in multiple mandatory registration schemes with similar requirements, without requiring the worker to re-provide certification documentation. This decreases the cost and administrative effort for workers and government, and reduces the risk of workers leaving the occupation or sector due to cost and complexity.

Data-driven improvements in service delivery: The dataset provided by a single national certification scheme covering the care and support workforce would enable government to make more informed policy and funding decisions, ensuring the sustainability of the workforce and that the sectors are appropriately supported into the future. This would also enable risk-based monitoring of workers based on past practice and trends in risk areas (geographic and/or practice), again enhancing the safety of this workforce.

What about the benefits for workers?

Recognising and formalising credentials, coupled with a capability framework and mandatory professional development for the care and support workforce, uplifts the professionalism of the workforce while improving the care for end users. Benefits for workers include:

A unified and skilled workforce: Certification by a single professional association provides a platform for nationally consistent opportunities for recognition and career progression across the care and support workforce, and facilitates worker mobility between sectors.

Opportunities for career advancement: By providing a hierarchical certification structure, like AHANA’s, certification recognises the fact that some workers do not have formal qualifications while also providing encouragement to pursue further training and professional development, better supporting them to advance in their careers and potentially specialise in certain areas of disability or aged care, or follow a career path into associated professions.

Professionalisation of the care and support workforce: Certification offers networking opportunities with other workers in the field, works to foster a sense of community, shared purpose and peer support. Being part of a certified profession can increase job satisfaction and morale, as workers feel more valued and recognised for their professional capabilities and being part of a professional workforce.

Reduced cost and administrative effort for continuing work, and increased funding opportunities to incentivise participation: These elements rely on government seeing the benefit of the certification framework and implementing coregulatory arrangements. Opportunities for government to lift quality standards without forcing workers out of the workforce include:

• Offsetting certification costs, to reduce the financial burden of certification for workers
• Recognising certification with a single peak body with registration under multiple national worker registration schemes, and
• Implementing new funding streams to reward certified workers for their commitment to enhanced standards of care, which will give them and their employers more market power and, in turn, incentivise further uptake.

Conclusion

Regulation of the care and support workforce does not have to end consumer choice. Instead, individual regulation of workers, through the self-certification of workers – using a model similar to that developed for allied health assistants – provides increased protection for service users. At the same time, self-certification provides recognition of the skills and expertise of the workforce in a way that enables them to work across different sectors and with a range of clients and establish a recognised career pathway.

Kelli Rixon is General Manager of HealthWork Solutions and is the author of today’s guest post. HealthWork Solutions provides regulatory and self-regulation consultancies for healthcare professions and peak bodies, and is currently supporting AHANA to coordinate an industry reference group to work towards co-regulation for allied health assistants. Contact Kelli to learn more.