Australian Association of Social Workers

Australian Association of Social Workers AHMAC Consultation Paper about Options for Regulation of Unregistered Health Practitioners AASW CONTACT: Professor Bob Lonne AASW National President E-mail: aaswnat@aasw.asn.au Kandie Allen-Kelly AASW Chief Executive Officer Phone: 02 6232 3903 E-mail: ceo@aasw.asn.au April 2011

AHMAC Consultation Paper about Options for Regulation of Unregistered Health Practitioners The Australian Health Minister s Council (AHMAC) is seeking feedback on its Consultation paper about Options for regulation of unregistered health practitioners. It proposes to establish some responsibility for complaints about unregistered health professions, including social workers working in health settings, but the measures are weak and unacceptable. This matter is a key priority for the AASW and its members Please send in a submission by Friday 15 April. All responses need to be provided on the Quick Response Form which can be found at: www.ahmac.gov.au Response forms should be sent to unregisteredhealthpractitioners@health.vic.gov.au Section 2 SCOPE If you are a professional association, can you provide an estimate of the number of unregistered health practitioners you believe to be practising in your profession or field. As the consultation proposal does not name social workers as one of the professions to be included, we assume that Governments are interested in the number of counsellors and therapists, and we cannot provide any estimate of the number of those, given there are no entry accreditation standards or any registration arrangements. Social workers are often employed as counsellors, therapists, case managers and a range of other job titles by Government and non-government agencies and this makes data collection more difficult. The most reliable estimate of the number of people who have completed an accredited social work degree is from DEEWR 1, whose work is based upon ANZSCO classifications. These figures indicate that there were 19,300 Social Workers in Australia at that time. Social Work is not a registered profession in any jurisdiction. The AASW is the only national professional body for social workers in Australia, and as there are around 6,000 AASW members, we can infer that around 13,300 social workers are not covered by the AASW practice standards and ethical complaints services. However each of these 13,300 was a graduate of an AASW accredited social work degree, and so has at the outset of their professional career demonstrated that they met required standards of skills, knowledge and values for professional social work practice (or been assessed as equivalent from an overseas social work qualification). The AASW is unable to offer any similar assurance about people other than social workers employed as counsellors, therapists and other relevant job titles, neither are we able to give any assurances about people offering private counselling or therapy services except when the person is eligible, and chooses to be, a member of the AASW. There are however a number of issues that mean that a headline figure of 19,300 in 2008 is unreliable. These are to do with: 1. Definition of a social worker The AASW is the organisation that sets national standards for social workers, their qualifying degrees and practice standards. However as social work does not enjoy protection of title, anyone is free to call Australian Association of Social Workers Page 2

themselves a social worker, regardless of their qualification, skills, values or roles. The AASW urges Governments to introduce protection of title for social work for allow the community to be better informed about the services and standards they can expect from qualified social workers. 2. Data collection There are a number of difficulties in developing a definitive overview of the Australian social work and human services workforce including: o the variety of data sources and collection methodologies; o the lack of consistency in different data sets use of occupational definitions particularly with variations in the use of terms such as social work, human services and community and welfare work. 3. A lack of political will to indentify social workers Social Work has been excluded from a number of important processes which would enable Governments to know the answer to this question. For example, the 2008 Department of Health and Ageing study 2 of the allied health workforce in rural and regional Australia did not count social workers. The AASW would welcome a discussion with Governments on how to discover the number of social workers in Australia. Section 4 THE PROBLEM Risks What do you think are the risks associated with the provision of health services by unregistered health practitioners? Lack of Government engagement to ensure quality and safety has meant that the public is at risk for sub-standard and mal-practice social workers, counsellors and therapists. Examples of the harm caused include the 1988-90 Royal Commission (The Chelmsford Inquiry) into Deep Sleep Therapy; the 1997 Wood Commission in NSW; various coronial inquests across Australia into the death of a child or children; the 2008 Special Commission of Inquiry into Child Protection Services in New South Wales; the 2010 Northern Territory Board of Inquiry into the Northern Territory s Child Protection System. Clients who are referred to public health or human services social workers are often vulnerable. Indeed, this is often the factor that has prompted the referral in the first place. Patients in public health settings are referred to see social workers when they need extra assistance above and beyond what is normally expected with their health condition or operation. The social worker may be employed by the health organisation, employed by an external organisation used for referrals (such as a non- Government organisation providing support for families), or self-employed. The risks to the patient are therefore can be transferred to an external organisation or individual. Examples include a new mother dealing with a disability to her child, an elderly person being discharged from hospital to an aged care setting, a patient experiencing mental health issues being referred to a social worker for community health support services, or a nurse or other professional becoming concerned about drug or alcohol issues are asking the social worker to assess the patient and provide a referral to a specialist agency. Patients in this situation, by virtue of the issue that has prompted the intervention of the social worker, are therefore less likely than the rest of the population to be able to judge clearly what constitutes malpractice and substandard professional practice when it is experienced, and required enhanced protection for Government. Poor practice standards, and malpractice can not only leave clients financially, physically or mentally worse off, but it can exacerbate the problem that has caused them to seek assistance. The risk is Australian Association of Social Workers Page 3

therefore that the issue that has caused the vulnerability can worsen, which can result in suicide and harm to others. In private settings, where social workers are not necessarily subject to normal organisational standards of supervision, good management practices and regular contact with other professionals, the risk is increased. Lack of clarity of professional title means that the public is unaware of the qualifications required or expertise that may exist in the range of professionals who see clients with significant mental health, personal and relationship problems. A 2011 AASW survey 3 revealed that over 60% of respondents assume that a counsellor or therapist has at least a Bachelor s degree in a relevant discipline, while in face no qualification is required. To what extent have the risks associated with these activities been realised in practice? There are plenty of cases where these risks have resulted in death, suicide and self-harm, as well as significant financial losses to the clients / patient, emotional distress, exacerbated mental health issues or increased stress in family relations. Recent examples include a social worker, known to the Health Services Commission in Victoria, who is engaged in a sexual relationship with a client, a disabled 17 year old girl, the examples used in the 2010 ABC 4 Corners program Over the Edge which aired in April 2010. 4 Lack of regulation and legally enforceable practice standards, professional ethics, and safeguards means these harmful occurrences can go unnoticed and unreported. Nationally and internationally unregistered and unregulated social workers have been found to have seriously harmed hospital and community based children, mature adults and the aged and infirm. High profile cases in the UK and New Zealand (for example) resulted in social work becoming a registered profession, thereby reducing the risk and incidence of dangerous practice and/or malpractice, making practitioners accountable and ensuring continuous professional development. Do you know of instances of actual harm or injury? There are many examples but two high profile one are as follows. 1. For 20 years a NSW social worker used his professional role and position of trust as a lure for young victims. During this time a number of allegations of improper sexual contact with children were made, but were never properly investigated. When the social worker was confronted with the complaints he would resign from his position and begin work as a social worker with a new employer. During this time, his employers included the Department of Child Welfare as well as various hospitals and schools. His crimes against children were not addressed until they were publicly broached during the Royal Commission into the NSW Police Force. Wood Royal Commission into the NSW Police Force 1997 2. A 24-year old woman experiencing alcohol addiction and the impacts of childhood incest sought the services of a social worker who worked in a sexual assault unit of a public hospital. It is alleged that the social worker began to describe her client as special, sessions increased to twice weekly, contact began outside of sessions, and then sexual contact began during and outside of sessions. Australian Association of Social Workers Page 4

The client eventually disclosed this to the unit manager. The unit manager informed the social worker of the complaint. After that discussion the manager allegedly told the client that they had got confused. The client lodged a complaint with the health department complaints unit and the AASW. The health department undertook a full investigation including obtaining case file notes and witness interviews. As a result the social worker is no longer eligible for employment in the public health sector. But he is still free to practice as a social worker elsewhere as neither the health department nor the AASW has the power to prevent him from doing so. 5 What evidence is available on the nature, frequency and severity of risks? Without professional regulation and protection of title there is no real mechanism to accurately monitor or record this. Internationally there is research that evidences that the nature, frequency and severity of risk is at level sufficient to cause serious concern to the professions, governments and the public. Due to the lack of reliable data about social workers, particularly those who choose not to join their professional association. What factors increase or reduce the risk that individuals will suffer harm as a result of the activities of unregistered health practitioners? Increase of risk: workload, lack of ongoing training and professional supervision, lack of accountability, non-ownership of title, lack of legal structure, lack of remedial processes. Reduction of risk: manageable workloads, professionally organised and developmental training, high quality professional supervision, ownership of title, sound and workable legal frameworks, professional conduct processes that have authority. Section 5 THE OBJECTIVES OF GOVERNMENT ACTION What do you think should be the objectives of government action in this area? Harm is best avoided by acting prior to it occurring, and thus the objective of Government action should be to ensure quality in the health professions, as well as proving a mechanism to remove from practice those who breach certain standards. The extent of harm can vary, and is unpredictable. The factors that lead to high quality in the health professions are known to Governments, as they exist in the registration and accreditation board that supervise the health professions, and other sectors where Governments intervene. These factors include: Accreditation standards to ensure that only high quality professionals enter the labour market; Continuing professional education programs that all regulated professionals are required to take on a regular basis; Regulations regarding recency of practice and diminished intellectual or physical capacity to practice; A program of assistance to professionals who require support to perform better in their professional duties; The authority to remove non-performing or unethical practitioners from the workforce. A negative licensing scheme on its own without any of the measures above will not protect the public from harm until after a high level of harm has occurred at least once, and will then rely upon the client to take action before the rogue practitioner can be removed. Negative licensing does nothing to ensure quality services are delivered in the first place, and that is the best way to ensure that the chances of harm occurring are minimised. Secondly, Governments have the responsibility to ensure the community is equipped to identify the skills, qualification and expertise that a range of professionals working in the helping field offer. The Australian Association of Social Workers Page 5

Australian public wrongly assumes that all counsellors, therapists and people who describe themselves as social workers have high qualifications. A recent Roy Morgan poll commissioned by the AASW showed that 63% of those who responded assume that counsellors, therapists, psycho-therapists and social workers all have a Bachelor degree 6. In fact, no qualification is required to establish a private practice and offer counselling and other therapeutic services, as a social worker, in Australia. While the AASW accredited courses are all a four year university degree (or equivalent) the absence of protection of title means the community is not able to be certain what qualifications or standards someone who identifies as a social worker actually has. Social work needs; ownership of title, regulation and accountability through national registration, requirements for continuous professional development of members, standards of tertiary education of next generation workers that meet community needs, and tertiary entry requirements that ensure individuals enrolled in courses are deemed safe to practice. Section 6 THE OPTIONS Do you think there is a case for further regulatory action by governments in this area? Yes. What do you think of the various options? Option 1: No change Not an option. There is a problem that causes significant harm, particularly to vulnerable Australians, and it is Governments responsibility to address it Option 2: A voluntary code of practice for unregistered health practitioners In essence many health practitioners are already bound by the codes of their profession (but only if they re members of the relevant professional association). Thus, this option would have no real impact on the current situation for members of the AASW. However there are steps that Governments could take that fall short of national registration and exceed a voluntary code of practice and it is disappointing that these options have not been better canvassed in the discussion paper. For example, Governments could: o work with professional associations to implement accreditation standards for entry to a profession. o work with professional associations to require Government employees to be members of a relevant professional association o develop industry-wide standards for professional development to ensure practitioners stay up to date o support professional associations complaints management systems and processes that provide a recourse for clients and their families in the event of poor or negligent practice All of these measures would provide greater quality of services, and assist in reducing the number and severity of cases that require a stronger intervention. The AASW calls on Governments to consider these options, their effectiveness and their costs, more fully, before deciding on measures for regulation of unregistered health professions. Option 3: A national statutory code of conduct for unregistered health practitioners The best of the 3 options presented, but would only address the most serious end of the spectrum of poor and negligent practice. It would not address the vast majority of what most professions, including the AASW, already do. Australian Association of Social Workers Page 6

On balance, do you have a preferred option? What are your reasons? Only regulation (either statutory or self-regulation with Government support) will ensure the safeguards being sought. The AASW could support option 3 (Negative Licensing) if, and only if, it is accompanied by an increased engagement by Governments in the regulation of professionals providing counselling and therapeutic services. Governments should consider the current self-regulation elements of this performed by the AASW and consider entry accreditation standards, continuing professional development standards, complaints management and ethics consultation services for professionals working in this area. What do you think are the costs and benefits of the three options? There would be a bureaucratic (financial) cost for some benefit for the worst cases of poor practice, negligent practice and malpractice if option 3 is selected. If you are a practitioner, can you advise of what additional costs you think you would incur with the introduction of a statutory code? Are there are some aspects of a statutory code that are likely to be more costly than others. AASW members strongly support national registration and protection of title for social workers. In a membership survey in 2009 7, 89% of members said they supported registration (3% opposed it). The survey had a response rate of over 27%. AASW members are willing to pay any additional personal costs associated with providing the public with greater safety. AASW members already pay their membership fees, which in many ways already provides the public with a degree of safety and recourse against poor practice (but only for social workers who elect to join the AASW). Governments should consider why they expect AASW members to provide this guarantee to the community with no oversight from Government or agencies. AASW members fees page for: a national ethics complaints management service providing clients and their families with accessible, affordable client-focussed recourse against members; a world class national Code of Ethics; The development of national social work education and accreditation standards; A national continuing professional development program; The development of the Australian College of Social Work (launching in July 2011) to demonstrate the highest standards in professional practice; Accreditation to provide clinical mental health services through Federal programs including Better Access to Mental Health services. In addition, the 27 accredited schools of social work 8 at Australian Universities pay for a regular review of their qualifying and higher qualifications on Social Work. Extent to which national uniformity is desirable (section 6.3.1) Do you think there should be a nationally uniform code of conduct for unregistered health practitioners or are different codes in each State and Territory acceptable? A national code. Should there be nationally uniform or nationally consistent arrangements for investigating breaches of the code and issuing of prohibition orders, or should States and Territories each implement their own arrangements? Nationally uniform. Australian Association of Social Workers Page 7

Should there be a centralised administrative body that administers the regulatory scheme, or should it be administered by each State and Territory government? The AASW expresses no view on this matter. Scope of scheme (section 6.3.2) If a statutory code of conduct were to be enacted, to whom should it apply? To everyone who provides a health service. Which practitioners, professions or occupations should be included? All health practitioners in the widest interpretation, including allied health, child protection, mental health and aged care (social workers, occupational therapist, etc, as well as those already registered). The AASW notes with disappointment that social workers are not named in the list of included practitioners and urges Governments to include social workers. Social workers are the largest allied health workforce in public health (in Queensland Health, for example, there are currently 746 full-time equivalent social workers. In comparison, there are 718 physiotherapists, 667 occupational therapists, 414 psychologists and 11 neuropsychologists in full-time equivalent figures. In NSW Health, more social workers are employed than any other allied health profession 9. The omission of social workers from explicit coverage of the proposals should be rectified. Should it apply only to practitioners who deliver health services? If so, what should be the definition of a health service? Health is usually applied to medical situations, however there are a range of services that impact on an individual s, family s or community s wellbeing. So for example child safety, aged care and accommodation would all be considered health services under this definition. Health service should be defined more broadly than proposed. Following the Ottowa Convention, most international jurisdictions agree that health services offer individuals and communities the resources to stay healthy and achieve wellbeing. These services include (for example), family counselling services, child welfare services, homelessness services, family violence services, disability services, as all of these offer a health benefit (or a health protective service) to their clients. Many of these programs are funded through State and Territory health departments and it is logical that the scheme should apply to all of the staff in these services. A narrow definition of health service will not assist the community to understand the measures available to them. As the scheme will apply in some settings but not in others employing the people with the same qualifications and offering identical services. Social workers, counsellors and therapists work in all of the above services and more. Should it apply to registered practitioners who provide health services that are unrelated to their registration, for example, a registered nurse who is working as a naturopath or massage therapist? Yes Should it only apply to practitioners who directly deliver services, or should it also apply to those who deliver health services through the agency of another person, for example, the owners or operators of businesses that provide health services? No would require separate arrangements. Agencies could be required to complete an agency registration requirement, to ensure they are capable of delivering the service they are funded to do, but that is a separate matter. Australian Association of Social Workers Page 8

Administrative arrangements (section 6.3.3) Do you have a preferred option for the legislative and administrative arrangements through which a code of conduct for unregistered health practitioners is administered and complaints about breaches of the code are investigated and prosecuted? Option 3B What are your reasons? Uniformity, consistency and transparency. Content of a national code of conduct (section 6.3.4) What do you think should be included in a national statutory code of conduct? As with the NSW Code of Conduct. Do you have any comments on the NSW Code of Conduct for Unregistered Health Practitioners? The AASW would be interested to know the extent to which the NSW community is aware of the Code of Conduct. The AASW views the code of conduct as a very poor substitute for Governments taking action on entry accreditation standards, practice standards, a clear scope of practice and protection of title. What do you think are the strengths and weaknesses of the NSW Code? The Code can only be enforced in the breach. It does not offer insight into good practice, and so is not intended as a guide to assist the vast majority of health professionals trying to work to high professional standards. It only comes into effect for those operating at a very low standard. It demonstrates that the NSW Government has taken an overly narrow view of protecting the public from harm, and has not engaged in how to deliver high quality services to the public. The Code of Conduct is overly focussed on safety and the expense of quality. While Governments are rightly concerned to protect clients from poor and bad practice, they also need to ensure that all professionals providing a health service do so to high standards. Protection of title, accreditation and professional development standards, scope of practice documentation and a Code of Ethics are vital elements to quality services. Do you think it provides a good model? What are your reasons? It provides an adequate model to deal with safety but only once a breach has occurred. It does not ensure that a practitioner with a determination to break the code of conduct will be unable to do so. Unless Governments intervene to set accreditation standards, particularly for practitioners in private practice, clients will continue to be harmed. Prosecutions and hearings (section 6.3.5) Do you have a preferred option for the mechanism through which prohibition orders should be issued, that is, via an administrative order decided by a Commissioner, or via a tribunal or court hearing? We don t take a view on this matter What are your reasons? Consistent with natural justice and procedural fairness and The Administrative Review Council (ARC) Best Practice guidelines Australian Association of Social Workers Page 9

Grounds for issuing a prohibition order (section 6.3.6) What relevant offences (if any) should provide grounds for a prohibition order to be issued? Serious offences which place the client at a significant and immediate risk for example sexual conduct or extortion The evidence we have from the AASW ethics complaints management service is that the vast majority of AASW members are keen to perform their professional duties to a high standard, but from time to time need assistance to achieve this. Only a small number provide negligent or deliberately bad practice. The scheme will make little difference to the vast majority of social workers and their clients. What other grounds should apply before a prohibition order may be issued? Financing of scheme (section 6.3.7) How do you think a regulatory scheme to investigate and prosecute breaches of a national statutory code of conduct for unregistered health practitioners should be funded? By the Commonwealth. What are your reasons? Regulation of professions that deal with vulnerable and disadvantaged people is critically important, primarily as a protection mechanism. Thus, the Commonwealth should see this as a duty not an option. Any other comments Do you have any other comments to make about these proposals? The AASW is disappointed that the supporting documents provide no detail of the current self-regulation programs carried out by a number of professions including Social Work, and would welcome the opportunity to provide detail on these to Governments to assist in their decision making. It is disrespectful, and displays a lack of prior engagement with the profession, for Government to use the terms unregistered practitioners in relation to social workers. AASW members have told me they find the terms offensive. There is no reason for the Government to view only those professions registered as professions, and there are a range of self-regulation measures in place, as described in this document. These terms, if used in a public domain, would create uncertainty and lack of trust in the community about the skills and purpose of social work professional practice. Australian Association of Social Workers Page 10

CONTACT DETAILS: Name: AASW CEO, Kandie Allen-Kelly Address: PO Box 4956, Kingston, ACT 2604 Email: ceo@aasw.asn.au Are you a: Professional association Would you like to be informed of the outcome of the consultation? Yes Thank you for taking the time to make a submission. Endnotes: 1 DEEWR (2008) Quarterly Labour Force Survey estimates, Canberra 2 Department of Health and Ageing (2008), Report on the Audit of Health Workforce in Rural and Regional Australia, April 2008. Commonwealth of Australia, Canberra. See http://www.health.gov.au/internet/main/publishing.nsf/content/work-res-ruraud 3 Roy Morgan Catibus Survey, conducted March 22-242011, commissioned by the AASW, forthcoming publication 4 ABC TV 4 Corners website reference http://www.abc.net.au/4corners/content/2010/s2862588.htm Program aired 5 April 2010. 5 C. Boeckenhauer, L. Michael, N. Ormerod, A. Wansbrough, eds., (1998), Violating Trust Professional Sexual Abuse, Wild & Woolley Pty Ltd. 6 AASW commissioned Roy Morgan Catibus Survey, conducted March 22-242011, forthcoming publication 7 AASW (2009) National Bulletin, Volume 19, No 2 (Winter) Page 15, available at http://www.aasw.asn.au/document/item/712 8 For the list of accredited schools see http://www.aasw.asn.au/whatwedo/social-work-education 9 Figures are from emails from Department of Health officials or from public documents. Australian Association of Social Workers Page 11