English Language Skills Registration Standards — Australian and Global Comparative Assessment

—Executive Summary

Lesleyanne Hawthorne — Professor: International Health Workforce Anna To — Research Fellow

2013

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ACKNOWLEDGEMENTS    First, we would  like  to  express  our  sincere  appreciation  to  the  61  key  informants  from  seven countries interviewed to inform this study. Derived from Australia, Canada, Ireland, New Zealand, Singapore,  the United Kingdom, and  the United  States of America,  the majority were Chairs or Registrars of the regulators  involved, with an exceptional  level of relevant expertise at senior as well as operational  levels. By agreement, organisations rather than  individual key  informants are named in this report (with specific titles only provided when requested). Of the 37 regulatory body interviews  conducted,  10 were  in medicine,  10  in  nursing,  7  in  pharmacy,  6  in  dentistry,  2  in physiotherapy, and a further 2 with broader assessment bodies (the Health Professionals Council in the UK and World Education Services in Canada). In terms of source countries 9 interviews were conducted  with  regulators  in  Australia,  8  in  Canada  (including  several  provinces),  5  in  New Zealand, 5  in  the UK, 4  in  Ireland, 3  in Singapore and 3  in  the USA. A  further 5  interviews were conducted with  language testing experts (Australia), 4 with senior academics (Australia and New Zealand  in the fields of medicine and nursing), and 3 with government policymakers (in Canada). These  telephone  interviews  lasted 0.75  to 1.5 hours. All were  transcribed  for  thematic analysis, followed by  return  to key  informants  for  review. Their views have  informed  this  study at every level. Regrettably, given space constraints, only a range of interview excerpts could be provided to illustrate key issues throughout the Full Report.  Second, we gratefully acknowledge the provision of the complete Occupational English Test (OET) database for our analysis by the test administrator, the Centre of Adult Education (Victoria). We note it is rare to secure access for independent analysis of test results on a de‐identified basis. As advised by the  language testing experts  interviewed,  independent researcher access to  language testing databases is typically highly restricted. Our analysis of the OET has permitted definition of the impact of a range of English language testing requirements on the candidate base, and hence is relevant to the AHPRA review process.  Third, we sought email advice concerning select language testing and instrument related issues, in particular from the administrators of the IELTS, OET and TOEFL tests. The clarification provided on select points was very helpful, supported by a  range of  forwarded materials. We also benefited from direct advice elicited  from  the Cambridge, MELAB  (Michigan English Language Assessment Battery), Pearson and CanTEST administrators.  Fourth,  we  would  like  to  express  our  sincere  appreciation  to  John  Pill,  an  academic  with longstanding  global  expertise  in  language  testing,  from  both  operational  and  research perspectives.  (This  experience  previously  included  administration  of  the  OET.)  With  AHPRA’s agreement  John  read  the Draft  versions  of  the  Full  and  Executive  Summary  ELSRS  Reports,  to provide external academic review of the literature analysis. His comments were very helpful, with additional references incorporated here.   Fifth, we received excellent support from our two research assistants, Ms Lorraine Devitt and Ms Claudia Sandoval of  the Australian Health Workforce  Institute. Lorraine meticulously  transcribed the  50  telephone  interviews, while  Claudia  accessed  the  extensive  literature  required  for  our review,  assisting  also  with  the  global  ELSRS  web  audit  we  conducted  in  relation  to  eight 

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comparator  countries  (Australia,  Canada,  Ireland,  New  Zealand,  Singapore,  South  Africa,  the United Kingdom, and the United States of America) and the key English  language tests currently used. (Please see Attachments 1 and 2 for detail, noting these were finalised late 2012.)  Last but not  least,  it has been a continuing pleasure to work under the supervision of Ms Helen Townley  and Mr  Chris  Robertson  (on  behalf  of  the  Australian  Health  Practitioner  Regulation Agency [AHPRA]) throughout this project. Significant time was required to arrange interviews and secure written feedback, given the stature of the key  informants  involved. Helen and Chris were gracious  throughout  the study and of  invaluable assistance. They  facilitated  the arrangement of interviews  with  National  Board  Chairs  and  Executive  Officers;  chaired  a  very  useful  AHPRA Workshop  in November 2012  (allowing us to secure direct  input  from the National Boards); and arranged our preliminary findings session at the NRAS Conference in Melbourne earlier this year, which elicited valuable feedback.   With  our  sincere  thanks  to  everyone  who  contributed  to  this  project,  including  the  National Boards for their review comment following consideration of the Draft Report (December 2012 to February 2013) and our global key informants.     Lesleyanne Hawthorne and Anna To Australian Health Workforce Institute Faculty of Medicine, Dentistry and Health Sciences University of Melbourne   

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EXECUTIVE SUMMARY   1.   English Language Testing – Context and Major Instruments  Language  testing  is  used  for  a  wide  variety  of  purposes,  with  profound  political,  social  and economic impacts. Current applications include the determination of refugee status, eligibility for citizenship, control of international student entry and placement, selection of skilled migrants, and access  to  professional  registration.  Within  this  context  English  testing  has  become  a  highly lucrative global business, with market share tenaciously sought.   The global mobility of international students has driven instrument development since the 1950s, given the need to determine capacity to study in English. The Test of English as a Foreign Language (TOEFL) and the International English Language Testing System (IELTS) have predominated to date: 

TOEFL: A pen and paper grammar‐based  test developed  in  the USA  in  the 1960s, with a range of variants emerging  since  (most notably  the  introduction of a  speaking  test with the  development  of  an  internet‐based  TOEFL‐iBT  version).  By  2009  the  TOEFL  was recognised  by  more  than  6,000  institutions  in  over  130  countries,  in  particular  the Americas and parts of Asia.  

IELTS: A performance‐based test developed by the UK Cambridge consortium  in the  late 1980s,  supported  by  Australian  trialling  and  input.  By  2009  IELTS  had  one  million candidates  per  year, with  the  test  available  in  120  countries  across  500  locations.  The Cambridge English as a Second Language Tests (including IELTS) annually report over three million candidates, taking tests in 2,500 centres across 130 countries1.  

TOEFL  and  IELTS’ near monopoly  status  is  currently being  contested by  the  emergence of new English tests such as the Pearson Test of English Academic (PTE): 

Pearson: Developed by the global publishing group, the PTE has recently been approved by  the Australian  and UK  governments  for  student  visa  purposes.  It  has  secured  rapid global recognition, including by 200 Australian institutions to date, claiming a high level of reliability.   

2.   English Language Testing of Skilled Migrants ‐ Australia  English testing became a primary Australian strategy to select skilled migrants three decades back.  A series of reports in the 1980s demonstrated poor English language to triple the unemployment risk  for males, while doubling  it  for  females.  In 1990 the Chair of the Australian Medical Council stated  ‘… all English speaking developed countries  take  the view  that  foreign medical graduates who  choose  to  emigrate must  demonstrate  in  objective  testing  a  good  deal  of  proficiency  in English  as well  as  the  level  of  professional  competence  expected  of  graduates  of  their  chosen country’.2 Similar views were held  in other fields, such as engineering. Within this context,  in the late  1980s  the  performance‐based  Occupational  English  Test  (OET)  was  developed  to  assess migrant health professionals’ English at the start of the registration process.  

OET:  Administered  by  the  Council  of  Education  (Victoria)  to  2012,  the  OET  examines candidates' speaking,  listening,  reading and writing skills  in  linguistic contexts simulating future  professional  practice  in  12  fields  (dentistry,  dietetics,  medicine,  nursing, occupational therapy, optometry, pharmacy, physiotherapy, podiatry, radiography, speech 

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pathology and veterinary science). From 2005 to 2011 the OET assessed 28,924 candidates in 40 global locations, with the test available up to 10 times per year3. 

 In  1993  Australia mandated  English  language  testing  for  skilled migrants  in  112  ‘occupations requiring English’  (including all health  fields). Since 2007  IELTS Band 6 has been required  (raised from Band 5), or Grade B on the OET. Higher levels are set by the Department of Immigration and Citizenship  (DIAC) where  regulatory bodies  require  these.14 By  July 2012 English  language ability had  become  Australia’s  key  criterion  for  skilled migrant  selection  (with  applicants  required  to prove they possess ‘vocational’ English), alongside qualification level and employer sponsorship.   To  provide  the  National  Boards  and  AHPRA  with  advice  concerning  English  language  skills registration standards (ELSRS), the current project undertook: 

A  global  web  search  to  define  the  tests  used  and  regulatory  body  registration requirements  in  eight  jurisdictions  (Australia,  Canada,  Ireland,  New  Zealand, Singapore,  South  Africa,  the  United  Kingdom,  and  the  United  States).  (See Attachments 1 and 2.) 

Completion  of  50  extended  interviews  (or  equivalent)  to  assess  ELSRS  practice  and issues from the perspective of the heads/ registrars/ managers of regulatory bodies in seven  of  these  jurisdictions  (excluding  South  Africa),  in  addition  to  government policymakers and language testing experts (61 key informants in all)2. 

An  extensive  literature  review  to  assess  the  evidence  base  in  relation  to  current Australian ELSRS requirements in health fields. 

Analysis of  the OET database  from 2005  to 2011  (28,924  candidates)  to define  the recent impact of English language testing in Australia by key variables 3.  

 

1 As affirmed by the Department of  Immigration and Citizenship  (DIAC),  ‘Where the nominated occupation requires a higher  level of English  (equivalent to  IELTS  test score of more than 5  in each of the  four test components) because  it forms part of that occupation’s registration, licensing or membership requirement, the visa applicant must have at least the standard of English language proficiency required for the grant of that registration,  licence or membership.’ (DIAC, 2010,  ‘Employer  Sponsored Workers –  September 2009 Changes  to  the  English  Language Proficiency Requirements’, http://www.immi.gov.au/skilled/skilled‐workers/changes‐eng‐req.htm, accessed 16 August 2012). 

2 In  consultation with  AHPRA  the  primary  interview  focus was  placed  on  regulatory  body    perspectives. Of  the  37 regulatory  body  interviews  conducted,  10  were  in  medicine,  10  in  nursing,  7  in  pharmacy,  6  in  dentistry,  2  in physiotherapy, and a further 2 with broader assessment bodies (the Health Professionals Council  in the UK and World Education Services in Canada). In terms of source countries 9 interviews were conducted with regulators in Australia, 8 in Canada  (including several provinces), 5  in New Zealand, 5  in  the UK, 4  in  Ireland, 3  in Singapore and 3  in  the USA. Despite several months of attempts, interviews could not be arranged with key informants in South Africa. A further 5 interviews  were  conducted  with  language  testing  experts  (Australia),  4  with  senior  academics  (Australia  and  New Zealand in medicine and nursing), and 3 with government policymakers (Canada). Interviews typically lasted 0.75 to 1.5 hours.  All were  transcribed  for  thematic  analysis,  followed  by  return  to  key  informants  for  review.  (See  ELSRS  Full Report.) In three cases regulatory bodies chose to provide written input rather than interviews, and in two cases there were second interviews (given the level of data involved). 50 interviews were thus conducted in all.    3 We gratefully acknowledge the provision of the complete OET database by the Centre of Adult Education, noting it is rare to secure access for independent analysis of test results on a de‐identified basis. As advised by the language testing experts interviewed, independent research access to the IELTS database is typically highly restricted. 

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3.   English Language Standards for Registration  In recent decades the  IELTS and TOEFL tests have been the main  instruments used to determine migrants’ eligibility for registration across multiple fields and  jurisdictions. By 2012 48 Australian regulatory bodies had mandated IELTS standards (compared to the dominance of TOEFL in select parts  of  Asia  and  North  America).  Highly  diverse  requirements  have  been  set,  with  modest scientific evidence to date to inform these decisions. For example 73 IELTS Research Reports have been published by  the Cambridge  consortium  in  the past  two decades.  Just  four have assessed standards for professional regulation purposes, typically on an audit rather than a validation basis. According to the author of two such reports, ‘IELTS was originally intended and designed as a set of  international benchmarks  to assess an  individual’s proficiency  for academic  study  in English‐speaking  contexts…  The  growing  trend  for  IELTS  to  be  adopted  by  users  outside  of  academic, including governments, professional associations and employers, may constitute a risk for the test owners if the assessment system cannot be validated for the purposes for which it is being used.’5  

 The current standards specified by Australian regulatory bodies vary widely, as follows:  

Law: IELTS Band 8 (writing), 7.5 (speaking) and 7 (reading and listening)  

Teaching: IELTS Band 7.5 required across all 4 English sub‐tests (or equivalent) 

Medicine  and  allied  health  professions:  IELTS  Band  7  (7.5  in  pharmacy)  or Occupational English Test (OET) B  

Engineering:  IELTS Band 6  (with additional  inputs  considered,  for example  candidate interview performance) 

Architecture: Interview required 

Accounting: No stated requirement  In terms of medicine and allied health, global regulatory bodies have adopted markedly different requirements in terms of testing. This represents a dynamic policy space. As demonstrated by the web audit and 50 interviews, regulators may specify: 

Few or multiple tests ‐ Australia allowing two (the IELTS and the OET), Singapore four, and Canada eight (with additional French tests accepted). 

Different  scores – Ranging  in  IELTS  from Band 6 on  some  skills  to Band 7.5 overall (with Band  7  the  norm);  in  TOEFL  iBT  (the  internet  version)  from  74  to  95;  and  in TOEFL  PBT  (the  print  version)  from  537  to  600,  with  few  field‐specific  studies undertaken to support specification. 

Highly  variable  scores  by  select  field  –  In  IELTS  ranging  from  a  ‘one  size  fits  all’ approach  as  in  Australia  (IELTS  Band  7  [with  pharmacy  7.5])  or  OET  Grade  B,  to substantial  variability  by  field  (pharmacy  typically  mandating  the  highest  scores globally compared to lower scores in some countries for nursing). 

Different  test  exemptions  –  Ranging  from  nil;  to  native  or  near‐native  English speakers from defined source countries; to international students qualified in the host country; to international students qualified in the host country having also completed secondary education in the medium of English. (For detail see web‐based ELSRS audit.)  

Different  test  types – Ranging  from generic  tests  (such as  the  IELTS, TOEFL and  the Michigan  English  Language  Assessment  Battery);  to  field‐specific  tests  (such  as  the OET  and  the Canadian  Language Benchmarks Assessment  for Nurses  in Canada);  to embedded  assessment  (such  as  in  the  USMLE  Clinical  Skills  test  based  on 

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communication with standardised patients); to  interviews rather than tests (in select fields, such as nursing in Singapore). 

Different pass timeframes – Ranging from the requirement to pass all four sub‐tests at a single compared to multiple sittings. 

Different  lengths  of  result  currency  – With  regulators  specifying  from  six months (nursing in British Columbia) to two years before a fresh test is required.  

4.   Competing Values in Relation to ELSRS Standards  Despite  this  policy  variability, without  exception,  the  37  regulators  interviewed  affirmed  their prime  responsibility  to  be  the  protection  of  public  safety  and  the  maintenance  of  stringent regulation  standards. This was  strongly affirmed by  the global  regulators  interviewed, across all fields.  In Australia  the Health Practitioner Regulation National Law as  in  force  in each state and territory  (‘the National  Law’)  requires  each National  Board  to  develop  and  recommend  to  the Ministerial Council requirements about  the English  language skills necessary  for an applicant  for registration  in  the profession  to be  suitable  for  registration  in  the profession. A National Board may decide an individual is not a suitable person to hold practising categories of registration in the profession  if,  in  the  Board’s  opinion,  the  individual’s  competency  in  speaking  or  otherwise communicating in English is not sufficient for the individual to practise the profession.    Further,  the  objectives  of  the  National  Law  require  National  Boards  to  consider  a  number  of factors  when  they  recommend  an  English  language  skills  registration  standard  to  Ministerial Council. These include:  

(a) to  provide  for  the  protection  of  the  public  by  ensuring  that  only  health  practitioners  who  are suitably trained and qualified to practise in a competent and ethical manner are registered; and 

(b) to  facilitate workforce mobility across Australia by  reducing  the administrative burden  for health practitioners wishing  to move between participating  jurisdictions or  to practise  in more  than one participating jurisdiction; and 

(c) to facilitate the provision of high quality education and training of health practitioners; and (d) to facilitate the rigorous and responsive assessment of overseas‐trained health practitioners; and (e) to  facilitate  access  to  services  provided  by  health  practitioners  in  accordance  with  the  public 

interest; and  (f) to enable  the continuous development of a  flexible,  responsive and  sustainable Australian health 

workforce and to enable innovation in the education of, and service delivery by, health practitioners. 

In addition to this mandate, as affirmed by the 37 regulatory body interviews, ELSRS standards are inevitably shaped by the broader policy agendas and values of the national contexts in which they are embedded. Examples include the following: 

In Canada  the recent Pan‐Canadian agreement on  internal  trade  (2009), and  the  federal foreign  credential  recognition  initiative  are  now  forcing  development  of  common assessment  standards  across  the  13  provinces  and  territories,  despite  significant regulatory body concerns. Advocacy for more  liberal recognition of foreign credentials  is also being  spurred by  the establishment of  rights‐based Fairness Commissioners  in  four provinces, focused on immigrants.  

In  the  UK  and  Ireland  the  multilateral  European  Union  Directive  has  freed  EU‐EEA nationals from the requirement to be assessed, in contrast to mandatory English language testing  for  ‘third  country  nationals’  ‐  the  latter  typically  derived  from  Commonwealth countries,  and/or  native  English  speakers.  Given  this,  credential  and  English  language 

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assessment are de facto outsourced to employers ‐ a matter of significant concern to the regulatory bodies. The EU Directive was under  review at  the  time of writing. There was also  a major  review  of  the  Professional  and  Linguistics Assessment Board  (PLAB)  being undertaken by the General Medical Council in 2012.  

The US, confronting mass registration applications, in the 1990s devised the solution of a ‘single  pathway,  with  the  same  (national)  exams  and  same  standards’  for  local  and international medical graduates. The USMLE includes an embedded medical English exam (replacing  the  TOEFL  since 2004),  followed by  interview‐filtered  selection  to  supervised residency places (compared to the use of stand‐alone English tests and national exams in other health fields). The National Council of State Boards of Nursing in the past decade has undertaken a range of benchmarking and standard‐setting review processes. 

In New Zealand public safety standards must be upheld in the context of the highest rate of  reliance  on  international  medical  and  allied  health  professionals  in  the  OECD, exacerbated by exceptional rates of out‐migration within a three year period.  

In Singapore similar pressures exist, in a society where fertility rates have fallen to 1.1 (the world’s  third  lowest), and  the  recruitment/  retention of  IHPs has emerged as a national priority.  

 Within  this  complex  policy  environment,  specification  of  English  language  skills  registration standards can also be influenced by a range of competing values, ranging from: 

Protection of public safety – core  to regulatory bodies’ mission, and  the prime value  to which they adhere.  

Global  competition  for  human  capital  resources  –  spurring  under‐supplied  countries/ regions  to  recruit/  retain  international  health  professionals  through  relatively  liberal registration standards. 

Efficiency – maximising the utilisation and retention of  international health professionals (particularly those who are sponsored). 

Social  justice –  reflecting  individual human  rights‐based national/  state  reform agendas designed to liberalise migrants’ access to registration (in cases such as Canada supported by a legislative base). 

Government  commitment  to  bilateral  or multilateral  agreements  –  designed  to  free trade  in  goods  and  services,  supported  by  mutual  foreign  credential  recognition  (for example in Europe [EU] or the Asia‐Pacific [APEC]). 

   These pressures exacerbate the challenge of defining and defending appropriate English language standards.  5.   Limits to the Research Base Supporting ELSRS Decision Making by Regulatory Bodies   Within this context medical and allied health regulators reportedly often ‘inherit’ ELSRS standards and instruments, rather than prescribe these on the basis of field‐specific scientific research. They may have access to minimal health‐specific research to support the decision‐making process.  According to a range of international key informants, operational factors can influence test choice ‐ most notably tests’ global availability (on and offshore), frequency of administration, competitive price,  speed of  results,  and  availability of preparatory  courses. Regulators  report modest  to nil knowledge as to why specific test requirements or standards exist ‐ comments including that these 

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were ‘heritage’ decisions (for example that ‘the test administrators/ experts advised this’, or ‘my predecessor might know’, or ‘it’s lost in the mists of time’). Once set, ELSRS requirements tend to be  maintained  –  with  standards  lifted  should  complaints  about  practitioners’  facility  occur. Exceptions include recent US reviews in the field of nursing, and detailed Canadian assessments of English  requirements  for  nurses,  pharmacists,  physiotherapists  and  medical  laboratory technicians.   It is worth noting that the 2012 General Medical Council review of the Professional and Linguistics Assessment  Board  examination  explicitly  excluded  the  English  language  proficiency  of international medical graduates. Rather, the review was designed to ensure4: 

… that the Professional and Linguistic Assessments Board test continues to be an effective, objective,  fair,  and  non‐discriminatory  method  to  test  whether  international  medical graduates have the knowledge and skills needed to work as doctors in the UK. This review will  ensure  that  all  our  key  interest  groups  continue  to  be  confident  in  this method  for assessment.6 

 Reviews such as this are  inevitably resource and time‐intensive. Within the PLAB, assessment of effective  communication  is  embedded  in  the  objective  structured  clinical  examination  process (candidates  being  trainee  doctors  who  have  successfully  completed  the  GMC  Foundation Programme first year).   It  is worth noting however that the review panel sought explicit  input on whether  the  PLAB  examined  ‘the  right  range  of  knowledge  and  skills  required  for  safe  and effective’ UK medical  practice  –  a  question with  the  potential  to  elicit  views  regarding  English language capacity5.    In  terms  of  Australia  the  following  ELSRS  issues  were  raised  by  the  2010‐12  House  of Representatives  Inquiry  into Overseas Trained Doctors  ([OTDs] also  relevant  to  the allied health professions)6: 

1. The  appropriacy of  the  standards  required  for professional  registration  (given  the National Law requirement to register IMGs ‘able to communicate effectively in English to a standard expected of medical practitioners practising in Australia’).7 

2. The  scope  of  tests  (including  the  perceived  failure  of  current  ELSRS  standards  to ensure practitioners possess the communication skills required for clinical practice). 

3. Tests’ reliability and predictive capacity. 4. The length of validity of test results. 5. The  impact of  recent administrative changes  (most notably National Boards’ 2010+ 

requirement for all four English sub‐tests to be passed at a single sitting). 6. The quality of rater training (in the context of perceived variability). 

4  Issues  to be addressed  include  the appropriacy of  the PLAB,  the  standards  set  for both parts of  the  test  (including whether these conform to best practice), the length of validity of passes, any limit to the number of attempts allowed, the PLAB’s reliability and validity in relation to differentiating between candidates, and (most importantly) ‘to examine whether international medical graduates granted full registration after passing the PLAB test are more or less likely than other cohorts of doctors to experience difficulties in medical practice in the UK’, based on a range of research sources. The PLAB was last reviewed in 2003.  5 General Medical Council (2012), ‘Call for Evidence on the Review of the Professional and Linguistic Assessments Board Test – 30 January‐30 April 2012’, General Medical Council. London, www.gmc.uk,org, p. 6.  6 Three Inquiry Recommendations (21‐23) directly address ELSRS standards and issues. 

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7. The dearth of  feedback provided  to candidates  (with a potential  to  improve  future test performance). 

8. The  impact of  ‘invisible’ English  language tests  (such as Australia’s Pre‐Employment Structured  Clinical  Interview8  which  precedes  the  clinical  placement  process,  and specialist college assessment). 9 

 The resulting Lost  in the Labyrinth report  (March 2012) affirmed  ‘that a standard  is needed as a medical  practitioner’s  ability  to  communicate  effectively  in  English  is  a  fundamental  aspect  of good  quality  and  safe medical  practice  in Australia’.10 At  the  same  time  the  specified  limits  to English  language assessment  for professional  registration were  confirmed  to  the  Inquiry by  the Chair of the Medical Board of Australia: 

… the English language test is basic competency to speak, to listen, to write and to read. It does not deal with cultural awareness, and  it does not deal with  issues about  the use of language in a medical cultural setting. That is supposed to be part of the orientation that people get  in the work setting when  they start work.  It  is supposed to orientate them  to the cultural situation, the workplace, and the particular needs of that context.11  

 

6.   The Transforming ELSRS Context – Factors Influencing Migrant Health Professional Registration Applications to AHPRA 

 It is timely to review whether these limits to ELSRS scope remain appropriate, in the context of the recent  transformation of health workforce migration  to Australia. As defined by a 2012 Scoping Report prepared by Hawthorne for Health Workforce Australia12: 

The scale of international health professional (IHP) arrivals has grown immensely in recent years (around 50,000 skilled category migrants approved every five years, with thousands  of  additional  IHPs  arriving  as  spouses  or  through  the  family  and humanitarian  categories).  A  growing  number  of  migrants  will  therefore  apply  to AHPRA onshore (unfiltered in advance for human capital attributes). 

Source  countries  have  become  exceptionally  diverse  (now  spanning  up  to  210 nations). 

Health  fields  have  changed  (with  nurse  arrivals  exceeding  those  in medicine,  plus rapid recent growth in pharmacy, physiotherapy and dentistry).13 

Temporary rather than permanent entry has become the norm (the entry mode for four‐fifths of recent international medical graduates [IMGs] in Australia). 

The majority  of  skilled  migrants  are  currently  sponsored  –  with  457  visa  health professionals  immediately commencing clinical work, typically on the basis of  limited or restricted registration. 

Within  this  context,  clinical  communication  skills  have  become  increasingly important  (despite  these  not  being  the  original  focus  of  Australian  ELSRS requirements). 

English language testing is now high stakes – by 2012 the key determinant of migrant health professionals’ selection, registration and early employment outcomes.  

 In  the  past  decade  unprecedented  numbers  of  international  students  have  also  qualified  in Australia and seek to remain. By 2010 18,487  international students were enrolled  in medical or allied health degrees,  including around 3,000 medical and 9,000 nursing students. An estimated 78%  of medical  students  to  2012  secured  PGY1  places14.  Around  eight‐ninths  of  recent  nurse 

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applicants  to  ANMAC  for  skilled  migration  assessment  have  been  from  former  international students in Australia. Universities seem likely to pressure National Boards to allow such applicants test exemptions.  

 7.   Key English Language Skills Registration Standards (ELSRS) Issues   The  following  section  summarises  key  ELSRS  project  findings,  based  on  analysis  of  the  global literature,  information  provided  by  the  61  key  informants,  and  the OET  database  analysis.  For more  detail  see  Attachment  1  (Global  Benchmarking  Eight  Country  Audit)  and  Attachment  2 (English Test Genesis and Instrument Audit), noting these were finalised late 2012. 

 7.1 The Limits to the Research Base  In  an  age  of  globalization,  the  English  ability  of  international  health  professionals  represents  a critical public safety issue. Language testing instruments are required, with high standards set. The Boards’ current use of IELTS and the OET may be entirely appropriate. At the same time the first Australian study to assess medical complaints found international graduates had 24% higher odds and a 41% higher risk of adverse findings, with IMGs at disproportionate risk qualified  in Nigeria, Egypt,  Poland,  Russia,  Pakistan,  the  Philippines,  and  India.  The  authors  noted  these  ‘“at  risk” countries…  share some similar features: English is not the primary language, and all have medical education and health systems that are quite different to Australia’s. However, this explanation  is incomplete  because  the  same  can  be  said of  several other  countries.”15’ Additional  research  is required to assess the association between ELSRS standards and field‐specific complaints in select fields, noting  that non‐native speakers of English such as Chinese or Vietnamese  IMGs were not found to be experiencing significant problems.   The  literature  to  inform English  language skills  registration standards  for health professionals  to date is in fact slight. Few health‐specific studies exist. Many are based on small sample sizes. There are major research gaps. (For example the majority of studies have focused on medicine, despite growing registration demand in allied health fields.) Test designers frankly acknowledge the limits to  their  research base,  reflecting  sparse  funding and methodological  challenges. They also note their position as ‘perpetual outsiders’  in defining English performance requirements ‐ attempting to  capture  for  the  purposes  of  test  design  authentic  speaking,  listening,  reading  and  writing requirements, while ensuring ‘item fit’ (for example through the use of Rasch analysis).16    7.2 The Merits of Generic Compared to Field‐Specific Tests  As noted, operational factors favour the use of IELTS – key attractors being its relative cheapness (a third the cost of the OET), global availability and frequency, plus access to preparatory courses and practice materials.17   This  is despite the  fact  that  IELTS was designed to assess  international students’ readiness to undertake tertiary English‐medium study.  There  has  been minimal  investigation  to  date  of  the  validity  of  using  generic  tests  to  assess candidates’ performance in health‐specific contexts. According to the Cambridge consortium, the test’s  ‘communicative  ability  is…  sensibly  moderate.  Its  delivery…  is  impressive.  It  is  well‐maintained  and  research‐led.  It  tests,  very  deliberately,  all  four  skills’.18   At  the  same  time,  as noted  in  an  IELTS  Research  Report,  ‘The  question  of  whether  the  IELTS  testing  system  is 

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appropriate  for  testing  broader  skills  such  as  those  required  for  a  professional  operating  as  a doctor, nurse, veterinary  surgeon, engineer,  teacher or accountant arises because  there  is  little research which focuses on validating the testing system for these purposes.’19 As  affirmed  by  the  61  interviews  this  is  a  volatile  policy  space.  In Canada, for  instance, consideration is increasingly being given to the design of field and country‐specific language tests. By contrast the US is satisfied with the relevance and appropriacy of its embedded USMLE Clinical Skills  English  language  test  in medicine,  while  Singapore  champions  the  value  of maintaining interview‐based assessment in the field of nursing.  7.3 Standard‐Setting for Registration  National Boards currently mandate identical English language standards for each health field, the exception being pharmacy. No  substantial  studies however have been  commissioned  to  inform this  decision  to  date,  though  advice  from  clinical  settings  and  test  administrators  is  regularly considered.  This  is  also  largely  the  case overseas – with  select Canadian  and US benchmarking exercises being exceptions. In the US, for instance, 2500+ ECFMG candidates were reviewed in 10‐11  Clinical  Skills  Assessment  encounters.  Generalizability  theory  was  used  to  assess  the consistency of spoken English ratings. A high  level of reliability was found across 10  independent evaluations. Proficiency  in spoken English was correlated with TOEFL scores and native  language status  (English  compared  to  ‘other’). The  researchers were  in a position  to  conclude  that  ‘valid measures of spoken English proficiency’ were obtained. They also found a ‘high reproducibility of the ratings over encounters and standardised patients’ in simulated medical environment.  Within this context, the ECFMG is confident of its standards and current processes7.   While current National Board standards may be appropriate, as demonstrated by analysis of the OET database from 2005‐2011 they have highly differential impacts by field. In 2011, for example, 62% of dental and 52% of medical candidates passed the OET, compared to 38% of pharmacists, 32% of physiotherapists, and 17% of nurses. Nurses fared exceedingly poorly on the OET all seven years examined, with particular impact on select countries of training (such as the Philippines and China).  According  to  one  IELTS  paper,  ‘In  2010,  the Nursing  and Midwifery  Board  of  Australia raised the English language proficiency requirement for registration as a nurse to an Overall score of 7.0 in the Academic module of the IELTS Test, with 7.0 in each of the components that comprise the  Test…  Although  little  research  has  been  conducted  into  the  relevance  of  this  score  for professional  employment,  an  IELTS  score  of  7.0  is  fast  becoming  instituted  as  the  standard  to which all NESB candidates seeking professional employment in Australia should aim.’20   Is this standard warranted? Alternatively, given the medical complaints study noted, should ELSRS standards in that field be higher? This is currently unknown.   7.4 Exemptions from English Language Testing – Native Compared to Non‐Native Speakers  Defining exemptions from English language testing is also challenging. In 2011 just 62% of UK and 74% of South African candidates passed the OET (all fields). Very substantial numbers would have been  native  speakers  of  English, with  an  estimated  third  being  non‐native  speakers migrating 

7 Boulet, J, Van Zanten, M, McKinley, D & Gary, N (2001), ‘Evaluating the Spoken English Proficiency of Graduates of Foreign Medical Schools’, Medical Education Vol 35: 767-773.

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through the UK8. This raises the issue of whether it is appropriate to exempt native speakers (NS) from taking ELSRS tests, when evidence suggests many would perform poorly.  There have reportedly been no studies to date assessing native speaker compared to non‐native speaker (NNS) performance on the OET. A range of IELTS studies have been conducted, though not in relation to health. According to one such study, many native speakers would be rated Band 5 (or Modest User) on  the  IELTS scale –  ie  ‘Has partial command of  the  language, coping with overall meaning  in most  situations,  though  is  likely  to make mistakes.  Should  be  able  to  handle  basic communication in own field.’ Research suggests the scores of native English speakers are neither homogenous nor high (this research based on TAFE‐enrolled students); that many native speakers would be ineligible to commence university studies if required to reach IELTS scores of Band 6 or above (particularly on all four sub‐tests); and that significant differences exist even between highly educated native speakers (eg barristers outperforming tertiary education lecturers)9.   These findings raise significant equity issues21. It is in part for this reason that the UK and Ireland currently allow no automatic exemptions from English language testing for native English speakers who  are  third  country  nationals  (despite  this  measure  appearing  to  defy  common  sense). Universalising English  testing however would have significant registration  impacts  in Australia.  It would make  it  a  less  attractive  destination  to  native  English  speaking  health  professionals  (for example from South Africa, Ireland or the UK).  7.5 Exemptions from English Language Testing – Former International Students  The  research  confirmed defining  test  exemptions  for  former  international  students qualified  in Australia  to  be  similarly  problematic. While  tertiary  institutions  set  entry  scores,  there  is  no certainty students’ English ability will subsequently improve. As demonstrated by the largest study to  date  (initiated  by  DIAC),  substantial  numbers  of  international  students  exit  their  Australian degrees with  IELTS  scores of Band  5 or below.22  Language  gains  of half  an  IELTS Band may be expected  when  students  study  English  full‐time  for  three  months.23  Research  demonstrates however minimal IELTS gains between entry and exit scores for students completing degrees, over enrolment periods spanning 3 to 4.5 years. While some students  improve, others get worse, and many remain stable.24 Few longitudinal studies on this issue exist. Despite such evidence, National Boards seem certain  to be  lobbied by universities  to provide  former  international students with English  language  test  exemptions.  These  are  currently  allowed  in  a  range  of  comparator jurisdictions such as Canada, Ireland, Singapore and New Zealand (noting some variations by field). Countries may also exempt students qualified wholly in the medium of English, or holding degrees from the UK, USA, Canada, Australia or New Zealand.     

8 We note that up to a third of skilled applicants to Australia from the UK may be third country nationals, based on advice to L Hawthorne in the years since 1996 from the Department of Immigration and Citizenship. South African nationals also include third country nationals, and/or non-native speakers of English (eg Afrikaans speakers). 9 McNamara, T. (1996), Measuring Second Language Performance (Longman, UK), see Chapter 7, ‘Mapping and Reporting Abilities and Skill Levels’, pp. 182-197.

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7.6   The Requirement to Pass All English Four Sub‐Tests at a Single Sitting  Based  on  the  literature  review  and  interviews,  there  is minimal  evidence  to  date  to  support Australia’s 2010+ requirement for candidates to pass all four English language sub‐tests at a single sitting – a measure  resulting  in  significant  registration delays and cost. As demonstrated by  the OET  database  analysis,  for  example,  18%  of  Filipino  candidates  passed  all  4  sub‐tests  in  2011, compared  to  a  37%  pass  rate  in  2005 when  this was  not  required.  The measure  has  proven particularly challenging for nurses, whose pass rates fell for most countries of training (including ‐20% for South Korea, ‐17% for China and ‐10% for the Philippines).   IELTS administrators state they require proof of all four skills in a single administration to allow ‘a maximally reliable composite assessment of a candidate’s overall language proficiency… This is the way the test has been built,  it  is not a modular test and therefore the four component modules are  not  offered  as  separate  tests  to  be  taken  at  different  times’.10  The  requirement  is  also reportedly an administrative convenience to IELTS, which is not imposed in a range of comparator countries (for example in select fields in Canada, New Zealand and Ireland).25  The risk of language attrition  between  attempts  is  a  further  rationale  (though  IELTS  administrators  concede  this typically occurs  at  lower  rather  than higher  English proficiency  levels). At  the  same  time  it has been confirmed by an IELTS study that native speakers (typically associated with a mean score of Band 7) perform with ‘unexpected’ variability across different subtests26.   OET administrators  see no  justification  in  this policy measure, despite  similar  revenue benefits. According to the OET, ‘Our stance against the 4‐in‐1 policy is supported by the academic literature surrounding  attrition,  particularly  for  learners  at  higher‐level  proficiencies. Given  the  relatively high  point  ‘on  the  ladder’  represented  by  the  current  standard…  it  is  fundamentally  unfair  to require  higher‐level  achievers  to  repeatedly  demonstrate  competency  in  a  sub‐skill  (they  have already demonstrated it) and it is unlikely to diminish quickly’. It makes better sense ‘to define the skill/s  which  need  practice,  and  address  this  for  the  benefit  of  ‘boards  and  professions  and patients’.27 The language testing experts consulted for the present study agreed.  

7.7 Length of Test Result Validity  Similar points were raised concerning Australia’s two year period for test result validity – an issue which  received  attention  in  the House of Representatives  Inquiry on OTDs  (see  the  Lost  in  the Labyrinth  2012  report).  A  range  of  studies  have  demonstrated  that  ‘high  proficiency  learners plateau for several years until attrition begins’. Should a test score  ‘shelf‐life’ be applied, testing experts advise this should differentiate between high and low level candidates, in a context where those scoring IELTS 7 and OET B (or higher) would be ‘likely to show little loss (of skills) for up to 4 years,  even  with  little  or  no  use’.28  A  two  year  validity  period  however  is  common  across comparator jurisdictions.     

10  It  is worth noting that New Zealand has maintained a 12 month cumulative pass option for nurses, which IELTS has 

been obliged to accept. 

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7.8  Test Validity  Test validity  represents a  critically  important  issue.  In addition  to  the attraction of  face validity (where  test  content may  appeal  to  candidates,  despite  being  statistically  irrelevant29)  research concerning validity addresses fitness for purpose, including: 

Construct validity ‐ the design and construction of the components of the test. 

Content  validity  –  whether  a  test  is  based  on  a  job  analysis  (ensuring  the representativeness of  the  sample  to)…  select  tasks  to  represent  the  job… develop a rating form’). 

Predictive validity – examining ‘the extent to which the predictions we would make in the basis of test performance about subsequent performance in the criterion situation are borne out’. 

Consequential  validity  –  assessment  of  the  impact  of  the  tests  in  the  real world, including  the  nature  of  candidates’  ultimate  performance  in  a  context where  ‘the broader  impact of  language tests  in terms of …. the  life chances of test candidates… has hardly been studied’.30  

Development of appropriate rating criteria – to determine ‘how performances will be judged (and) the relevant criteria against which judgements are made’. 

 While some research has been conducted on test validity  in relation to the OET,  focused on the first three aspects, there  is a dearth of research to date on the test’s predictive or consequential validity. No research examining the validity of  IELTS for health professional registration could be found, despite the existence of a substantial number of validity studies31.  This  represents  a  significant  issue  ‐  one  raised  by  the  House  of  Representatives  inquiry,  in  a context  where  substantial  numbers  of  sponsored  migrants  in  the  past  decade  immediately secured clinical employment without the extended supervised period once presumed. The  latter remains mandatory in many comparator jurisdictions (for example in the US for USMLE candidates who must undertake residencies; in Canada where internationally trained dentists must repeat the last two years of university study; and  in  Ireland where pharmacists must undertake  internships, with ‘a very risk‐adverse patient focus and approach taken to all decision‐making’).   As demonstrated by the literature, effective clinical communication is an immensely complex task. It requires fluent English, adroit cross‐cultural awareness, empathy, use of specialist terminology, idiom and  jargon, and a capacity  to adapt communicative  style  to a variety of  situations. These skills far exceed English. While there  is scope to design more targeted tests,   experience to date however suggests proposals for integrating clinical and language assessment are likely to be ruled out, deemed ‘too complex and costly by the profession’32. Given these limitations, the designer of the OET (for instance) notes it is important to ‘be modest about any claims one may wish to make that tests such as the Occupational English Test provide  information on ‘the ability of candidates 

to communicate effectively in the workplace’33. The same would be true of IELTS. 

 

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7.9  Test Reliability  The  reliability  of  test  results  is  an  important  issue.  IELTS  has  been  associated with  significant problems  in  terms of  this  in  the past. According  to Australia’s 2005‐06  skilled migration  review, test‐takers at this time had ‘a 40% chance of securing a different (IELTS) result on re‐testing, based on  a  .77  published  reliability  score  for  speaking  and writing’.34 While  in  2011  IELTS  reported  a higher level of reliability had been gained, there reportedly remains no certainty that spoken and written tests will be double‐marked35. Within this context, the test experts  interviewed observed problems with  securing consistent  speaking and writing  scores. The OET  is  reported  to perform relatively well in terms of reliability, following significant recent improvements.   A global  literature has evolved concerning rater reliability – a major challenge  for  ‘performance’ rather than discrete item MCQ tests (the IELTS and the OET being the former, the TOEFL being the latter).36 Research demonstrates  candidate assessment  in  the  speaking  test  to be  influenced by raters’  professional  background,  interpersonal  style,  gender,  variable  use  of  the  rating  criteria, assessment mode (whether by distance or in person), topic choice etc.  

7.10 Provision of Candidate Feedback  Finally,  as  noted  by  the  House  of  Representatives  inquiry,  candidates  to  date  receive minimal feedback on their English language standards for registration. There is a dearth of research related to feedback issues.  

8.   Conclusion   As  defined  in  the  Executive  Summary,  a  key  objective  of  the  National  Registration  and Accreditation Scheme  is to ensure the protection of the Australian public,  including through  ‘the rigorous  and  responsive  assessment  of  overseas‐trained  health  practitioners’.  Specification  of English  language skills registration standards  is central  to  this process,  in an age of globalization where Australia  is  importing  around  50,000  international  health  professionals  every  five  years.  The  majority  of  IHPs  are  sponsored  on  457  visas,  to  address  workforce  maldistribution  and undersupply.  Derived  from  highly  diverse  source  countries,  these  migrant  professionals  have immediate prospects of clinical employment (particularly in medicine).   The Boards’ current registration requirements may be entirely appropriate and fit for purpose. At the same time Australian policy is founded on a limited (and at times questionable) evidence base, as  in  a  range of  comparator  jurisdictions.  Further  research  concerning  the  effectiveness of  the instruments used, their predictive capacity, and the standards required for clinical practice seems warranted. Globally and within Australia,  language testing for registration has entered a dynamic policy phase, with a range of regulatory bodies reviewing their practice.    

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SNAPSHOT ‐ KEY RESEARCH FINDINGS     

Issue  

Finding 

Uses of English language testing 

Global uses of English language testing include the determination of refugee status, eligibility for citizenship, control of international student entry and placement, selection of skilled migrants, and access to professional registration. Within this context English testing has emerged as a lucrative global business, with market share tenaciously sought.  

Major tests  Since the 1950s the mobility of international students has driven instrument development (including the IELTS, TOEFL and recent Pearson tests). The OET by contrast was designed in Australia to assess speaking, listening, reading and writing skills in linguistic contexts simulating future professional practice (12 medical and allied health fields).   

Current significance of English language testing in Australia  

By July 2012 English language assessment had become Australia’s key criterion for skilled migrant selection, alongside qualification level and employer sponsorship. It is the main hurdle to professional registration in the medical and allied health fields.   

Use of English language testing by Australian regulatory bodies 

By 2012 48 Australian regulatory bodies had mandated IELTS for registration purposes (compared to the dominance of TOEFL in select parts of Asia and North America). Highly diverse requirements have been set (ranging from Band 6 to Band 8). There is minimal specialist research to date to inform standard‐setting for the health professions in Australia or overseas.   

The ELSRS research base  Seventy‐three IELTS Research Reports have been published by the Cambridge consortium in the past two decades. Just four have assessed standards for professional regulation purposes, typically on an audit rather than a validation basis. According to the author of two such reports, ‘IELTS was originally intended and designed as a set of international benchmarks to assess an individual’s proficiency for academic study in English‐speaking contexts… The growing trend for IELTS to be adopted by users outside of academic, including governments, professional associations and employers, may constitute a risk for the test owners if the assessment system cannot be validated for the purposes for which it is being used.’  

The Australian ELSRS context 

In Australia the Health Practitioner Regulation National Law  in force  in each state  and  territory  (‘the  National  Law’)  requires  each  National  Board  to develop and recommend to the Ministerial Council requirements about the English  language  skills  necessary  for  an  applicant  for  registration  in  the profession to be suitable for registration in the profession. A National Board may decide an individual is not a suitable person to hold practising categories of  registration  in  the  profession  if,  in  the  Board’s  opinion,  the  individual’s competency  in  speaking  or  otherwise  communicating  in  English  is  not sufficient for the individual to practice the profession.    

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Recent trends in Australia  It is important to note the scale of international health professional arrivals has grown immensely (around 50,000 skilled category migrants approved every five years); source countries have become exceptionally diverse; health fields have changed; temporary rather than permanent entry has become the norm; the majority of IHPs are currently sponsored (with clinical communication immediately important); and substantial numbers of health professionals have qualified onshore (the study‐migration pathway likely to lead to requests for English language testing exemptions).   

The impact of broader societal trends on ELSRS standards 

The 37 regulators interviewed for the ELSRS project affirmed their prime responsibility to be the protection of public safety and the maintenance of stringent regulation standards. Despite this, standards are inevitably influenced by the broader policy agendas and values of the national/ state contexts in which regulators are embedded. Factors include health workforce shortages; agreements to facilitate worker mobility and internal trade; rights‐driven credential recognition initiatives; changed skill migration policies; overriding bilateral and multilateral agreements (etc).  Pressures such as these can be seen as jeopardising ESLRS standards (for example allowing automatic test exemptions for EU‐EEA nationals in the UK and Ireland). The EU Directive is under 2012 review, with key informants suggesting language testing exemptions may be challenged.  

Global ELSRS practice in medical and allied health fields 

Global regulatory bodies adopt highly variable requirements in terms of English testing. This is currently a dynamic policy space. As demonstrated by the eight country web audit (Attachment 1), and 50 interviews conducted with key informants, regulators may specify few or multiple tests (Attachment 2); different test types (ranging from generic, to field‐specific, to embedded, to interview‐based); require diverse scores by test and field; allow different types of exemption; permit variable lengths of result validity (ranging from 6 to 24 months); and impose different operational requirements (for example to pass sub‐tests at a single or sequential sittings).    

Limits to the research base  In an age of globalization, the English ability of international health professionals is regarded as a critical public safety issue. Tests are clearly required, with high standards set. In Australia the Boards’ use of IELTS and the OET may be entirely appropriate. The literature to inform English language skills registration standards however to date is slight. Few health‐specific studies exist. Many are based on small sample sizes. There are major research gaps. A 2012 analysis of Australian medical complaints data found international graduates had 24% higher odds and a 41% higher risk of adverse findings, with select IMGs who were non‐native speakers of English and trained in quite different systems at disproportionate risk. Within this context there may be English‐related issues, however this is unknown.  

Issues raised by the House of Representatives 2010‐12 inquiry on IMGs 

The following ELSRS issues were raised by the 2010‐12 House of Representatives Inquiry into Overseas Trained Doctors (of relevance also to the allied health fields): the English standards required for professional registration; the choice and scope of tests; their stability, reliability and predictive capacity; the length of validity of test results; the impact of the requirement to pass all four subtests at a single sitting; the quality of rater training; the dearth of performance feedback to candidates; and the impact of ‘invisible’ English language tests (such as PESCI or specialist college 

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interviews).  

Generic compared to field‐specific tests 

The ELSRS literature review undertaken demonstrated there has been minimal global or Australian investigation of the validity of using generic tests to assess candidates’ performance in health‐specific contexts. As noted in an IELTS Research Report, ‘The question of whether the IELTS testing system is appropriate for testing broader skills such as those required for a professional operating as a doctor, nurse, veterinary surgeon, engineer, teacher or accountant arises because there is little research which focuses on validating the testing system for these purposes.’ According to the 50 ELSRS interviews, tests are typically ‘inherited’ rather than recently chosen, with the rationale for instrument choice often ‘lost in the mists of time’.  

Standard‐setting  There is minimal evidence to support ELSRS standard‐setting in the health professions to date (for the IELTS or the OET). While National Board requirements may be appropriate, tests also have differential impacts by field. In 2011, for example, 62% of dental and 52% of medical candidates passed the OET on first or repeated attempts, compared to just 38% of pharmacists, 32% of physiotherapists, and 17% of nurses. 

 Test exemptions  Defining English test exemptions is challenging. There have been no studies 

to date assessing native speaker (NS) compared to non‐native speaker (NNS) performance on the OET. In terms of IELTS research the scores of native English speakers are revealed to be neither homogenous nor high; many native speakers completing secondary education would be ineligible to commence medical or allied health university studies if required to secure IELTS scores of Band 7 or above (particularly on all four sub‐tests); and significant differences exist even between highly educated native speakers (eg barristers outperforming tertiary education lecturers in terms of scores). For this reason the UK and Ireland allow no automatic exemptions from English language testing for third country nationals who are native English speakers. Defining test exemptions for international students qualified is similarly problematic. Research demonstrates minimal IELTS gains between entry and exit scores for students completing degrees, over enrolment periods spanning 3 to 4.5 years.  

Requirement to pass all four subtests at a single sitting 

There is minimal available evidence to date to support Australia’s 2010+requirement for candidates to pass all four English language sub‐tests at a single sitting – a measure resulting in significant registration delay and cost. IELTS mandates this (though some jurisdictions have refused). OET administrators report no scientific justification.  

Length of test result validity 

The length of test result validity may merit review (particularly for candidates resident and engaged in clinical practice in Australia). A range of studies have demonstrated that ‘high proficiency learners plateau for several years until attrition begins’, within minimal change anticipated in a 3‐4 year period.  

Test validity  While some research has been conducted on test validity in relation to the OET, there is a dearth of scientific evidence to date concerning the test’s predictive or consequential validity (which reportedly has not been commissioned). No research examining the validity of IELTS for health professional registration was found, despite the existence of a substantial 

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range of IELTS validity studies. 

Test stability and reliability  IELTS has been associated with significant problems in terms of stability in the past. According to Australia’s 2005‐06 skilled migration review, test‐takers at this time had ‘a 40% chance of securing a different (IELTS) result on re‐testing, based on a .77 published reliability score for speaking and writing’. While in 2011 IELTS reported a higher level of reliability had been gained, there remains no certainty that spoken and written tests will be double‐marked. The OET is reported to perform relatively well in terms of reliability, following significant recent improvements on select tests.   

Rater reliability  A global literature has evolved concerning rater reliability – a major challenge for  ‘performance’  rather  than pen and paper  tests  (the  IELTS  and  the OET being  the  former,  the  TOEFL  being  the  latter).  Research  demonstrates candidate  assessment  in  the  speaking  test  to  be  influenced  by  raters’ professional  background,  interpersonal  style,  gender,  variable  use  of  the rating  criteria,  assessment mode  (whether by distance or  in person),  topic choice etc.  

Conclusion  A key objective of the National Registration and Accreditation Scheme  is to ensure  the  protection  of  the  Australian  public,  including  through  ‘the rigorous and responsive assessment of overseas‐trained health practitioners’. Specification  of  English  language  skills  registration  standards  has  become central to this process, in an age of globalization where Australia is importing around 50,000 international health professionals every five years.    The  National  Boards’  current  ELSRS  requirements  may  be  entirely appropriate  and  fit  for  purpose.  At  the  same  time  Australian  policy  is founded on a limited (and at times questionable) evidence base. This is also the case  in a range of comparator  jurisdictions. Within  this context,  further research  on  the  effectiveness  of  the  instruments  used,  their  predictive capacity, and the standards required for clinical practice seems warranted. A positive  exemplar  is  the  ECFMG  validation  process  undertaken.  (See Executive Summary.)  

 

21

  1 For a detailed analysis of the evolution of IELTS, and its merits, see Davies, A (2008), Assessing Academic English  –  Testing  English  Proficiency  1950‐1989  –  The  IELTS  Solution,  Studies  in  Language  Testing  23, University of Cambridge ESOL Examinations, Cambridge University Press. 

2 Blacket, R (1990), ‘Foreign Medical Graduates: The Experience of the Australian Medical Examining Council and  the Australian Medical  Council  –  Implications  for Medical  Immigration  and  the Medical Workforce’, Medical Journal of Australia, Vol 153, August 6, p. 129.  3 For a detailed analysis of the development and trialling of the OET, see McNamara, T (1990), Assessing the Second Language Proficiency of Health Professionals, PhD Thesis, Department of Linguistics and Language studies, University of Melbourne. 4  Department  of  Immigration  and  Citizenship  (2010),  ‘Employer  Sponsored Workers  –  September  2009 Changes  to  the  English  Language  Proficiency  Requirements’,  http://www.immi.gov.au/skilled/skilled‐workers/changes‐eng‐req.htm, accessed 16 August 2012.  5 Merrifield, G (2012), ‘An Impact Study into the Use of IELTS by Professional Associations and Registration Entities – Canada, the UK and Ireland’, IELTS Research Reports, Volume 11, www.ielts.org, accessed 30 July, p.  5,  11; Merrifield,  G  (2008),  ‘An  Impact  Study  into  the  Use  of  IELTS  by  Professional  Associations  and Registration  Entities  –  Australia,  New  Zealand  and  the  USA’,  IELTS  Research  Reports,  Volume  8, www.ielts.org, accessed 30 July, p. 5, 11.  6  General Medical  Council  (2012),  ‘Broad  Themes  of  the  Review  and Members  of  the Working  Group’, http://www.gmc‐uk.org/static/documents/content/Broad_themes_of_the_review_and_members_of_the_working_group.pdf, accessed 1 July 2012, p. 1.  7 Ibid, p. 50.  8 A  PESCI  ‘is  used  to  assess  an  IMG’s  suitability  for  a  particular  role  based  on  the  assessed  risks  of  the particular  position.  It  requires  the  IMG  to  undergo  a  structured  interview  based  on  clinical  scenarios  to demonstrate that they have the knowledge, skills and experience to work in a particular position. The PESCI is conducted under the auspices of AMC accredited providers by a panel of at least three members, two of whom need to be familiar with the clinical and professional demand of the type of position involved’.  9 House of Representatives Standing Committee on Health and Ageing (2012) Lost in the Labyrinth Report on the Inquiry into Registration Processes and Support for Overseas Trained Doctors, Parliament of the Commonwealth of Australia, March, Canberra, p. 87‐88.  10 Ibid, p. 130.  11 Ibid, p. 200‐201  12 Hawthorne, L (2012), Health Workforce Migration to Australia – Policy Trends and Outcomes 2004‐2010, Health  Workforce  Australia,  Adelaide,  http://www.hwa.gov.au/work‐programs/international‐health‐professionals/health‐profession‐migration   

22

13 Health Workforce Australia  (2012), Health Workforce 2025, Volume 1 and Volume 2, Health Workforce Australia, Adelaide.   14 Hawthorne, L (2012), ‘International Medical Migration – What is the Future for Australia?’, Special Issue, Medical  Journal  of  Australia  Open,  197(2),  23  July,  Medical  Workforce  –  Towards  2025  Volume  2 Supplement  1  18‐21;  Hawthorne,  L  &  To,  A  (2012),  The  Early  Migration  and  Career  Trajectories  of International Medical Students Qualified in Australia, Medical Deans of Australasia, Sydney, 

15 Elkin, K, Spittel, M & Studdert, D  (2012),  ‘Risks of Complaint and Adverse Disciplinary Findings Against International Medical Graduates in Victoria and Western Australia’, Medical Journal of Australia 197 (8), 15 

October, p. 450. It should be acknowledged that L Hawthorne is one of K Elkin’s PhD supervisors, with this paper based on her doctoral research. 16 McNamara, T (1996), Measuring Second Language Performance, Longman, Sydney, Chapter 6; Sarangi, S (2003), ‘Introduction – Trading Between Reflexivity and Relevance: New Challenges for Applied Linguistics’, Applied Linguistics, Vol 24 No 3, pp. 283‐4; Candlin, C & Candlin, S (2003),  ‘Health Care Communication: A Problematic Site for Applied Linguistics research’, Annual Review of Applied Linguistics, Vol 23, No 8.   17 Read, J & Wette, R (2009), ‘Achieving English Proficiency for Professional Registration: The Experience of Overseas‐Qualified Health Professionals  in  the New Zealand Context’,  IELTS Research Reports, Volume 10, No. 4.  18 Ibid, p. 110.  19 Merrifield (2008), op cit.  20 Ibid., p. 4.  21  Ibid, p. 197.  22 Birrell, B, Hawthorne, L & Richardson, S  (2006). Evaluation of  the General Skilled Migration Categories, Commonwealth of Australia, Canberra, 2006.  23 Elder, C & O’Loughlin, K (2003), ‘Score Gains on IELTS After 10‐12 Weeks of Intensive English Study’, IELTS Research Reports, Volume 4, IELTS Australia Pty Ltd, Canberra.    24 Craven, E (2012), ‘The Quest for IELTS Band 7.0: Investigating English Language Proficiency Development of International Students at an Australian University’, IELTS Research Reports, Volume 13, p. 11.  25 Maret,  B  (2012),  Emailed  advice  to  L  Hawthorne  received  19  June,  from  IDP  Education  Australia,  in relation to the research evidence to support the requirement for all four  IELTS sub‐tests to be passed at a single sitting.  26 Davies, A (2008), op. cit., p. 96. 27 Advice received on this issue to Hawthorne’s emailed request on 15 June 2012, from the Manager of the Occupational English Test Centre, Melbourne.  28 Roever, C  (2009),  ‘Attrition and Language Testing – Shelf‐Life of Test Scores and What  it Means  for the OET’,  School  of  Language  and  Linguistics,  University  of  Melbourne,  Presentation  at  OET  Conference, Melbourne.  

23

 29 Davies, A (2008), op. cit., see pp. 94-98 regarding the rationale for IELTS shifting from field-specific modules to a generic version. 30 McNamara, T (1996), op cit., p.16‐25.  31 See Davies, A (2008), op. cit.  32 This comment was made by one of the language testing experts interviewed, who is Australia‐based, and has very substantial  international experience. By agreement, no  individual  informants are  identified  in this study.  33 McNamara, T (1996), op cit., p. 41. 

34 Birrell, B, Hawthorne, L & Richardson, S  (2006), Evaluation of  the General Skilled Migration Categories, Commonwealth of Australia, Canberra, p. 111.  35 The authors had a series of email communications to B Maret, B (2012), from IDP Education Australia, in relation to this issue, which was not clarified at the time of the study’s completion (late 2012). 

36 See for example Lumley, T & O’Sullivan, B (2005), ‘The Effect of Test‐Taker Gender, Audience and Topic on Task Performance in Tape‐Mediated Assessment of Speaking’, Language Testing, Vol 22 No 4; McNamara, T & Lumley, T (1997), ‘The Effect of Interlocutor and Assessment Mode Variables in Off‐Shore Assessments of Speaking Skills  in Occupational Settings’, Language Testing, Vol 14; Elder, C (2005), ‘Individual Feedback to Enhance Rater Training: Does It Work?’, Language Assessment Quarterly, Vol 2, No. 3; Brown, A (2000), ‘An Investigation of the Rating Process in the IELTS Oral Interview’, IELTS Research Reports, Volume 3, No 3.   

FINAL Contrastive Country Audit

5 November 2012

ELSRS Attachment 1:

Global Benchmarking – Eight Country Audit

Please note:

• The English language skill registration standards (ELSRS) reported below were derived from our global web audit (conducted January 2012, updated

October 2012). This detailed audit was supplemented by reference to data derived from the transcribed interviews conducted with 61 ELSRS key

informants, which for a range of countries/ fields referenced current policy developments including reviews.

1. Australia

Policy

Overview Prior to 2008: There were variations in registration requirements between both the Australian states and territories, and the different health

professions.

March 2008: The Council of Australian Governments (COAG) created the National Registration and Accreditation Scheme (NRAS) to make

consistent registration requirements for 10 health professions; and English proficiency standards among the elements of registration were

revised. These were applied to temporary as well as permanent skilled migrants for selection and registration purposes.

Test options: For the purposes of professional registration, passes are required in the IELTS or OET tests, as defined below.

National Variability

Standards are uniform nationally and there are only minor differences between standards for the five health professions, as detailed below.

Skilled Migration General Skilled Migration (GSM):

• Specific requirements are in place with 65 points required for GSM selection.

• All applicants (regardless of country of origin) are required to pass English language test before visa application is lodged.

• Minimum requirement is a band score of 6 in each of the four components of the IELTS test (or equivalent standard in a specified test)

• Bonus points are solely awarded if applicants achieve IELTS (or equivalent) score of at least 7 in each test component, with 20 bonus points

for IELTS band 8 (with English and qualification level from July 2011 the key determinants of selection).

Temporary Skilled Migration (457 visa):

• Applicants must be sponsored by an employer to fill a nominated position.

• English language testing mandated for temporary health professionals.

• Exemptions apply for holders of passports from Canada, New Zealand, Republic of Ireland, United Kingdom or United States of America if

24

FINAL Contrastive Country Audit

5 November 2012

they are nominated in an occupation that does not require a level of English competency for grant of registration, license or membership.

• Applicant would need to have at least the English proficiency standard required for registration license or membership for nominated

occupation.

Key Trends March 2010: Changes to English language skills registration standards (detailed below) were approved by the Australian Health Workforce

Ministerial Council and legislated by the Health Practitioner Regulation National Law Act 2009.

Implemented: From 1 July 2010 (Western Australia joining October 2010)

Australian Health Practitioner Regulation Agency (AHPRA): Governed by the National Law and from July 2010 are responsible for implementing

the NRAS across the country.

National Health Practitioner Boards: Currently there are 10 Boards responsible for regulating their respective professions, supported by AHPRA.

Additional National Boards are to be established in 2012.

Target Groups Health professionals who were not taught and assessed in English: If an applicant is internationally qualified or did not undertake and

complete their secondary education in English, or in Australia, Canada, New Zealand, Republic of Ireland, South Africa, United Kingdom and

United States of America, they must submit evidence of their competency in English language.

Governance Medical Board of Australia Nursing and Midwifery

Board of Australia

Dental Board of Australia Physiotherapy Board of

Australia

Pharmacy Board of

Australia

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

IELTS Overall: 7, Speaking: 7, Writing: 7, Listening: 7, Reading: 7

Note: For Dentistry, IELTS was accepted from 1 July 2010 where previously OET was the only test accepted.

Overall: 7.5, Speaking: 7,

Writing: 7, Listening:

7, Reading: 7

OET Overall: B, Speaking: B, Writing: B, Listening: B, Reading: B

Additional

Conditions

Evidence that they have

completed 5

equivalent FT years of

education1 taught and

1 This must include pre-registration program of study of 2 FT equivalent years for nurses and midwives, and 1 year for enrolled nurses that is approved by the relevant

nursing and/or midwifery regulatory body.

25

FINAL Contrastive Country Audit

5 November 2012

assessed in English in

any of the recognised

countries listed as

exempt below.

• Since 2010, IELTS and OET passes must be achieved in one sitting.

• Test passes must have been obtained within 2 years prior to applying for registration. Test results will be accepted as current if:

o the candidate has actively maintained employment2 in their profession using English as the primary language of practice in a

country where English is the native language since the test; or

o they are registered as a student in an approved program of study (for Medicine only; programs not listed in standard); or

o they are continuously enrolled in a program of study taught and assessed in English and approved by the recognised nursing

and/or midwifery regulatory body in any of the countries listed in the registration standard below (for Nursing, Midwifery and

Enrolled Nurses only; programs not listed in standard)

• Board reserves right to revoke exemptions listed below

Exemptions

Successful completion of :

• Professional and

Linguistic

Assessments Board

(PLAB) (UK); or

• New Zealand

Registration Exam for

Overseas Doctors

(NZREX).

From 19 September 2011:

• Board has discretion

to grant exemptions

where there is

compelling evidence

demonstrating English

language proficiency

equivalent to the

required standard.

• Applicants registered

as RN or midwife in

New Zealand.

Prior to 19 September:

• Discretion to grant

exemptions due to

compelling reasons

was not stated.

• No exemptions for

As detailed below. As detailed below.

Limited registration

exemptions are

usually related to

postgraduate training

where students would

be considered for an

exemption if they just

fell short of the

language test

requirements.

As detailed below.

2 For Dentistry, although it is not formally written in policy, the Board may accept a test that is older than two years if the applicant is enrolled in a course approved by the

Board.

26

FINAL Contrastive Country Audit

5 November 2012

select countries of

training (including

English speaking

background

countries) existed.

Criteria: If the applicant provides evidence that they undertook and completed secondary education that was taught and assessed in English in

one of the countries listed below. And if the applicant’s tertiary qualifications in the relevant professional discipline were taught and

assessed in English in one of the listed countries below.

Countries: Australia, Canada, New Zealand, Republic of Ireland, South Africa3, United Kingdom and United States of America.

Limited registration: Board may grant exemptions where applicants apply for limited registration, such as:

• To perform a demonstration of clinical techniques.

• To undertake research that involves limited or no patient contact.

• To undertake a period of postgraduate study or supervised training while working in an appropriately supported environment that will

ensure patient safety is not compromised.

These exemptions will generally be subject to conditions requiring supervision by a registered health practitioner and may also require the use

of an interpreter.

2. Canada

Policy

Overview Overall: Professional registration requirements in Canada are complex due to policy variations between national bodies, the 13 provinces/ territories

and the professional bodies. This has been compounded by the finding that information specifically on English language standards is not always

readily available or explicitly defined (noting for this audit French language testing requirements were by agreement excluded).

Test options: For the purposes of professional registration, passes are required in the IELTS, MELAB, TOEIC, CanTEST, CELBAN or TOEFL tests, as defined

below.

National

Variabilit

Provincial variability (Medicine and Nursing):

• Language testing requirements are highly variable across the 13 provinces/ territories of Canada.

• For these fields, English language requirements are provided below for the 5 most populous and 2 least populous provinces by key field, to indicate

3 Although the policy states that Pharmacy applicants from South Africa may be granted an exemption from English language testing, the Pharmacy Board has indicated

that they are not actually exempt due to the variability of candidates’ English skills.

27

FINAL Contrastive Country Audit

5 November 2012

y

the scale of variation from the major population centres to under-supplied provincial sites.

• In descending order of population size, the most populous provinces are Ontario, Quebec4, British Columbia, Alberta, Manitoba, Saskatchewan; and

the two least populous are Newfoundland and Labrador, and Prince Edward Island.

National standards (Pharmacy and Physiotherapy):

o English language requirements are determined by a national body. While provinces are able to apply additional requirements, each has

followed the standards established by the national authority.

Dentistry:

o No English proficiency standards have been set as this is assessed as part of the National Dental Board of Canada (NDEB) Written Exam.

Skilled

Migration

Permanent Skilled Migration (Federal Skilled Worker Program):

• All applicants must include the results of an English or French language test as part of their application. In a major policy change, as of 26 June 2011

no exemptions apply. (Previously, self-report was allowed. This coincided with the admission of large numbers of health professionals with poor or

minimal English, and significant employment displacement.) Bonus points (up to 24 points out of the 67 points required) are only allocated if the

minimum scores are achieved as follows:

o IELTS (General Training only) – Overall: N/A, Speaking: 4, Writing: 4, Listening: 4.5, Reading: 3.5.

o As of 1 January 2013 IELTS minimum requirements will be changed to: Speaking: 6, Writing: 6, Listening: 6, Reading: 6 and language

assessment will be mandatory upfront.

o CELPIG-General – Overall: N/A, each component (Speaking, Writing, Listening, Reading): Level 2H (equivalent to CLB 4)

Temporary Skilled Migration (Temporary Foreign Workers):

o English proficiency standards are those as set by the relevant professional regulatory boards.

Key Trends Medicine:

o A new national standard has been set up but has not yet been implemented in each province. The Registrars have approved the Standard and

the next steps will be to obtain the appropriate and required ministerial approval to proceed. Standards below related to that as at February

2012. Please see Policy Developments under Medicine below.

Nursing:

o Policies pertaining to English language requirements have been stable overall.

Physiotherapy:

o The Canadian Alliance of Physiotherapy Regulators have undertaken a review of language proficiency testing for internationally trained

physiotherapists. The review recommendations below refer to the outcomes of report prepared in August 2012.

Pharmacy:

o In 2009, a pan-Canadian mobility agreement was put in place for Pharmacy and worked through the National Association of Pharmacy

Regulatory Authorities (NAPRA). This has meant the standardisation of English language standards across the 10 provinces. For Medicine, the

4 Quebec, the second most populous province, has its own quite separate jurisdiction with French proficiency requirements. The French tests that are accepted include: TESTcan, Test

d’evaluation de Francais (TEF) and Test de francais international (TFI). As the focus of this audit is on English language test requirements, standards set in Quebec have been excluded.

28

FINAL Contrastive Country Audit

5 November 2012

National Assessment Collaboration (NAC) was established in 2004, under the governance of the Medical Council of Canada (MCC).The aim of

NAC is to develop streamlined assessments for IMGs to obtain a medical licence in Canada regardless of jurisdiction of assessment. English

language requirements have not yet been standardised.

Target

Groups

Health professionals who gained their qualifications from a non-English speaking country:

o If applicants did not attain qualifications from accredited programs or select countries (detailed below), they must (with the exception of

Dentistry) successfully complete and pass an English test.

Governance

(National and

Select

Provincial

Bodies)

Dentistry:

• National Dental Board of Canada (NDEB)

• Royal College of Dental Surgeons of Ontario

• College of Dental Surgeons of British

Columbia

• Alberta Dental Association and College

• Manitoba Dental Association

• College of Dental Surgeons of Saskatchewan

• Provincial Dental Board of Nova Scotia

• New Brunswick Dental Society

• Newfoundland and Labrador Dental Board

• Dental Council of Prince Edward Island

Physiotherapy:

• Canadian Alliance of Physiotherapy

Regulators (The Alliance)

• College of Physiotherapists of Ontario

• College of Physical Therapists of British

Columbia

• Physiotherapy Alberta College & Association

• College of Physiotherapists of Manitoba

• Saskatchewan College of Physical Therapists

• Nova Scotia College of Physiotherapists

• College of Physiotherapists of New

Brunswick

• Newfoundland and Labrador College of

Physiotherapists

• Prince Edward Island College of

Physiotherapists

Pharmacy:

National Association of Pharmacy Regulatory

Authorities (NAPRA)

• Ontario College of Pharmacists

• College of Pharmacists of British Columbia

• Alberta College of Pharmacists

• The Manitoba Pharmaceutical Association

• Saskatchewan College of Pharmacists

• Nova Scotia College of Pharmacists

• New Brunswick Pharmaceutical Society

• Newfoundland and Labrador Pharmacy

Board

• Prince Edward Island Pharmacy Board

Medicine:

• Medical Council of Canada

• College of Physicians and Surgeons of

Ontario

• College of Physicians and Surgeons of British

Columbia

• College of Physicians and Surgeons of

Alberta

• College of Physicians and Surgeons of

Manitoba

• College of Physicians and Surgeons of

Nursing:

• College of Nurses of Ontario

• College of Registered Nurses of British

Columbia

• College & Association of Registered Nurses

of Alberta

• College of Registered Nurses of Manitoba

• Saskatchewan Registered Nurses’

Association

• Association of Registered Nurses of

Newfoundland and Labrador

29

FINAL Contrastive Country Audit

5 November 2012

Saskatchewan

• College of Physicians and Surgeons of

Newfoundland and Labrador

• College of Physicians and Surgeons of Prince

Edward Island

• Federation of Medical Regulatory

Authorities of Canada

• Association of Registered Nurses of Prince

Edward Island

Test Instruments and Levels – Dentistry, Physiotherapy and Pharmacy

Instrument Dentistry Physiotherapy Pharmacy

General

comment

• There are no English language requirements

• Applicants must complete the NDEB Written

Exam and Objective Structured Clinical

Examination (OSCE), within which English

ability is part of the assessment.

• Applicants must also be a licensed member

with the relevant provincial regulatory

body, none of which have additional

requirements for English proficiency.

• A two year review process is currently

nearing completion.

• Applicants must apply for credentialing

through the Canadian Alliance of

Physiotherapy Regulators (CAPR - The

Alliance) which has a set of English

proficiency standards.

• While individual provinces may have

additional requirements, none currently

deviate from those set by CAPR.

• Standards are currently under review.

• English language requirements are defined

by the National Association of Pharmacy

Regulatory Authorities (NAPRA).

• Applicants must gain registration with the

relevant provincial regulatory body, all of

which require the minimum language

standards below.

IELTS

(Academi

c)

Not applicable Overall: 7, Speaking: 7, Writing: 7, Listening: 7,

Reading: 7

Review recommendation: Overall: 7, Speaking:

7, Writing: 6.5, Listening: 6.5, Reading: 7

Overall: 7, Speaking: 6, Writing: 6, Listening: 6,

Reading: 6

Standard Error of Measurement (SEM) is

accepted by all provinces at +/-0.5 of each

band score.

TOEFL iBT

Overall: 80, Speaking: 19, Writing: 19, Listening:

20, Reading: 20

Review recommendation: Overall: 86, Speaking:

21, Writing: 21, Listening: 21, Reading: 21

Overall: 97, Speaking: 27, Writing: 25, Listening:

N/A, Reading: N/A

TOEFL PBT Discontinued unless TOEFL iBT is unavailable.

Previous requirements: Overall: 585, TSE:

45, TWE: N/A, Listening: 50, Reading: 50,

Overall: 580, TSE: 50, TWE: 5, Listening: N/A,

Reading: N/A, Structure: N/A

30

FINAL Contrastive Country Audit

5 November 2012

Structure: 50

Review recommendation for countries with only

this version: : Overall: 585, TSE: N/A,

TWE:4, Listening: 55, Reading: 56, Structure:

60

TOEFL CBT Discontinued. Overall: 237, TSE: 50, TWE: N/A, Listening: N/A,

Reading: N/A, Structure: 26

MELAB Overall: 85, Speaking:3, Writing: N/A, Listening:

N/A, GCVR: N/A

The review has suggested that this test may be

discontinued due to low uptake (around 3%

of candidates take the MELAB).

Overall: 88, Speaking:3, Writing: 82, Listening:

N/A, GCVR: N/A

TOEIC Overall: N/A, Speaking: 160, Writing: 160,

Listening and Reading total: 800

Review recommendation: Discontinue test5.

Not accepted

CanTEST Overall: 4, Speaking: 4.5, Writing: 4, Listening: 4,

Reading: 4

Overall: N/A, Speaking: 4.5, Writing: 4.5,

Listening: 4.5, Reading: 4.5

Additional

Condition

s

Not applicable • Results do not need to be obtained in one

sitting.

• Results are valid for 2 years from test date

Exemptions

Applicants who completed an NDEB-accredited

programs in USA and Australia are exempt.

If education was in English, or completed in

Australia, USA, NZ, Ireland, South Africa, UK

or France.

• Applicants with a university degree from a

Canadian or US program accredited by

Canadian Council for Accreditation of

Pharmacy Programs or Accreditation

Council for Pharmacy Education.

5 TOEIC has been recommended to be discontinued because the test does not include professional licensure as an ‘appropriate use’; and its format is very different from

the other approved tests.

31

FINAL Contrastive Country Audit

5 November 2012

• For Ontario only: Applicants who completed

the majority of their primary, secondary and

university education in English are generally

granted an exemption. Applicants may

submit adequate non-objective evidence of

proficiency. Such as, authored publications

accompanied by letter from a professor who

can attest to language proficiency.

Test Instruments and Levels – Medicine and Nursing

Instrument Medicine Nursing

General comment • Requirements for only the 5 most populous and 2 least populous

provinces are listed below.

• Standards for Alberta and Saskatchewan were not available -

relevant authority has been contacted, awaiting response.

• Information on the website for Ontario currently only lists English

standard requirements for certificate of registration for

postgraduate medical education rather than for licensure. Ontario

will soon be adopting the recently established National Standard

(please see Policy Developments below).

Requirements for only the 5 most populous and 2 least populous

provinces are listed below.

IELTS (Academic) British Columbia: Overall: 7, Speaking: 7, Writing: 7, Listening: 7,

Reading: 7

Newfoundland and Labrador: Overall: N/A, Speaking: 7, Writing: 7,

Listening: 7, Reading: 7

Ontario (once National Standard is adopted): Overall: 7, Speaking: 7,

Writing: 7, Listening: 7, Reading: 7

Ontario: Overall: 6.5, Speaking: 7, Writing: 6.5, Listening: 6.5, Reading:

6.5

British Columbia, Alberta, Manitoba, Saskatchewan, New Brunswick;

Newfoundland and Labrador: Overall: 7, Speaking: 7, Writing: 7,

Listening: 7.5, Reading: 6.5

Prince Edward Island: Overall: 7.5, Speaking: 7.5, Writing: 7.5,

Listening: 8, Reading: 7

TOEFL iBT

British Columbia: Overall: 95, Speaking: 25, Writing: N/A, Listening:

N/A, Reading: N/A

Manitoba: Overall: 100, Speaking: 25, Writing: N/A, Listening: 25,

Reading: N/A

Newfoundland and Labrador: Overall: 92, Speaking: 24, Writing: 20,

Ontario: Overall: 74, Speaking: 26, Writing: 14, Listening: 18, Reading:

19

Newfoundland and Labrador: Overall: 86, Speaking: 26, Writing: 20,

Listening: 20, Reading: 20

32

FINAL Contrastive Country Audit

5 November 2012

Listening: 20, Reading: 20

Ontario (once National Standard is adopted): Overall: 96, Speaking:

24, Writing: 24, Listening: 24, Reading: 24

TOEFL PBT Ontario: Overall: 537, TSE: 50, TWE:N/A, Listening: 53, Reading: 53,

Structure: 53

TOEFL CBT

(discontinued test)

Prince Edward Island: Overall: 237, TSE: 50, Writing: N/A

Ontario: Overall: 203, TSE: 50, TWE:N/A, Listening: 19, Reading: 20,

Structure: 20

MELAB Not accepted Ontario: Overall: 75, Speaking:3, Writing: N/A, Listening: N/A, GCVR:

N/A

TOEIC Not accepted Ontario: Overall: 720, Speaking: N/A, Writing: N/A, Listening: 350,

Reading: 350

Prince Edward Island: Overall: 930, Speaking: 190, Writing: 200,

Listening: 495, Reading: 435

CELBAN Not accepted (NURSING SPECIFIC TEST) Ontario: Overall: N/A, Speaking: 8, Writing: 7, Listening: 9, Reading: 8

British Columbia, Alberta, Manitoba, Saskatchewan, New Brunswick;

Newfoundland and Labrador, Prince Edward Island: Overall: N/A,

Speaking: 8, Writing: 7, Listening: 10, Reading: 8

Additional

Conditions

British Columbia and Newfoundland and Labrador: Test results are

valid for 2 years.

British Columbia: Test scores must be submitted within 6 months of

test date.

Newfoundland and Labrador: Applicants whose first language is not

English, or who have completed their nursing education in a

country where the everyday language is not English, are required

to successfully complete an English test.

Exemptions

British Columbia: If the language of instruction at medical school was

in English. And the primary language of patient care was English.

And applicant was trained in a native English country.

Newfoundland and Labrador: If the applicant's medical education and

experience was in one of the countries recognised by the College

as having English as a first language. Or if they have a high school

diploma. Or have a minimum of two years of undergraduate

education (in any field) in English from one of the countries that

have English as a first language.

Ontario: If the candidate completed a nursing program in countries

recognised by the College as native English or French countries.

Or if they are registered and have practised nursing in a country

where English or French is the official or predominant language, in

the last five years.

Alberta, Manitoba, Saskatchewan: If English is the language they first

learned at home in childhood, is the language which they identify

as knowing best and being most comfortable with or is the

language they primarily use for reading, writing, listening and

speaking.

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FINAL Contrastive Country Audit

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Policy

Developments

A new National Standard has been established by Federation of

Medical Regulatory Authorities of Canada (FMRAC) with all

provinces moving to adopt this in due course:

IELTS: Overall: 7, Speaking: 7, Writing: 7, Listening: 7, Reading: 7

TOEFL iBT: Overall: 96, Speaking: 24, Writing: 24, Listening: 24,

Reading: 24 (to be phased out in 2016)

Exemptions: If candidates completed their medical education and

patient care experience in one of the countries that have English

as a first and native language (ie. Australia, Bermuda, British

Virgin Islands, Canada, Ireland, New Zealand, Singapore, South

Africa, United Kingdom, United States of America, US Virgin

Islands, Caribbean Islands: Anguilla, Antigua and Barbuda,

Barbados, Dominica, Grenada, Grenadines, Jamaica, St. Kitts and

Nevis, St. Lucia, St. Vincent, Trinidad and Tobego)

The Federal government and Provincial and Territorial governments

negotiated an internal trade agreement for the recognition of

registration across the country (except Quebec which is slightly

different).

An umbrella organisation was established in the last year (separate

from the Canadian Nursing Association) and it was decided that

they would only accept IELTS and CELBAN for nurses. It is

anticipated that everyone who has not been educated or

practising in an English area will have to take the test. This has not

yet been through legislation.

For Ontario, this will take effect on 1 January, 2013:

IELTS: Overall: 7, Speaking: 7, Writing: 7, Listening: 7.5, Reading: 6.5

CELBAN: Overall: N/A, Speaking: 8, Writing: 7, Listening: 10, Reading:

8

3. Ireland

Policy

Overview Overall: In Ireland, professional registration in the fields below is typically vested with the relevant over-arching registration authority.

Test options: For the purposes of professional registration, passes are required in the IELTS or TOEFL tests, as defined below.

National Variability None. Registration is also automatic for members of EU-EEA countries.

Skilled Migration Permanent Skilled Migration (Long Term Residency):

• No English language requirements have been set for eligibility purposes.

• However applicants wishing to apply for Long Term Residency must have a minimum of 5 years reckonable residence on the date of

submission. Only legal residence in the State on work permit, work authorisation or working visa conditions will be counted as reckonable

residence.

Temporary Skilled Migration (Work Permit):

• This is an employer-sponsored visa.

• Non- European Economic Area (EEA) nationals require a work permit.

34

FINAL Contrastive Country Audit

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• No English language requirements have been set for eligibility purposes.

Key Trends Registration standards have been stable over time.

Target Groups Medicine, Dentistry and Pharmacy: English proficiency tests are usually a requirement for individuals who are not members of the European

Union (EU) or the EEA.

Nursing: In addition to the above, applications are not accepted from the following:

• Non-EU trained nurse or midwife who has not been engaged in the practice of nursing/ midwifery during the five years prior to the

application date; or

• State Enrolled Nurse only, State Certified Nurse only, Licensed Practical Nurse only, Vocational Nurse only, USA Associate Degree only or

Nurses Aide only; or

• An applicant who undertook only the June 2006 examination in the Philippines; or

• Bulgarian qualification of ‘фелдшер’ feldsher only (EU/2005/36 Directive Article 23a)

Physiotherapy: There are no exempt groups.

Governance Irish Medical Council Irish Nursing Board (An

Bord Altranais)

Dental Council (Comhairle

Fiacloireachta)

Irish Society of Chartered

Physiotherapists

Pharmaceutical Society

of Ireland (PSI)

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

General comment Please see note in Target

Groups section.

English language test

results are a

requirement to sit the

Dental Council exam.

EU and EEA applicants

must make a

Statutory Declaration

that they are

competent to do

business in English.

IELTS (Academic) Overall: 7, Speaking: 6.5,

Writing: 6.5,

Listening: 6.5,

Reading: 6.5

Overall: 7, Speaking: 7,

Writing: 7, Listening:

6.5, Reading: 6.5

Overall: 7, Speaking: N/A,

Writing: N/A,

Listening: N/A,

Reading: N/A

Overall: 7, Speaking: 6.5,

Writing: 6.5,

Listening: 6.5,

Reading: 6.5

Overall: 7, Speaking: 7,

Writing: 6.5,

Listening: 6.5,

Reading: 6.5

TOEFL iBT

Not accepted Not accepted Overall: 100, Speaking:

N/A, Writing: N/A,

Listening: N/A,

Reading: N/A

Not accepted Overall: 97, Speaking: 27,

Writing: 25, Listening:

25, Reading: N/A

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FINAL Contrastive Country Audit

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TOEFL PBT Not accepted Not accepted Overall: 600, TSE:N/A,

TWE: N/A, Listening:

N/A, Reading: N/A,

Structure: N/A

Not accepted Overall: 590, TSE:N/A,

TWE: 5.5, Listening:

59, Reading: 56,

Structure: 56

TOEFL CBT

(discontinued

test)

Not accepted Not accepted Overall: 250, TSE: N/A,

TWE:N/A, Listening:

N/A, Reading: N/A,

Structure: N/A

Not accepted Not accepted

Additional

Conditions

• Results must be

achieved in one

sitting (not explicitly

stated in policy but

emerged from

interview with

Medical Council)

• IELTS results are valid

for 2 years.

• Results must be

achieved in one

sitting.

• Test results are valid

for 2 years or must

provide evidence of

having worked full

time as a nurse in an

English-speaking

environment since

the test.

Tests results are valid for

2 years prior to

application date.

Results do not need to be

obtained in one

sitting.

Not stated • IELTS and TOEFL iBT

must be attempted in

same sitting.

• Tests are valid for 2

years or applicant

must provide

evidence of having

lived and worked or

studied full time in an

English speaking

context.

Exemptions

Applicant is exempt if they

have:

• a recognised

qualification under

the Registration

Rules; or

• a basic medical

degree /internship

training through

English

• passed the United

States Medical

licensing Examination

EU-trained applicants are

exempt.

Applicant may be entitled

to acquired rights if

they have worked in

an EU country in 3 of

the previous 5 years

depending on the

country [from

interview but not

explicitly stated in

policy]

Applicant is exempt if:

• they are nationals of

EEA Member States;

or

• their dentistry degree

was obtained through

English.

There are no exemptions. If applicant:

• has qualification from

an EU or European

Economic Area (EEA)

member state; or

• is a national of a

member state of the

EU or EEA; or

• has passed at least six

subjects in the Irish

Leaving Certificate

examination.

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FINAL Contrastive Country Audit

5 November 2012

(UMSLE) from 2004

• a Cambridge ESOL

CAE - CEFR Level C1

Policy

Developments

Under the revision of the EU directive, the relevant authorities should be able to ask for proof of English competence prior to registration if

deemed necessary [from interviews with Nursing and Dentistry informants – policy not yet finalised].

4. New Zealand

Policy

Overview Overview: The Boards / Councils require that applicants prove their English proficiency through evidence of successful completion of a prescribed

English test. Further, the assessment of communicative competence is embedded in clinical examinations where these are required as part of

the pre-registration process. Councils have a discretionary power to require applicants to provide proof of English language competence at any

time.

Test options: For the purposes of professional registration, passes are required in the IELTS or OET tests, as defined below.

National

Variability

None

Skilled Migration Permanent Skilled Migration (Skilled Migrant Category):

• Minimum requirement is an overall score of 6.5 in the IELTS General Training or Academic module.

• Evidence may be provided that minimum English proficiency requirements are met, for example if the applicant’s qualification was gained

through a course of study in which English was the only medium of instruction. This is decided on a case-by-case basis.

Temporary Skilled Migration (Essential Skills Work Category):

• This visa is for applicants who have a job offer from a New Zealand employer.

• Applicants must be fully or provisionally registered in New Zealand, details are listed below.

Key Trends February 2010: Health sector regulatory bodies receive a proposal from Health workforce NZ (HWNZ) on behalf of the Ministry of Health

suggesting select shared functions for all health-related regulatory authorities together with reduction in the number of regulatory authority

board members to improve workflow efficiencies in processing registration, rectification and professional standards.

Target Groups Health professionals who gained their qualifications from a non-English speaking country are required to submit evidence of English proficiency.

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FINAL Contrastive Country Audit

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Governance Medical Council of NZ

(MCNZ)

Nursing Council of NZ Dental Council of NZ

Physiotherapy Board of

NZ

The Pharmacy Council of NZ (PCNZ)

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

IELTS (Academic) Overall: N/A, Speaking:

7.5, Writing: 7,

Listening: 7.5,

Reading: 7

Overall: 7, Speaking: 7,

Writing: 7,

Listening: 7,

Reading: 7

Overall: 7.5, Speaking:

7, Writing: 7,

Listening: 7,

Reading: 7

Overall: 7.5, Speaking: 7,

Writing: 7, Listening:

7, Reading: 7

Overall: 7.5, Speaking: 7, Writing: 7,

Listening: 7, Reading: 7

OET Not accepted Overall: B, Speaking: B,

Writing: B,

Listening: B,

Reading: B

Overall: N/A, Speaking:

B, Writing: B,

Listening: B,

Reading: B

Overall: N/A, Speaking: B,

Writing: B, Listening:

B, Reading: B

Overall: B, Speaking: B, Writing: B,

Listening: B, Reading: B

Additional

Conditions

• IELTS is the only

English test

approved by the

Council.

• Results must be

obtained in one

sitting.

• IELTS test results

are valid within 2

years of

registration

application. Or 2

years of NZREX

exam date (for

new candidates).

Repeat candidates

do not need to

IELTS:

Band 7 in each Sub-test

must be achieved

within 12 months

of first sitting the

test.

Results do not need to

be achieved in a

single sitting.

OET and IELTS results

must be obtained

within 2 years of

the date of

application for

registration.

• Results must be

obtained in one

sitting.

• Results are valid

for 2 years for new

applications or 3

years for repeat

registration exam

candidates who

have lived and

worked in a

country where

English is the first

language.

• The Council has

discretionary

power to require

For postgraduate

physiotherapy

students, who have

not received their

primary

physiotherapy degree

in New Zealand the

Board will accept the

academic acceptance

criteria and English

language criteria of

the educational

institutions/organisat

ions.

• OET and IELTS results must be

obtained within 2 years of the

date of application.

• OET results do not need to be

achieved in one sitting

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FINAL Contrastive Country Audit

5 November 2012

resit IELTS for up

to five years of last

NZREX attempt uf

they have been

residing

continuously in the

countries listed

below.

an applicant to

provide proof of

English language

competence at any

time.

Exemptions

• If primary medical

qualification is

from: NZ,

Australia, the UK,

Ireland, USA,

Canada or a South

African medical

school where

English is the sole

language of

instruction; or

• If applicant:

Completed at least

24 months FTE of a

PG qualification at

the University of

Otago or the

University of

Auckland, and

provide references

from two

professors; or

• Has evidence of

continuous work

as a registered

medical

practitioner in an

Nurses who have

qualified and

gained registration

in Australia.

• If applicant

graduated from a

joint Dental

Council

(NZ)/Australian

Dental Council

accredited

program; or

• English is the

applicant’s first

language; and the

applicant

completed their

UG dental training

in NZ, Australia,

UK, USA, Ireland or

Canada where

English is the sole

language of

instruction and

assessment.

• If applicant can

demonstrate

continuous practice

as a registered

physiotherapist for at

least 2 years within

the 3 years

immediately prior to

application in one of

the following

countries:

• England, Wales,

Scotland, Northern

Ireland, Eire, Canada,

Australia, South

Africa and/or USA,

where English was

the first and primary

language used in the

physiotherapy

practice setting; and

provide details of

two referees (similar

to that for Medicine).

• International students who

completed their Pharmacy training

in NZ are exempt (from interviews

– not explicitly stated in policy)

• If applicant is registered in

Australia unless the PCNZ finds

that the applicant does not

communicate effectively in English

in which case the PCNZ reserves

the right to place restrictions on

eligibility to practise.

For those who are not registered in

Australia, Canada, Ireland, UK or

USA they may be exempt:

• If English is the official language of

the applicants’ country; and

• Have evidence of completion of

UG pharmacy degree where Eglish

was the sole language of

instruction and assessment; and

• Have written testimony by an

employer of applicant’s

continuous work in pharmacy

where English was the first

language for at least 2 years within

the previous 5 years.

• Have written testimonies on

39

FINAL Contrastive Country Audit

5 November 2012

institution where

English was the

first and prime

language for at

least 2 years

within the 5 years

prior to

applications6; or

• Was registered

with the MCNZ on

or after 18 Sept

2004 and whose

registration was

cancelled for administrative

reasons7.

letterhead signed by at least 2

suitably experienced pharmacists

who speak English as a first

language of applicant’s ability to

comprehend and communicate

effectively in written and oral

English in a clinical setting with

patients and colleagues.

For those who are registered in

Australia, Canada, Ireland, UK or

USA they may be exempt:

• If English is their first language; or

• They pass the English test as

specified by the above

requirements (IELTS must be

obtained in one sitting; unclear if

this is also the case for OET); or

• If they have an approved

IELTS/OET exemption through

provision of written testimonials

as set out for applicants for other

countries.

5. Singapore

Policy

Overview Overall: Each health profession below has its own regulatory authority that sets the English language requirements.

Test options: For the purposes of professional registration in Medicine and Pharmacy, passes are required in the IELTS, OET or TOEFL tests, as

6 Must provide names and contact details of at least two referees who are senior suitable medical practitioners who speak English as a first language and who can attest to

the applicant’s ability to comprehend and communicate effectively in English in a clinical setting with both patients and professional colleagues. 7 Must provide names and contact details of at least two referees as detailed above.

40

FINAL Contrastive Country Audit

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defined below.

National Variability None

Skilled Migration

Permanent Skilled Migration (Professionals/Technical Personnel and Skilled Workers Scheme):

• No English language requirements have been set.

• Applicants must hold a P or Q pass8 or S Singapore employment pass.

Temporary Skilled Migration (S Pass – employer sponsored visa):

• No English language requirements have been set.

Key Trends Physiotherapy from January 2011: Physiotherapists must be registered with the Allied Health Professions Council, a national regulatory body

for allied health professions. English language standards have not yet been set and were not previously in place.

Pharmacy from September 2008: Singapore Pharmacy Board reconstituted as Singapore Pharmacy Council for rigorous registration processes.

Medicine: English language requirements have been consistent over time, and are set by Singapore Medical Council.

Nursing, Dentistry: No English proficiency standards are in place, as set by Singapore Nursing Board and Singapore Dental Council, respectively.

Target Groups Doctors and pharmacists who were not taught and assessed in English:

• Applicants need to sit an English test.

• Exemptions exist for pharmacists with a degree from the United Kingdom, United States of America, Canada, Australia or New Zealand.

Physiotherapy, Nursing, Dentistry:

• No test requirements are in place.

Governance Singapore Medical Council Singapore Nursing Board Singapore Dental Council Allied Health Professions

Council

Singapore Pharmacy

Council

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

General comment • No formal English

tests are mandated

however informal

assessments of

English language skills

are embedded in

• No specific policy on

English standards or

testing was stated on

the website.

• Must have a

Singapore Dental

• No specific policy on

English standards or

testing was stated on

the website.

• From January 2011,

physiotherapists must

8 The fixed monthly salary of the applicant determines whether the applicant is eligible for a P or Q pass.

41

FINAL Contrastive Country Audit

5 November 2012

face-to-face

interviews conducted

in source countries.

• Applicants must have

completed a nursing

program equivalent

to an accredited

program in Singapore

and have a job offer.

Decided on a case-by-

case basis.

Council-recognised

degree or must sit

exam.

• Applicants are

exempt if degree is

attained in UK, NZ,

USA, Australia,

Canada, Hong Kong

and Ireland.

register under the

Allied Health

Professional Bill

which is still under

development.

IELTS (Academic) Overall: N/A, Speaking: 7,

Writing: 7, Listening:

7, Reading: 7

Not applicable Not applicable Not applicable Overall: 7, Speaking: 7,

Writing: 7, Listening:

7, Reading: 7

OET Overall: N/A, Speaking: B,

Writing: B, Listening:

B, Reading: B

Not accepted

TOEFL iBT

Overall: 100, Speaking:

N/A, Writing: N/A,

Listening: N/A,

Reading: N/A

Overall: 94, Speaking: 26,

Writing: 24, Listening:

22, Reading: 22

TOEFL PBT Overall: 600, TSE: N/A,

TWE: N/A

Overall: 587, TSE: 50,

TWE: N/A, Listening:

N/A, Reading: N/A,

Structure: N/A

TOEFL CBT

(discontinued test)

Overall: 250, TSE: N/A,

TWE: N/A

Overall: 240, TSE: 50,

TWE: N/A

Additional

Conditions

Test results must be

obtained in one

sitting9.

All tests valid for 2 years

from test date

Test results are valid for 2

years and must be

obtained in one

sitting10

.

9 This is not formally stipulated on the Singapore Medical Council website but emerged from the written data provided by senior Council members

10 This is not formally stipulated on the Singapore Pharmacy Council website but emerged out of the interview with senior Council members.

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FINAL Contrastive Country Audit

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Exemptions

Applicants are exempt if

the instruction of

their basic medical

course was in English.

Employer-sponsored

nurses are exempt

from a face-to-face

interview as the

employer has

screened them and

apply to SNB on their

behalf.

Not applicable Not applicable Applicants are exempt if

their pharmacy

degree was attained

in the UK, USA,

Canada, Australia or

NZ.

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6. South Africa Please note:

Despite a range of approaches made over several months, it did not prove possible to arrange interviews with South African key informants. The

information below is thus wholly web-sourced, and may be less current.

Policy

Overview Overall:

Test options: Where applicable, IELTS is the accepted test.

National Variability Medicine, Dentistry and Physiotherapy exist within the Health Professions Council of South Africa (HPCSA) and have similar requirements. No

information was listed for Nursing.

Skilled Migration

Permanent Residence can be applied under the following permits:

Work Permit: Applicants must have a job offer/contract on a permanent basis from their future employer. It must be demonstrated that the

position was advertised and that no South African citizens or permanent residents could fill the position. This is subject to yearly limits of

available permits.

Temporary Residence:

General Work Permit: Employer must demonstrate that no citizens/permanent residents could fill the role and document proof of efforts.

Candidate’s proof of qualifications must be evaluated by South African Qualifications Authority. Candidate must also have proof of:

registration with the professional body where applicable; and their experience and skills in line with the job offer.

Quota Work Permit: Candidates apply for this permit if their profession is listed in the government gazette list where quotas for the maximum

number of foreign workers are stated. Applicants must have 5 years experience in their occupation.

Exceptional Skills Work Permits: Similar to the Quota Work Permit but is broader and does not involve a published list of occupations. The

applicant must have: a letter from a foreign or South African organ of state or from an established South African academic, cultural or

business body confirming the exceptional skills of the applicant; and publications and testimonials to substantiate exceptional skills or

qualifications.

Note: No English language requirements were stated on the Department of Home Affairs website for any of these permits.

Key Trends HPCSA was established in 1928 with most recent changes to the Health Act made in 2007.

Target Groups Overall: Those who obtained a qualification in a language other than English.

Governance HPCSA - Medical and

Dental Board

South African Nursing

Council (SANC)

HPCSA - Medical and

Dental Board

HPCSA - Professional

Board for

South African Pharmacy

Council

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FINAL Contrastive Country Audit

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Physiotherapy,

Podiatry and

Biokinetics

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

General comment Practitioners who

obtained their

qualifications in a

language other than

English must

complete the IELTS.

No information around

English standards was

listed on website.

SANC has been contacted

directly via email.

Practitioners who

obtained their

qualifications in a

language other than

English must

complete the IELTS.

English language

proficiency is

assessed as part of

the Examination for

Registration. The test

comprises a

theoretical and

practical/clinical exam

with latter involving

two examiners and a

moderator.

English standards set

below are for the

qualification for entry

into the Professional

exam.

IELTS (Academic) Overall: 6, minimum

individual band scores

not stated

Overall: 6, minimum

individual band scores

not stated

N/A Overall: 6, minimum

individual band scores

not stated

Additional

Conditions

Candidates’ academic

written and verbal

skills relating to

academic language

are informally

assessed during the

Board’s examination

when applicable.

No specific statements

were made regarding

test validity period or

the ability to use

results from multiple

sittings.

Candidates’ academic

written and verbal

skills relating to

academic language

are informally

assessed during the

Board’s examination

when applicable.

No specific statements

were made regarding

test validity period or

the ability to use

results from multiple

sittings.

No specific statements

were made regarding

test validity period or

the ability to use

results from multiple

sittings.

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FINAL Contrastive Country Audit

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Exemptions

Candidates from English

speaking countries

and candidates with

English as a first or

second language

qualification on

secondary school

level are exempt.

Candidates from English

speaking countries

and candidates with

English as a first or

second language

qualification on

secondary school

level are exempt.

No exemptions stated on

website.

7. United Kingdom

Policy

Overview Overall: Each health profession below has its own regulatory authority that sets the English language requirements.

Test options: For the purposes of professional registration, passes are required in the IELTS, as defined below.

National Variability None

Skilled Migration

Permanent Skilled Migration and Temporary Skilled Migration (Tier 1 (General) and Tier 2):

Applicants can score up to 10 out of 100 points for English language ability. They must score points in this area or their application will be

refused.

• A large range of tests are accepted including: IELTS, TOEIC and TOEFL iBT. The full list is available from:

www.ukba.homeoffice.gov.uk/sitecontent/applicationforms/new-approved-english-tests.pdf

• Minimum requirement is Level C1 of the Common European Framework of Reference (CEFR) in all 4 components.

Key Trends Physiotherapy: Physiotherapy (along with 14 other health professions) is regulated by the Health Professions Council which was set up by the

Health Professions Order 2001. From 1 April 2011, TOEFL and Cambridge International General Certificate of Secondary Education are no

longer accepted.

Nursing: As of February 2007, the Nursing & Midwifery Council (NMC) decided that a score of 7 was the lowest level acceptable for language

skills for nurses (previously 6.5). This change resulted from public consultations and evidence collected from the British Council.

Medicine, Dentistry: English language requirements have been stable.

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FINAL Contrastive Country Audit

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Pharmacy: Policy on English language requirements was only implemented in 2002. Prior to that, English testing was not required.

Target Groups Overall: Non-EU and non-EEA nationals are generally required to sit an English test.

Governance General Medical Council

(GMC)

Nursing & Midwifery

Council (NMC)

General Dental Council

(GDC)

Health & Care Professions

Council (HCPC)

• General

Pharmaceutical

Council (GPhC)

• Pharmaceutical

Society of Northern

Ireland (PSNI)

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

General comment IELTS scores must be valid

when applicants sit

the PLAB Part 1 test.

Overseas qualified

dentists must sit the

Overseas Registration

Exam (ORE) if they

are not eligible for

exemption.

Candidates must

submit passed IELTS

results for the

purpose of the ORE.

IELTS is the accepted test.

Applicants are

strongly advised to

contact HPC first if

they propose to rely

on an alternative test.

Non-EEA applicants need

to complete an

Overseas Pharmacists

Assessment Program

(OSPAP) programme

before they can apply

for registration.

Applicants may also

be interviewed as part

of this process to

verify their clinical

knowledge.

IELTS (Academic) Overall: 7, Speaking: 7,

Writing: 7, Listening:

7, Reading: 7

Overall: 7, Speaking: 7,

Writing: 7, Listening:

7, Reading: 7

Overall: 7, Speaking: 6.5,

Writing: 6.5,

Listening: 6.5,

Reading: 6.5

Overall: 7, Speaking: 6.5,

Writing: 6.5,

Listening: 6.5,

Reading: 6.5 Website did not state

whether Academic or

General Training is

required.

England, Scotland and

Wales: Overall: 7,

Speaking: 7, Writing:

7, Listening: 7,

Reading: 7

Northern Ireland: Not

stated on website.

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FINAL Contrastive Country Audit

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PSNI has been

contacted, awaiting

reply.

Additional

Conditions

• Results must be

achieved in one

sitting.

• Results are valid for 2

years.

• Results are valid for 2

years. Where the test

score is more than

two years old, it can

only be accepted as

evidence of present

level of ability if the

person can prove that

they have actively

used or tried to

improve their English

language proficiency.

• Results must be

achieved in one

sitting.

• Results are valid for 2

years.

Not stated on website. • Results must be

achieved in one

sitting.

• Results are valid for 2

years. If successful

results are over 2

years old applicants

do not need to re-sit if

within the last 2 years,

they have completed

a postgrad course of

study (taught and

examined solely in

English). Or providing

a reference from an

employer/tutor/

lecturer covering at

least 3 months FT

employment or study.

Exemptions

• EU nationals are

exempt. No other

exemptions apply.

The following exemptions

apply to the ORE and

by extension, English

testing:

• Applicants who

gained their primary

dental qualification

from a university in

the EEA or

Switzerland; or

• Applicants with select

qualifications from

Hong Kong,

• EU nationals or those

who are entitled to

be treated as

nationals are exempt.

• Nationals of the EEA,

or anyone with a

European Commission

(EC) right, or Swiss

Nationals who benefit

under European law

(since 1 June 2002)

are exempt at

application stage.

However they are still

required to meet the

GPhC’s code of

conduct and to ‘have

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FINAL Contrastive Country Audit

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Singapore, Malaysia,

South Africa, New

Zealand and Australia,

some of which had to

have been completed

before 2001.

the language skills to

communicate and

work effectively with

colleagues’. In some

instances, EEA

nationals may be

required to complete

the OSPAP (as decided

on a case-by-case

basis).

• GMC may consider

evidence other than

an IELTS certificate

unless applicants have

already taken the

IELTS and failed. In

which case, they must

retake the IELTS and

achieve the required

scores.

Policy

Developments

Key informants have suggested that in practice, there has been a decoupling of qualification recognition and language testing in the EU

Directive, whereby EU applicants may be asked to demonstrate English competence on a case-by-case basis.

The EU Directive is currently undergoing a review process, with a range of key informants anticipating changes will be made to enable language

testing of EU/EEA health professionals throughout the EU, in addition to third country nationals.

8. United States of America

Policy

Overview Overall: Professional registration requirements for health professionals vary greatly among states. Generally, foreign trained professionals must

demonstrate their proficiency in English by exam or if certified by a sponsor. To demonstrate the range of English testing requirements,

details are provided for the 5 most populous states (California, Texas, New York, Florida, Illinois, Vermont and Wyoming) compared with

the 2 least populous states (Vermont and Wyoming).

Test options: For the purposes of professional registration, passes are required in the IELTS, TOEFL and TOEIC, as defined below.

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FINAL Contrastive Country Audit

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National Variability

Medicine: English language requirements are uniform.

Dentistry: Requirements for Dentistry were not stated on the website.

Nursing, Physiotherapy and Pharmacy: Requirements are generally consistent with the standards set by the relevant national body. However

there is some variation between states.

Skilled Migration Permanent Skilled Migration (Employment-based Immigration: Third Preference EB-3):

• No English language requirements were stated on the website.

Temporary Skilled Migration (Temporary Non-immigrant Workers):

• No English language requirements were stated on the website.

Key Trends Overall: The professions generally have a national body or credentialing authority that sets English language requirements. State boards are

responsible for licensure and are typically able to apply additional requirements. English assessment was embedded in the United States

Medical Licensing Examination (UMSLE) from 2004.

Target Groups Overall: Health professionals from a non-English speaking country are generally required to sit an English test.

Governance

(National and

Select State

Bodies)

National

• Federation of State

Medical Boards (FSMB)

• Educational

Commission for

Foreign Medical

Graduates (ECFMG)

Select States

• Medical Board of

California

• Texas Medical Board

• NY State Board of

Medicine

• Florida Board of

Medicine

• Illinois Department of

Financial and

Professional

Regulation Division of

Professional

National

• National Council of

State Boards of

Nursing (NCSBN)

• Commission on

Graduates of Foreign

Nursing Schools

(CGFNS)

Select States

• California Board of

Registered Nursing

• Texas Board of

Nursing

• NY State Board of

Nursing

• Florida Board of

Nursing

• Illinois Board of

Nursing

• Vermont State Board

National

American Dental

Association (ADA)

Select States

• Dental Board of

California

• Texas State Board of

Dental Examiners

• New York State Board

for Dentistry

• Florida Board of

Dentistry

• Illinois State Board of

Dentistry

• Vermont Board of

Dental Examiners

• Wyoming Board of

Dental Examiners

National

• Federation of State

Boards of Physical

Therapy

• Foreign Credentialing

Commission on

Physical Therapy

(FCCPT)

Select States

• Physical Therapy

Board of California

• Texas Board of

Physical Therapy

Examiners

• Physical Therapy,

Podiatry &

Ophthalmic

Dispensing Office of

the Professions NY

State Education

National

• National Association

of Boards of

Pharmacy (NABP)

• Foreign Pharmacy

Graduate Equivalency

Committee (FPGEC)

Select States

• California State Board

of Pharmacy

• NY State Board of

Pharmacy

• Florida Board of

Pharmacy

• Illinois Department of

Financial and

Professional

Regulation Division of

Professional

Regulation – State

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FINAL Contrastive Country Audit

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Regulation

• Vermont Board of

Medical Practice

• State of Wyoming

Board of Medicine

of Nursing Department

• Florida Board of

Physical Therapy

• Illinois Department of

Professional

Regulation

• Office of Professional

Regulation, Vermont

• Wyoming Board of

Physical Therapy

Board of Pharmacy

• Vermont Board of

Pharmacy

• Wyoming State Board

of Pharmacy

Test Instruments and Levels

Instrument Medicine Nursing Dentistry Physiotherapy Pharmacy

General Comments • English assessment

component is

embedded within the

Clinical Skills

Assessment (Step 2) of

the UMSLE. Applicants

must pass this hurdle.

• No separate English

language requirements

exist.

• Applicants must pass

the UMSLE but must

first get Educational

Commission for

Foreign Medical

Graduates (ECFMG)

certification in order to

sit the USMLE.

• Graduate Medical

Education (GME) is a

• Most states require

applicants to

complete the

Commission on

Graduates of Foreign

Nursing Schools

(CGFNS) certification

program, a part of

which is the

requirement to pass

an English proficiency

exam. Such states

include New York,

Vermont and

Wyoming.

• Texas, Florida and

Illinois have separate

requirements11

.

• Requirements for

California were not

English standards were

not stated on the

website.

• Requirements for

California, New York

and Vermont were

not stated on the

website.

• Applicants need to

satisfy requirements

for FPGEC which sets

general standards on

English proficiency.

• Requirements for

Wyoming were not

stated on the

website.

11

It was unclear from the websites whether CGFNS certification was also a requirement for these states.

51

FINAL Contrastive Country Audit

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requirement for

unrestricted licence to

practice and varies

between states.

stated on website.

IELTS Not applicable New York, Vermont,

Wyoming:

Overall: 6.5 (no min

scores stated for

individual

components)

Texas:

Overall: 6.5, Speaking: 6,

Writing: 6, Listening:

6, Reading: 6

Florida:

Overall: 6.5, Speaking: 7,

Writing: N/A,

Listening: N/A,

Reading: N/A

No information stated on

website.

Not accepted Not accepted

TOEFL iBT

New York, Vermont,

Wyoming, Texas,

Illinois:

Overall: 83 (no min scores

stated for individual

components)

Florida:

Overall: 76

Texas, Florida, Illinois:

Overall: 89, Speaking: 26,

Writing:24, Listening:

18, Reading: 21

California, Texas, New

York, Florida, Illinois,

Vermont:

Overall: N/A, Speaking:

26, Writing:24,

Listening: 18,

Reading: 21

TOEFL PBT New York, Vermont,

Wyoming, Florida:

Overall: 540 (no min

scores stated for

individual

components)

Wyoming only:

Overall: 560, TWE:4.5

Florida only:

Overall:550, TSE:50 (no

other min scores

stated for individual

components)

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FINAL Contrastive Country Audit

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Texas:

Overall: 560, TSE:50,

TWE:4

Illinois:

Overall: 560

TOEFL CBT New York, Vermont,

Wyoming, Illinois :

Overall: 220

Texas:

Overall: 220, TSE:50,

TWE:4

Florida:

Overall: 207

Not accepted Florida only:

Overall: 213, TSE:50 (no

other min scores

stated for individual

components)

TOEIC New York, Vermont,

Wyoming, Florida:

Overall: 725 (no min

scores stated for

individual

components)

Not accepted Not accepted

MELAB Florida only:

Overall: 79

Not accepted Not accepted

ECPE Florida only:

Overall: MELAB converted

score of 79

Not accepted Not accepted

Conditions Not applicable No applications are

currently being

accepted from

applicants educated

in Haiti.

Not stated on website Not stated on website • TOEFL iBT must be

completed in one

testing session.

• Candidates must take

the TOEFL iBT in a

test centre located

within one of the

NABP member and

associate member

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FINAL Contrastive Country Audit

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jurisdictions

including:

o the 50 states of

America*;

o District of

Columbia;

o Guam;

o Puerto Rico;

o Virgin Islands;

o 8 Canadian

provinces; and

o New Zealand.

• TOEFL PBT and TSE

scores are only

accepted from

candidates if they

applied for FPGEC

(Foreign Pharmacy

Graduate Equivalency

Committee)

Certification before 1

April, 2010 and took

the exam before 30

June, 2010.

Exemptions

Applicants who received

their basic medical

degree or qualification

from a medical school

in Canada that is listed

in the International

Medical Education

Directory (IMED).

Texas: If nursing program

was conducted in

English.

New York:

• Passing the Canadian

Nurses Association

Test (CNATS).

New York, Vermont,

Wyoming:

• If nursing education

was in Australia,

• Canadian

practitioners get

eligible accreditation

through a reciprocal

agreement with

Commission on

Dental Accreditation

of Canada (CDAC).

• In 2002 the Dental

Board of California

implemented a

Not stated on website. There are no exemptions.

Applicants must sit the

test if they did not

complete a program

accredited by the

Accreditation Council

for Pharmacy

Education (ACPE)

which only lists US

jurisdictions.

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FINAL Contrastive Country Audit

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Barbados, Canada

(and select schools in

Quebec), Ireland,

Jamaica, New

Zealand, South Africa,

Trinidad and Tobago,

the UK; and

• Textbook and

instruction was in

English.

Florida:

• If nursing coursework

was in English and

English textbooks

were used.

Illinois:

• If first language is

English

process to approve

dental schools

outside the US and

Canada. Graduates of

those approved

dental school will be

able to sit for the

California Dental

Board

55