Navigating Professional Registration and Development Pathways: Perspectives of Healthcare Practitioners

The Saudi Commission for Health Specialties (SCFHS) has undertaken a comprehensive evaluation of its registration and classification services to pinpoint areas for optimization. Recognizing healthcare professionals as essential stakeholders, SCFHS actively solicited their perspectives to better understand their needs and to collect actionable suggestions for service enhancement. Employing a multifaceted research approach, this study utilized focus groups, a large-scale survey involving over 700,000 healthcare practitioners, and comparative benchmarking against selected G-20 nations. The findings indicate a strong desire among practitioners for a reorganisation of the current registration and classification procedures. Notably, there was a consensus for extending the registration period, with a predominant preference for a five-year duration. Participants also advocated for various improvements, such as an increase in Continuing Medical Education (CME) hours, financial cost reductions, and streamlining of registration processes. While benchmarking revealed that SCFHS's existing registration durations are generally on par with other G-20 countries, it also highlighted potential opportunities for diversifying registration types to better meet the needs of healthcare professionals.


Introduction
The Saudi Commission for Health Specialties (SCFHS) is an independent scientific professional body, established in 1992, tasked with classifying health certificate holders, evaluating their certificates, setting the foundations and standards for practicing health professions, and conducting the professional registration of health practitioners.The central aim of the SCFHS is to ensure that the health practitioner is well qualified with the skills, knowledge, and competencies necessary to diagnose and treat the disease in a distinctive and safe manner.Given this aim, the SCFHS is currently assessing its processes for registration and classification services to identify areas for improvement and development.The purpose of this study is to obtain and gain meaningful insights into the opinions of healthcare practitioners in the Kingdom on topics related to professional registration, classification, and registration renewal criteria in order to build a better understanding of their overall experience.To achieve this, the current SCFHS process for registration renewals was benchmarked and compared with a representative sample of G-20 countries to understand key similarities and differences in terms of registration duration, registration types, and classifications.This paper, based primarily on the opinions of healthcare practitioners, provides a detailed analysis of the results obtained from the three sources, SCFHS Registration and Classification Survey, Focus Groups, and Medical Licensure Benchmarking.Based on the findings from these data collection methods and the comments received from health professionals, recommendations for consideration to improve the overall experience are included.

Background and Methodology
This section provides a summary of medical registration benchmarking and the methods used to obtain information from health professionals and benchmarking.

Medical Registration Benchmarking (G-20 Countries)
To begin the process, a benchmarking exercise was undertaken to compare the Saudi Commission for Health Specialties (SCFHS) licensing process and duration with a set of G-20 countries.Comparison of current SCFHS registration duration, type, and classification with G-20 countries provides an overview of the similarities and differences that the SCFHS has with these systems.This can help in understanding aspects of the current system that can be changed and any learning that can be translated to aid improvement efforts locally.

Focus Groups
A total of 96 participants with different professional ranks participated in the focus group exercise.Health professionals from the following professions attended: Dentistry, Physicians, Nursing, Pharmacy, and Allied Health Professionals.As part of the focus groups, participants were asked about their views on the current registration and classification processes, whether their current job roles matched their classification, adding more registration types, and their opinion about empowering employers with the authority to assign professional grades.(To obtain a copy of the questionnaire, please contact research@scfhs.org.sa).Information obtained from the focus groups was analyzed thematically.

SCFHS Registration and Classification Survey
Following focus group discussion, a custom survey was designed to better understand the experience of the health professionals using SCFHS registration and classification services more widely.The first domain requested health professionals to rate their experience of using the SCFHS application process for registration, re-registration, classification, re-classification, and new qualification study.The survey was distributed to respondents via SMS.Each respondent was provided a unique survey link to provide their responses.(For more information about the survey and the included questions, please contact research@scfhs.org.sa) The second domain covered SCFHS registration procedures, mainly asking participants whether the current registration period was appropriate, the ideal registration period, and the reasons for their responses.The third domain sought participants' views about professional classification, and the last domain was regarding professional development.
As part of the survey, respondents were also asked two main qualitative questions, firstly regarding the main challenges faced during the relevant application process, and secondly, what could be done to improve their experience.Thematic content analysis was used on a representative qualitative sample based on the health profession of the respondents to understand the main emerging themes from their comments (1, 2).

Summary of Respondents
In total, 722,687 health professionals were invited to participate, of which 51,289 completed the survey (Response Rate: 7%).This far exceeds the recommended sample size required given the survey population (3).Invited health professionals were MumarisPlus users from 2018 with valid registrations.Below is a breakdown of survey respondents based on demographic variables collected as part of the survey.

Results
This section summarises the key findings obtained from the benchmarking exercise, focus groups, and surveys administered to health professionals.

Licence Duration
The license duration observed in Saudi Arabia is two years for all main healthcare fields (Physicians, Nurses, Dentists, Pharmacists, and Allied Health Professionals (AHPs)).When compared with selected G-20 countries, this duration is comparable as these countries mostly follow a registration duration of one to two years apart from a few countries (4,5,6,7,8,9,10,11,12,13,14,15,16,17,18).A key question raised during the focus groups and survey was the appropriateness of the current license duration.The responses received from focus group participants and the wider survey were consistent.Over two-thirds of respondents to the wider survey said that the current registration duration of two years was not appropriate.This trend persisted across health professions, although it was less pronounced among the Nursing and Midwifery health professionals (44% of respondents felt that the registration period of two years was appropriate).

Figure 1: Do you think the current registration period of "two years" is appropriate for your profession?
Respondents to the survey were also asked about the ideal duration of registration and when asked 70% of health professionals overall stated five years.

Figure 2: In your view, what is the ideal registration renewal period for your profession?
This result was consistent across health professions with over 60% of health professionals in all health professions stating that they considered five years as the ideal registration period.
The majority of health professionals that would like to see the registration duration increased, felt that within the two years duration, there is often no change in professional practice (62%).Many also stated that the current registration renewal process required improvement and that they did not want to repeat this process every two years (39%).Respondents also felt that an Additionally, some respondents also stated that a lack of vacancies made it difficult to accumulate the hours required for renewal and therefore would benefit from increasing the duration of registration.For instance, one respondent stated:

"The classification period is very short in relation to the lack of jobs and the difficulty of renewal…" (Translated from Arabic) [Laboratory and Medical Technology Respondent 20672]
On the other hand, among health professionals who felt that the current registration duration was sufficient (32%), the majority stated that it was required to keep health practitioners appraised on their specialty through continuous professional development (72%).

Classification Ranks
Key questions asked as part of the focus groups were regarding matching of health professional job grade with SCFHS classification, employer's reliance on SCFHS classification, empowering employers to determine job grade (classification rank), the impact of such changes on patient safety and community practice, adding more categories for professional registration, experience with the SCFHS registration renewal service, and re-registration requirements.
Overall, participants were in favor of empowering employers to determine job grades (classification rank).This could be due to the focus group participants also reporting that there was a mismatch between the classification assigned to them by the SCFHS and the job grade they had been assigned by their employer.
The survey asked health professionals about their professional classification.Firstly, health professionals were asked if they were working in the same health profession as their professional classification.87% of health professionals stated that they were indeed working in the same health profession as their SCFHS classification.The highest proportion of health professionals not working in the same health profession as their SCFHS Classification were in Health Administration and Community Health (40%), followed by Therapy and Rehabilitation (32%), and Technicians and Health Assistants (22%).Among health professionals not currently working in the same health profession, 36% were in the Ministry of Health.Similarly, 85% of health professionals confirmed when asked if their current professional grade was the same as the one listed in the SCFHS.Again, the highest proportion of health professionals for whom the current professional grade was not the same as the one listed in SCFHS were Health Administration and Community Health (33%), followed by Technicians and Health Assistants (26%), and Therapy and Rehabilitation (22%).A likely reason for this high proportion is the availability of job offers within these professional grades.

95%
In terms of SCFHS ranks, Assistant Specialists rank (43%) had the highest proportion of health professionals for whom the professional grade was not the same as the one listed in SCFHS.
For the majority of health professionals (61%), the professional grade was dependent on the SCFHS classification at their workplace.

Figure 4: What does your professional grade depend on in your workplace?
This was the case among all health professions, with the notable exception of Health Administration and Community Health where 38% of health professionals stated that their professional grade depended on the SCFHS classification.
As part of the changes being considered by the SCFHS, empowering employers with the authority to determine the professional grade is a key consideration.Therefore, as part of the survey, health professionals were asked about their opinion on whether employers should be given this authority.Figure 5 below provides a summary of the results.The majority of health professionals (68%) agreed that employers should indeed be empowered to assign professional grade.This result was consistent across health professions; however, as with previous questions regarding classification, Health Administration and Community Health had the highest proportion of professionals disagreeing (37%) along with Laboratories and Medical Technology (37%), and Dentistry and Related Specialties (35%).
Classification based on degrees and diplomas was also raised by respondents.Some respondents felt that they were being classified at a lower rank than what their degree warranted.,For example, one respondent stated that: On the other hand, some stated that classification was not available based on their degree.According to one technician: "There are no suitable classifications for some diplomas and master's degrees" (Translated from Arabic) [Technicians and Health Assistant Respondent 11335] While some respondents stated that their classification did not match their job grade, this was not the case for the majority of the respondents based on the survey results.Nonetheless, among the services offered by the SCFHS, the experience of using New Qualification Study services was rated the lowest by respondents to the survey.
When comparing classification ranks with select G-20 countries, these were unavailable for many countries.Some countries like Australia do not record classification ranks in accordance with registrations while others like the UK list registration types with respect to classifications.For instance, physicians in the UK are classified as: Foundation Year 1 (Provisional Registration), Foundation Year 2 and above (Full Registration), Specialist Consultant (Specialist Registration) and General Practitioner (GP Registration) (19).In Japan, licenses of Public Health Nurse, Midwife and Nurse are issued by the Ministry of Health, Labour, and Welfare whereas prefectural governors issue the Nurse Assistant License (15).In India, Dentists are ranked as: Dentist, Mechanics, and Hygienist (20) while in the UK they are ranked as Dentist and Dental care professionals (7).In South Africa, Pharmacists are ranked as: Pharmacy Student, Pharmacist Intern, Pharmacist, Responsible Pharmacist, Pharmacist's Assistant Basic, Pharmacist's Assistant Post-Basic and Pharmacy Technician (21) whereas in Canada they are ranked as: Pharmacy Technician and Pharmacist Registration (22).

Registration Type
Currently, only Full Registration is applied in SCFHS whereas variation in registration type is noticed in G-20 countries.In the UK full registration is implemented for Pharmacists and Nurses (12, 8), while there are four types of registration for physicians: Provisional, Full, Specialist and GP registration, and two types of registration for dentists: full and temporary registration (19).
In terms of registration duration, the current duration of 2 years followed by the SCFHS is comparable with those of other G-20 countries.However, unlike many G-20 countries, the SCFHS currently only provides one type of registration, Full Registration.Nonetheless, there are many similarities in the processes currently followed by SCFHS, in particular with Australia, both of which use a centralised system for registrations and renewals of health practitioners (23).

Discussion
The main purpose of this study was to obtain and gain meaningful insights into the opinions of all healthcare practitioners in the Kingdom on topics related to professional registration, classification, and CPD procedures to build a better understanding of their overall experience.
For this purpose, the SCFHS undertook a series of exercises to engage health professionals in discussing the current registration and classification procedures.The summary of key considerations provided below is based on the results obtained from these activities and can be considered by the SCFHS for implementation to improve the overall experience of health professionals with the registration and classification procedures.

Extending License Duration
A key aspect of discussion during focus groups and the wider survey of health professionals was the perceived appropriateness of the current registration period (two years).Over two-thirds of respondents to the survey (68%) stated that two years was insufficient and were in favour of increasing the registration period.Among these respondents, 70% were in favour of extending the registration period to five years.Importantly, the current license durations followed in Saudi Arabia (two years) are comparable to G-20 countries.Majority of the countries within G-20 for which information was available apply a registration duration of one or two years.There are some notable exceptions, such as the United Kingdom, that apply a duration of five years for Physicians (6), and Germany, where license renewal is not required (although registration with local Chamber of Physicians is required if moving provinces) (24).
Previously, the SCFHS applied a registration period of three to five years.However, there were challenges based on opposition to the clause of discontinuation from practice, as the practitioner is considered to be out of practice after two years of suspension, and registration is valid for five years.Therefore, the SCFHS modified registration for two years in accordance with the requirement of interruption of practice.
Additionally, health practitioners participating in the study linked the extension of license duration with difficulty obtaining CME hours.However, if the registration duration is increased, the required number of CME hours may also increase leaving the issue unresolved.Focusing on improving re-registration services and providing vocational development programs may therefore be a better option.

Changes to CME Hours
Results from the wider survey suggest that the majority of health professionals (67%) agreed that the number of professional development hours required for their specialty were suitable.However, there were challenges in fulfilling and completing the required CME hours within the current registration period.
Nonetheless, respondent comments do provide some challenges that SCFHS should work to overcome to improve the health professional experience.
• Cost of CME hour: Respondents noted that they needed to pay for CME hours which was increasing their financial burden.Fee charged for courses as part of CME hours should be reconsidered.

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Availability of free CME hours: Respondents have urged that SCFHS could consider arranging for free courses, lectures, or seminars to obtain their CME hours.This will ensure that the requirement is met on time and does not increase the financial burden on health professionals.

SCFHS Registration and Classification Process Improvements
Respondents to the survey stated that they found the registration and classification procedures complicated and would like to see the process simplified.
• Clarity of Requirements: Respondents requested more clarity regarding requirements for registration and classification.
Many respondents stated that the information available on the website was not easy to follow at times and that simplified requirements should be made available.
• Consider Staff Training: Respondents noted that it was at times difficult to contact SCFHS during the application process and that the whole application process took longer to complete or got delayed due to lack of communication.
• Reconsider classification process: Many respondents stated that the classification procedure should account for the experience.Currently, the classification awarded by SCFHS is based on the scientific qualification and experience does not replace scientific qualifications when granting a higher classification.
• Classification of Overseas Qualification: Respondents with overseas qualifications stated that their classifications took longer and at times were not appropriate or did not match their qualifications.There should be a clear and transparent process of classification in conjunction with an easily accessible appeal mechanism that will guarantee non-conflict of interest for the authority issuing the classification.

Empowering Employers to Assign Professional Grade
A central question asked of participants in the survey and the focus groups was about their thoughts regarding SCFHS dealing with the registration of the health professionals, while the employer is empowered to assign the professional grade.Within the focus groups and the survey, the majority of the respondents (68% of the survey respondents) were in favour of empowering employers with the authority to assign professional grades.

Additional types of Registration
Currently, the SCFHS only offers one type of registration -Full Registration, for all health specialities.Comparison with other G-20 countries shows that there is scope for the introduction of the other types of registration, such as temporary registrations.Respondents in the focus groups, when asked about introducing additional registration types, gave mixed responses.while some were in favour of adding more registration types, others felt that different registration types would lead to confusion.Additionally, SCFHS will need to provide clear guidance about their intended role, purpose and use to avoid any complexity in the process.

Conclusion
This study engaged health professionals to understand their perceptions and views about the current registration and classification process in Saudi Arabia.The study provides useful insights regarding the challenges currently being faced by health professionals and can inform improvement efforts to enhance the experience of practitioners using SCFHS services.

Figure 3 :
Figure 3: "Are you currently practicing in the same health profession of your SCFHS Professional Classification?" by Health profession.

Figure 5 :
Figure 5: In your view, do you see empowering employers with the authority to determine the professional grade (consultant/ specialist ----etc.) in accordance with the general controls specified by the SCFHS?
The classification does not correspond to the title of my graduation certificate" (Translated from Arabic) [Technicians and Health Assistant Respondent 13079]