SUMMARY OF SUBMISSIONS ON THE 2012 REVIEW OF THE HEALTH PRACTITIONERS COMPETENCY ASSURANCE ACT 2003.
INTRODUCTION
A total of 145 public submissions were received on the document entitled “2012 Review of the Health Practitioners Competence Assurance Act 2003” which was published in August 2012. The submissions came from a broad range of stakeholders, including Responsible Authorities, professional associations, health practitioner educators, health practitioners themselves, health service deliverers, government organisations, community organisations and consumers, as follows:
Respondent Group / Number of submissions / Respondent Group / Number of submissionsResponsible Authorities / 16 / Community groups who engage with health service consumers / 4
Professional Associations / 34 / Health care providers (non-DHB) / 5
Educators of health professionals / 28 / Individual consumers / 5
Groups of, or individual health professionals[1] / 35 / Unions / 2
Health sector employers / 2 / Government organisations / 5
International regulators / 1 / Law Society / 1
Unknown status / 7 / Total / 145
Appendix 1 of this summary contains the names of 140 submitters. The other five submitters requested that their names not be listed in the published summary of submissions.
The submissions have been summarised under 25 topics in 5 sections. The first 4 sections reflect the structure of the discussion document: ie Future Focus, Consumer Focus, Safety Focus and Cost Focus. The fifth section is a subset of the original Cost Focus section and is concerned with issues about the structure of the regulatory system.
The summary cannot reflect all comments or the nuances of each submission on any particular topic. It reflects the views most commonly expressed and from time to time reflects a single submission where the point made was striking or the perspective of the submitter seemed particularly valuable.
FUTURE FOCUS
The first discussion document suggested that the Act needs to balance its core function of protecting the safety of the public with its ability to influence the shape of the workforce and meet the needs of a changing sector. It suggested that the Act needs to support the development of a flexible and sustainable workforce and specifically that professional regulation needs to support the integration of care and the development of new service models.
The first discussion document also raised the following specific issues capable of making a contribution to the development of a sustainable workforce and the delivery of integrated care:
• scopes of practice
• the development of communication and team work skills
• pastoral care for practitioners
• the mobility of the health and disability workforce
• the standardisation of codes across health professions
• the promotion of education and training that has a wider focus and/or which is common across professions.
Workforce development
There were three strong themes in the response of submitters to this issue. Firstly, submissions tended to consider that the HPCA Act is not the predominant barrier to better integrated healthcare, increased flexibility and greater teamwork. Using the HPCA Act as a lever to increase integration, team work and workforce flexibility was therefore seen as likely to be minimally effective. Secondly, it was widely considered that some aspects of the current HPCA Act and the way in which Responsible Authorities are implementing it, already facilitate a flexible workforce. Thirdly, some submitters held strong opinions that the HPCA Act should not attempt to address any goals other than public safety because public safety would be likely to be compromised.
It was notable that many submitters were not clear about, or were concerned about the implications of using the terms “integrated care” and “flexible workforce”. In the case of “flexible workforce”, there was concern expressed that the consultation document reflected intentions that professionals would need to become highly generic workers and that there would be undesirable outcomes such as a lack of in-depth expertise, an absence of leadership in specialised areas and worsening recruitment and retention problems.
Education and training with a broader non-clinical focus
The consultation document discussed how integration of health care could be fostered by:
• registered practitioners having knowledge and skills in team work and communication
• shared education across professions in both initial and continuing education
There was widespread agreement that knowledge and skills in team work and communication would contribute to better integrated care. Many submissions gave instances of training in team work skills already occurring both at undergraduate and post graduate levels.
However, there was a lack of consensus about the role of Responsible Authorities in promoting those skills. Some submissions considered that such skills are not clinical skills, and therefore are not the business of Responsible Authorities.
There was some scepticism about the appropriateness of the Act directly addressing the need for a wider focus on the education of health professionals.
The submission of the Health and Disability Commissioner pointed out that: “care integration is an important factor in quality service provisions and quality and safety are becoming increasingly dependent on how multidisciplinary teams and clinical networks operate. Failure or inadequacy in care integration is a recurring theme in complaints…. which often result in consumers receiving a poor standard of care.” The Commissioner also pointed out that Right 4(5) of the Code of Health and Disability Services Consumers’ Rights gives consumers a right to co-operation among providers to ensure quality and continuity of service.
There was a lack of consensus about whether teamwork skills should be part of under-graduate or post-graduate education. Some submitters thought that it was more appropriate for employers and the Ministry of Health than Responsible Authorities to be concerned with post-graduate education in teamwork skills.
There was a concern that common learning might become a “one size fits all” approach that will not support public safety. There was little evidence in the submissions of shared education across professions occurring currently.
Scopes of practice
Recommendation 3 of the 2007-09 review recommended that Responsible Authorities “improve the processes relating to scopes of practice, including developing a set of principles and guidelines, regular review, a central web-based location for notifying new consultations and processes to allow any interested party to propose new or amended scopes.”
The discussion document set out six principles for the development and review of scopes of practice that arose from the 2007-09 review:
defining scopes to protect public health and safety rather than responding to professional preferences
defining broad scopes to enable as much workforce flexibility as is compatible with protecting public safety
setting qualifications that are the minimum requirements for public safety
allowing for movement between scopes by, for example, recognising the relevance of prior learning
consulting widely and openly without predetermined positions, and carefully evaluating and responding to submissions
basing decisions on the best available evidence, including from other professions, especially where scopes of practice overlap.
There was diverse opinion about the role of scopes of practice in creating workforce flexibility and it was evident that there are diverse approaches to the development of scopes of practice and a range of beliefs about what constitutes good practice.
Many submissions recognised that the use of broad scopes of practice is an effective means of achieving greater flexibility in the workforce and many submissions pointed to examples of innovative and effective scopes of practice.
On the other hand, a number of submissions point out that there is a high variability in Responsible Authority approaches to developing scopes of practice , with some taking an approach that emphasises limiting harm and others focusing on optimising public benefit. The submissions did not indicate a common understanding of the risks and benefits of broader and narrower scopes of practice. The potential benefit of overlapping scopes of practice was not always recognised.
There was discussion also in the submissions about who the audience for scopes of practice is intended to be. Concern was expressed about the difficulties of writing scopes in ways that are useful both to professionals and employers, and to consumers and the public at the same time. Some proposed that Responsible Authorities should provide “plain English” versions of scopes of practice for the general public.
Standardising Codes of Ethics/Conduct/Practice
The discussion document asked whether there was scope to better address the standardisation of codes of conduct and ethics.
While there were some submitters who were concerned about a potential loss of uniqueness of each profession if there were standardisation of codes of ethics and codes of practice, the majority of submissions agreed that there was sense in at least a degree of standardisation. It is clear that there is already some degree of commonality in the codes of separate professions through the sharing of documents.
Three models of standardisation emerged from the submissions:
(i) a single code (covering the current purposes of codes of ethics, conduct and practice) which is applicable to all regulated professions. Some submitters pointed to the success of the Health and Disability Code of Rights as evidence that a single code can be applicable to all health care providers.
(ii) a single base code, which is applicable to all regulated professions, but to which individual professions could add
(iii) the provision of principles for developing codes, with guidance to allow for the development of relevant profession-specific approaches.
Pastoral care
The discussion document asked whether Responsible Authorities could have a mandated role in health professionals’ pastoral care.
The term “pastoral care” was not closely defined in the first discussion document and some submitters questioned its meaning and intention. Many submissions noted the way in which Responsible Authorities will support rehabilitation, and others noted requirements for practitioners of some professions to access professional supervision as a matter of course.
The gap which the first discussion document was attempting to address was the lack of intentional provision of a system of proactive pastoral care to which practitioners could refer themselves or be referred to on a “without fear of prejudice” basis. Such provision could be similar in nature to the rehabilitation practices of Responsible Authorities with practitioners who have come to their notice. Accessing it, however, would be self-directed rather than directed as the result of findings by a Responsible Authority. Such pastoral care could support practitioners to continue or resume practice rather than leave their profession because of issues they or others consider might lead them to compromise public safety.
Almost all submissions addressing the issue rejected the notion that Responsible Authorities should be involved with such proactive pastoral care. The main reason for rejecting the notion was that it could compromise the focus of Responsible Authorities on public safety by also having a focus on the well-being of individual practitioners. A secondary reason was the issue of costs.
Submitters often, however, acknowledged that professionals would benefit from having occasional access to pastoral care and that patient safety would be enhanced. Many submitters considered that there is sufficient access to pastoral care already through professional associations, colleges and employers.
One Responsible Authority noted that it was considering sharing resources with other Responsible Authorities to establish a health committee to provide “health and fitness to practice” support. The committee would ensure the preservation of the professional distance required for the Responsible Authorities to fulfil their statutory obligations.
A number of submissions referred to known overseas models of pastoral care, including the National Clinical Assessment Service in the UK, a non-statutory body operating in several states in the US, and programmes for nurses, midwives and medical practitioners in Victoria, Australia.
Some submissions suggested that a pastoral care service could be centrally funded by government.
The mobility of the health and disability workforce
There were relatively few comments about this issue with comments falling into two themes. Both appeared to be specific to a few professions only. One theme was to urge Responsible Authorities to be flexible in the development and use of scopes of practice that would facilitate the contribution of international academics, researchers and post-graduate students to New Zealand professions, and the employment of highly qualified but narrowly skilled overseas-trained practitioners. Some Responsible Authorities appeared to be more flexible in this area than others.
The other theme concerned the operation of the Trans-Tasman Mutual Recognition Arrangement. It appears that a small number of Responsible Authorities have issues to work through with their Australian counterparts. A more general issue was the inability of Responsible Authorities to apply any new conditions on the scope or practice of a practitioner moving to New Zealand from Australia. This is of concern particularly when overseas practitioners register in Australia before moving to New Zealand.
CONSUMER FOCUS
The first discussion document considered a number of issues from the consumers’ perspective:
• public knowledge of the Act
• transparency of complaints processes
• the balance of lay person and professionals on boards
• the engagement of Responsible Authorities with the public
• the potential use of consumer forums
Public knowledge of the Act
The discussion document asked whether it was considered that there was more public knowledge of the Act now, since the recommendation in the 2007-09 review that the Ministry of Health and the Responsible Authorities should do more to inform the public about the Act.
The general view from submissions is that the lack of awareness by stakeholders, the public and the professions about what the legislation provides for persists despite the Ministry of Health and Responsible Authorities having taken some actions subsequent to the 2007-09 review. Submitters often said it was unclear what use is being made of the additional information that has been provided. Submitters also often questioned what it is that the public want to know and need to know beyond how to make a complaint.
Submitters considered the provision of information to the public to be a joint responsibility of the Ministry of Health and Responsible Authorities. In particular, there was a theme that the Ministry should be primarily responsible for public knowledge about the Act while Responsible Authorities should be responsible for public knowledge about their policies and practices.
One submitter noted that increasing knowledge about the Act is just one part of improving health literacy in New Zealand and that perhaps knowledge of the Act would be better dealt with in this wider context.