Health Competence Assurance: Scopes Of Practice
NO: 3-03 8 AUGUST 2003
Health Practitioners Competence Assurance Bill: Scopes Of Practice
The Association of Salaried Medical Specialists (ASMS) is the professional union that represents salaried senior doctors and dentists, the large majority of which are employed by district health boards. This is the third issue of our Parliamentary Briefings to MPs that outlines our concerns on the Health Practitioners Competence Assurance (HPCA) Bill supplementing our previously forwarded Issues Paper. The previous Parliamentary Briefings covered why we believed the Medical Practitioners Act should not be repealed and the appointment of members of registration authorities. This issue discusses our concerns over scopes of practice.
By repealing the Medical Practitioners Act (MPA) the Bill incorporates a significant shift in the legislative goalposts over the approach to registration of medical practitioners that itself has not been debated or originated out of a process of engagement with the medical profession.
The premise for registration under the MPA is that the registration authority (Medical Council) sets the standard (called the scope of practice under the HPCA Bill) for each branch of medicine and the individual practitioner seeks to be recognised as being able to practice within this standard/scope. Once they have met the standard the Council indicates whether they may practice in a particular branch of medicine with or without oversight or supervision, or on a probationary, interim or temporary basis.
Under the Medical Practitioners Act there are two other means of tailoring registration or scopes of practice. First, at a workplace or employment level the credentialling process matches what a practitioner is able to do with what they can do given a particular setting. Second, through the annual practising certificate that it issues, the Medical Council can place restrictions on a doctor’s practice in response to matters such as health, competence or discipline.
The Medical Practitioners Act, being based on broad rather than narrow scopes of practice, also has the flexibility to allow vocationally registered doctors to expand into related areas of medicine (eg, general practice into secondary care, anaesthetists into intensive care).
Both the Minister of Health and the Health Select Committee state that the intention of the Bill is to maintain broad scopes of practice. But, contrary to their intent, the HPCA Bill seriously risks extending fragmentation by providing for individual doctors to be registered with a narrower, personal scope of practice without having first achieved a broad scope.
In the medium to long term the Bill therefore risks difficulty in maintaining standards, difficulty in monitoring competence and confusion for practitioners and the public as to what services and standards to expect from a medical practitioner.
The Medical Council is behaving as a responsible statutory body in ensuring that scopes of practice for medicine remain broad. But while the Council is committed to a strong priority and preference for broad scopes, the Bill itself does not distinguish in terms of priority or preference between broad and narrow scopes of practice. The Council is applying an interpretation that is permissible but it is not the only type of application.
In this context the longer term consequences of shifting the legislative goalposts should not be underestimated. It is conceivable that a different Medical Council in the future (especially one that is politically appointed) could adopt a narrow approach, the effect of which would be disadvantageous to the health and safety of the public, or could be required through successful legal challenge due to the ambiguity of the Bill’s wording.
In our view the best way of resolving this problem would be to remove medical practitioners from coverage of the Bill, retain the Medical Practitioners Act and then use the three-year review process provided in the Bill to re-examine these matters in order to get them right.
Another way would be to amend the Bill by importing the registration requirements of the Medical Practitioners Act into the Bill replacing its scopes of practice provisions either just for medical practitioners (and also dental practitioners) or for all health practitioners. This way would be an improvement on the Bill in its current form not as good as retaining the Medical Practitioners Act for medical practitioners.
A third option is to amend certain clauses in the Bill to make explicit that scopes of practice are to be broad in accordance with its intention – in particular, clauses covering purpose, definitions, principles and application.
For example, in order to remove ambiguity over the purpose of scopes of practice being broad, Clause 3 (2) (b) should be amended to:
for the determination of broad scopes of practice within which each practitioner is competent to practice
In Clause 5 the deletion of (b) in the definition of scopes of practice would also remove confusion over the broad nature of scopes. Some aspects of (b) allow for registration authorities to put limitations on scopes of practice for practitioners who are unable to practice within their full broad scope for reasons such as addiction, age and competence are already addressed in Clauses 14 (3) and 28 (2)-(3) of the Bill.
On the basis of the above recommended amendments to the purpose and definitions clauses, Clause 12 covering guiding principles would be unnecessary. This would mean that the contradictory and confusing implication of individual application for narrow scopes (not to be confused for restricting ones activities within a broad scope) would be removed.
Further, in relation to Clause 16 (application and authorisation), more explicitness and clarity would be provided if sub-clause (b) (i) was amended to read:
an indication of the scope of practice as specified by the authority under section 10 (1) within which the applicant proposes to practice…