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Protecting The Safety Of The Public; Or Not!

In 2003 then Health Minister Annette King oversaw the successful passing of the Health Practitioners Competence Assurance Act (HPCAA). It has proved to be landmark embedded legislation

The Act brought together registration for all the recognised health practitioners, including doctors, nurses, dentists. and the over 40 numerous allied health professional occupations such as physiotherapists.

The Association of Salaried Medical Specialists had some misgivings about the bill that led to the new act. However,  through behind the scenes engagement, which I was party to as its executive director, were largely resolved.

The HPCAA is a legacy for Aotearoa New Zealand’s health system that King can be proud of.

Principal purpose of Health Practitioners Competence Assurance Act

The principal purpose of the 2003 Act (Clause 3) is protecting the health and safety of public by providing mechanisms to ensure the lifelong competence of health practitioners.

These mechanisms include provisions prohibiting those who are not qualified to be registered as health practitioners of a profession from claiming or implying to be health practitioners of that profession.

A critical provision is the establishment of registration authorities which prescribe scopes of practice, qualifications and experience (Part 2 of HPCAA). These authorities include medical, dental, nursing and allied health.

This prescription includes approving health practitioners for both registration and their scope of practice (with or without limitations within the scope).

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Registration can be either general or vocational (in the case of medicine, the term ‘specialists’ is commonly used for vocational registrants).

Health system moralities

Previously I have written about the importance of health systems having an alignment between its internal and external moralities (20 September): Aligning moralities to get the health system culture right.

Internal moralities primarily come from the cultures of the system’s health professionals. External moralities stem from legislative frameworks.

The HPCAA is one of these frameworks within Aotearoa New Zealand’s health system. The system would be much poorer without it.

Political threat to safety of public protection

There has been a strong political consensus supportive of the HPCAA with specific reference to its prime purpose of protecting the safety of the public in their health system.

But this protection is now threatened by two of the ACT Party’s general election health policies. They are interconnected.

They appear in a broader policy statement titled ‘Easing the health workforce’: ACT health policy on easing health workforce crisis.

David Seymour’s party’s two health policies would undermine protection of public safety

Whether this is driven by ideology or poor thinking (or both) is up for debate. But there is something about which there is no equivocation.

These two election promise would significantly weaken the robustness of the scrutiny by the registration authorities that is required for prescribing scopes of practice, qualifications and experience of health practitioners.

By compromising the functioning of the authorities it would put at risk the scrutiny of registration applications which is required to ensure the safety of the public.

What ACT proposes

ACT promises to establish an ‘occupational tribunal’ for recognising the “credentials” of overseas trained “medical professionals”.

There is imprecision in the terms ‘occupational tribunal’ and ‘medical professionals’. In context, however, the latter probably means all health practitioners, not just medical doctors.

Nevertheless imprecision is not the concern, although it does suggest a poor understanding of the HPCAA, including the importance of having several specialised registration authorities.

What is unclear is where this tribunal fits in with the existing registration authorities. Does it replace them for consideration of registration applications from overseas trained health practitioners?

If not, can the tribunal override registration authority decisions not to register some of these practitioner applications?

Further, there is no evidence that this new inadequately defined occupational tribunal would have any more expertise than the existing specialised registration authorities. Most likely it will have much less.

More dangerous than this new ambiguous occupational tribunal is another ACT electoral policy. It would give the health minister the power to override a decision of a registration authority’s decision or process.

This is perilous territory. It is critically important that registration authorities can act independently when exercising their delegated responsibilities under the HPCAA for ensuring the safety of the public.

It is not just the safety risk of being overruled by a politician with less expertise and experience. It is also the pressure this power would generate for the authorities of being influenced by the fear of being overridden.

Solutions looking for a problem

There is a lack of an evidence based problem definition for these electoral policies. It is overwhelmingly anecdotal, largely based on media reports, and of questionable relevance to ACT’s specific policies.

In other words, they are solutions looking for a problem.

ACT argues that its focus is on overseas health practitioners who were trained in similar healthcare system.

This appears plausible until one drills down further, at least in respect of medicine. It only takes a difference in emphasis to lead to a substantive difference in trained outcomes.

Much of Europe (and now the United Kingdom) have less generalist training and more sub-specialised training for hospital specialists than New Zealand.

Consequently, their training is narrower than New Zealand’s. Consequently close scrutiny is required to determine whether they had the experience to undertake what would be expected of them in our health system.

This difference in emphasis in the balance between generalism and sub-specialism from time to time has created difficulties for patient care. They can be resolved but close supervision is required.

Then there are differences within branches of medicine. A few years ago I was advised by the German doctors union that in their country orthopaedic surgeons practising in university hospitals largely did only outpatient clinics, but not surgery.

In Aotearoa, undertaking orthopaedic surgery is a requirement for working in public hospitals.

In the United States paediatricians are rather like general practitioners who have further trained in community paediatrics. In contrast, New Zealand training has a stronger emphasis on hospital paediatrics. Again close scrutiny and supervision is required. Often it works out but not always.

In other words, there can be substantive differences in training in health systems that might otherwise appear to be similar.

Right on crisis; wrong on solution

ACT is right that the health workforce crisis needs to be eased (in fact, it needs much more than easing).

But weakening the legislative protection for the safety of the public is not part of the solution.

It reflects simplistic soundbite-like structural thinking which, if enacted, would reduce scrutiny over registering health practitioners.

Rather than easing the crisis, these two policies are much more likely to worsen it.

It is time for ACT to think again.

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