Health Practitioners Competence Assurance Act 2003

Review of the HPCA Act

Wellington Workshop Summary, Monday 14 April

Session 1 – Scopes of practice and qualifications

The Ministry outlined the issues raised during the first phase of the review. These included:

Information about how scopes are supposed to work, and what information they should include, is not publicly available.
There is a great deal of inconsistency in the way scopes are being developed between professions.
Scopes of practice have worked well. However, there are inconsistencies; for example, in criteria versus description.
Current scopes have often been informed by professions. They often reflect what the profession wants to be doing, and do not always reflect the practice environment. As such, some practitioners and employers can be constrained in the services they can deliver.
Overlaps in scopes between professions are not always underpinned by common competencies.
It is not clear to practitioners, employers and the public where overlaps between scopes and professions exist.

Following discussions the following proposals for addressing these issues were made:

Where there is scope overlap between professions, the same task, as carried out by different clinicians, may need different levels of supervision depending on which profession the person carrying out the task practises. However, there is interest in the possibility of overlapping training/professional development for areas of overlap. The idea of boards working more closely together in areas of scope overlap was supported.
A moderation process could be developed in areas of overlap, so that practitioners from more than one profession can develop common competencies.
A system of primary and secondary registration (multiple registrations) could be created; professional development requirements could be lower in the second category.
The Ministry of Health could be clearer about what the definition of scopes can contain, and be more directive with boards.
Scopes, and the processes of developing them, should be standardized. Currently, scopes are implemented differently between RAs; standardizing this would aid in achieving the purpose of the Act, (protecting public safety). Alternatively, there could be national frameworks for defining competencies; these would be broad, as opposed to prescriptive.
Scopes of practice could include the competencies necessary to practice within a particular scope.
A regular cycle of consultation to review scopes was suggested. However, it should be up to the boards to decide when and how often. The Ministry should not regulate consultation (but providing guidelines on consultation may be useful). This would encourage a standard for consultation, and ensure that RAs did not leave out key groups (ie consumer groups that should be included), or parts of the process. In addition, a method of addressing concerns must be developed. All reviews, and any scope deviations arising from these reviews, must include a workforce impact assessment generated through provider consultation.
Legislation must be developed for people that do not fit into scopes of practice. This would aid in protecting the public, as there are people who are unqualified, unregistered, and working within a scope, but as they are not calling themselves a restricted title, they are not forbidden from doing this (unless they are carrying out restricted activities).
The public is not necessarily aware of the requirement for registration, or the intricacies of what scopes of practice entail. There needs to be education of the public (and of employers) that ensures high public awareness. The public needs to be aware that: 1. practitioners are working within the Act; 2. the profession monitors itself; 3. the public should check if a practitioner is registered with a current APC.
Scopes are working well; the focus should now be on educating the public and employers.
Scopes should recognise that different areas need different skill sets, and therefore may require a narrower/broader scope of practice. For example, practitioners practising in a rural area may be required from necessity to carry out a wider range of activities, and therefore may need a wider scope of practice than a practitioner practising in an urban environment.
Scopes should be broader, to facilitate professional judgement and credentialing. There is a need for a mechanism to provide assurance of confidence in credentialing systems.
It is natural for practitioners to specialise within a particular scope; for example, GPs that practise appearance medicine. In these instances, practitioners should be forced to maintain broader skills by having to work in more than one scope of practice, or otherwise be given a limited scope in which to work.
RAs should work more closely together on scopes of practice. Perhaps HRANZ could be funded to help with this, or the Ministry could have a facilitating role. There is need for teamwork when multiple bodies of knowledge are involved.
All new/emerging scopes should be notified. A “central bank” in which all RAs’ initiatives could be posted/lodged would be useful for this.
There should be a requirement, or at least an ability, for RAs to benchmark against national and international standards in setting scopes of practice.
Managing risk must be seen as a key component of all scope of practice considerations.
It was suggested that all health care workers should be registered, including health care assistants and aged care workers. However, the point was also raised that many in this workforce would not meet the minimum standards of competency for registration, thus still leaving an unregistered workforce.
DHBs should not employ non-registered practitioners. Additionally, employers should be required to employ registered practitioners, and thus take more responsibility for credentialing.
The Ministry of Health must act urgently on enforcing the Act and supporting the Act. Prosecutions must be meaningfully given out.
Under a licensing regime, some professions did not have the same problem with persons practising within scopes with no qualifications or competence assessment. Perhaps a return to a licensing framework is in order?
It is very important to establish guidelines around processes for returning to practice, particularly after significant time away from, the profession.
English tests need to be better. They need to reflect occupationally-based “communication”, not just language skills.
A better definition of “protecting public safety” should be included in the Act.
There is a lack of knowledge in the professions and the public as to the RAs’ roles. It is not known what RAs do, or what their money is spent on. There is a great deal of information, but it is not necessarily easy to access. Therefore, education on these issues (both to practitioners and to the public) should be ongoing.
A certain amount of workforce data is needed. There needs to be a commonly accepted standard for workforce information, and a national body (or the Ministry) should collect this. This would assist the RAs.

Session 2 – Authority structures and governance

The Ministry outlined the issues raised during the first phase of the review. These included:

The concern over the proliferation of RAs. Too many RAs create inconsistencies in the way the Act is put into operation.
The most significant costs come from supporting RAs (ie secretariat support).
There is concern that the current appointments process is not open and transparent, and that there is no scope for input from the professions.

Following discussions the following proposals for addressing these issues were made:

The larger boards that can manage their business should be left alone (“large” being defined by mass of the board and public safety). However, the idea of amalgamating smaller boards has been suggested.
It has also been suggested that smaller boards could be set up in more of a tribunal model. The model suggested in Sue Ineson’s report is a good model. RAs could be smaller, but able to refer things to an overarching “council”.
Larger, more established RAs should pass their knowledge down to smaller RAs.
There could be an opportunity for a number of boards to operate with a common secretariat; however, this would need to be a not-for-profit model, and have a commitment from the participating boards to work collaboratively and in partnership. However, this does not mean that the wholesale amalgamation of boards is supported. It may also be possible to contract out administrative functions.
The wholesale amalgamation of boards is supported by some, however, these people see advantages and disadvantages. While there are definite possibilities for a consistent approach to policy, there is also the possibility for the larger professions to dominate their smaller counterparts.
There is a fear that should all the boards be combined, the standards may sink to that of the lowest common denominator.
Administrative functions, such as IT systems, human resources and leases are administrative, and don’t need to be informed by the clinical specialties; therefore, there is room for sharing these tasks. This would create economies of scale, particularly amongst smaller boards. There should be collaboration, particularly of information and those items listed above, but not duplication. The idea of a shared IT system is popular.
Members elected by the profession should fill some, but not all, positions on the boards. However, it is acknowledged by some that elections could create conflicts of interest, and others are concerned that this is not a reliable method of choosing a board member, as it would largely rely on a “blurb”. It is also acknowledged that different RAs should be able to choose whether or not they choose to have elected, as opposed to simply appointed, members. This is tempered by the fact that while many professions are in support of elections, most RAs are not. However, elections have the potential to lift the RAs’ credibility with the professions.
There is also a suggestion of the boards representing the three different parties of interest in their membership, with one third representing the Crown, one third the profession and one third the public. An alternative structure would be to have a range of views represented on the board by a mixture of appointments and elections (see above point).
Lay people could be appointed to boards from a pool of “health consumers” (as in Australia). This would create standards for lay people and ensure lay people were trained. The proportion of lay people on a board is important, as any quorum needs to include a lay person.
The Act does not cover the Treaty obligation to have Maori representation. This should be rectified.
An alternative appointment body could be set up, such as an independent commissioner (such as in the UK).
The appointment process should be more transparent. Guidelines to the appointment process should be published and communicated widely.
The Ministry should take the lead in establishing what skills and attributes are required from board members to be effective. There is currently no consistency between boards in understanding what skills are necessary.
A central point would assist with such things as establishing a set of best practice guidelines, and determining the standards for declaring conflict of interest. This would lead to consistency in board function, and an increase in the quality of a board’s operations. As there would be a lack of duplication, it would also have the potential to drive down costs.
It should be made clear to boards exactly what their role is – that of governance, as opposed to an operational role.
Board members must be in good standing (ie not subject to current disciplinary processes). Members should be subject to performance reviews that the Ministry should receive. Alternatively, an independent commissioner could run the review process. All RAs need to have a governance performance appraisal structure.
Professional chairs, as opposed to members of the profession or lay people, could chair the boards. These chairs could chair several boards each.
The Ministry should support developing boards more. Additionally, during the establishment process, new boards should be able to access existing systems for other boards, eg IT systems, to prevent duplication. The Ministry should also provide transitional funding for new boards. This is particularly applicable as the RAs are being set up per the Crown’s requirements for public safety; therefore, the Crown should assist financially.
It would also be of assistance for the Ministry to take the lead in determining standards for continuing competence requirements.
Professional associations could have a role with selecting/endorsing board members.
HRANZ should have more sway/influence, and more trust should be put in HRANZ by the Ministry. It has also been suggested that its voluntary nature should change. This could assist in streamlining policies across boards, or perhaps running inductions for members of boards.
HRANZ could also take the lead in sharing of information.
A template of the model for reporting should be introduced, and would be very helpful, especially with the standardisation of information reported. Boards need to be able to assess their own performance and strive for improvement. They also need to have a set of common reporting criteria. It is seen as the Ministry’s role to monitor consistency of information.
The notion of a template is also applicable to the production (and publication) of annual reports, which should also include reporting against the functions of the Act and the findings of competence reviews. Annual plans and strategic plans are needed by all RAs in order to measure quality.
Members of boards should be inducted and given governance training. They also need to have an understanding of the profession (especially lay members). It has also been suggested that governance training should be ongoing and mandatory, in order to keep upskilling board members.
There should be a higher threshold for becoming a registered profession under the Act.
HRANZ could be used as a central information “bureau” to advise on processes, etc. Having set processes available would speed up processes. HRANZ would need to be centrally funded for this to occur.

Session 3 – Registration and recertification

The Ministry outlined the issues raised during the first phase of the review. These included:

Registration requirements and processes are inconsistent between RAs.
The bar for registering overseas trained practitioners is too high and the administrative processes costly and burdensome.
Recertification requirements are inconsistent between RAs.
Recertification is having a significant impact on rural practitioners who find it difficult and costly to meet requirements.

Following discussions the following proposals for addressing these issues were made:

Greater standardisation of registration pathways needs to happen. The interpretation of section 16 can be difficult to apply (although one attendee believed section 16 was too prescriptive).
A requirement should be incorporated (presumably into section 16) that the candidate for registration/recertification be “a fit and proper person”.
Sections 40 (Competence programmes) and 41 (Recertification programmes) require revision; competence should be required at outset, then continuing competence (as well as performance) should be required. For example, paramedics in the UK require validation and revalidation, and must maintain a portfolio.
Registration requirements are inconsistent.
Online registration may make it possible to bring the cost of registration down.
The cost for registration cannot be brought down, and it is important that requirements are not brought down; after all, the purpose is to protect public safety. In some cases, registration may need to be strengthened and tightened. It is claimed that DHBs (who pay many practitioners’ registration fees) are more interested in streamlining the costs than practitioners. Therefore, the need to expedite an employment process must be balanced with the need to ensure public safety.
Each board must be able to explain its registration costs, how these arise, and justify them.
Funding should be available for professions with shortages to enable practitioners to re-register; this is because the costs for re-registration can be very high for those on a low income.
Recertification should be evidence based. However, the technical meaning of “recertification” is not widely understood.
A suggestion that IETLS as the standard practice for English testing could be reviewed, as its application appears inconsistent between authorities. Even New Zealand-trained graduates who have English as a second language can fail to meet the IELTS standards. It is also suggested that IETLS is not flexible enough. However, it is also acknowledged that IETLS is the international standard and that it is rigorous, as is required to protect public safety.
If a person has specialised experience but lacks the necessary English requirements, it is possible that they could practise in their specialised area with limitations on their scope of practice.
Recertification should require a third party referee to attests to an individual’s declaration of their own competency.

Session 4 – Competence, fitness to practice, complaints and discipline

The Ministry outlined the issues raised during the first phase of the review. These included:

The process for making a complaint is not clear, particularly to members of the public.
The process for investigating and making determinations on competence and fitness to practise concerns is time consuming, costly and overly legalistic.
Competence and fitness to practise processes are inconsistent between RAs.
Policies relating to the release of information pertaining to competence or fitness to practise concerns are inconsistent and not transparent.

Following discussions the following proposals for addressing these issues were made:

There should be stricter requirements for notification (ie for lack of competency).
The distinction between the ability to set in place an interim suspension on the basis of competence or fitness should not exist; “serious risk of harm” should be used for both.
The complaints resolution process should be reviewed regularly to assess the performance of complaints resolution, and get facts and figures.
Disciplinary and competence issues are seen as the largest costs. The more closely competency is examined, the higher the cost. However, investment (although by who is unspecified) in professional development is likely to bring down the number of discipline/competency processes.
In cases of non-compliance with competencies, the onus of paying for competency to be examined should lie with the practitioner.
In disciplinary cases, the Act gives the practitioner numerous opportunities to make oral and written submissions. This can greatly increase the costs of a process (as calling in a quorum of board members repeatedly can be expensive). The balance could be reset somewhere between fairness to practitioners and public safety.
The focus on competence reviews is on education, not punative action. However, there is a lack of information about whether people are fit to practise; information about this should be publicly available.
A better balance must be struck between the private interests of practitioners and public safety. Perhaps RAs could be subject to some provisions of the OIA?
The professional conduct committee (PCC) process should be streamlined. There should be a common set of guidelines across all RAs, and common workshops for PCC members (like Health Practitioners Disciplinary Tribunal (HPDT) training).
RAs should be releasing names of practitioners who are found guilty by the HPDT, but not those who are subject of competence reviews. However, others think that more information than this should be published (and that privacy issues can be surmounted by anonymisation).
The HPDT should be funded by the Ministry, as it is a public board. Training of members should also be funded by the Ministry.
Why the Health and Disability Commissioner (HDC) sends complaints back to the RAs at times needs clarification.
The Act currently makes competence processes legalisitic and more subject to delay than is desirable. This should be altered.
The Ministry needs to enforce the Act more strongly – particularly section 7.
Statistical information about complaint areas should be collated and published (and could be ranked by seriousness or risk). The top five or ten complaint areas could be identified, which would help the RAs in working on these areas. HRANZ could work in this consistency of data.
Prevention is better than complaints. Boards should encourage good continuing professional development (CPD) to encourage better competence.
As practitioners can keep on practising until a complaint is heard, an interim supervisor could be appointed by the board until a complaint is heard. The cost of this would be paid by a practitioner’s indemnity insurance.
There should be consistency across the boards as to what is published, and whether or not the information about the HPDT and their decisions is publicised.
The Act needs to specify more clearly what information an RA can release to an employer in the case of a complaint to an RA against one of the employer’ employees.
There are different perceptions of how the Act is implemented, particularly in regards to competence, fitness to practise and quality assurance. The larger RAs who have had more experience in these areas have a lot to offer the smaller RAs, who could benefit from “test cases” or “case studies” to illustrate the implementation of the Act. This information should be shared, and HRANZ is a possible body for doing this.
In a situation where a practitioner is employed, normal employment processes should be used more routinely as a “first step” prior to an official discipline investigation by the HDC

Suggestions from final session

There is a great desire for consistency coming through. A body needs to be established (or HRANZ could be developed further) that can help develop that consistency, as the RAs are too busy. This could be funded by the Ministry of Health.
There is concern about the choice of an overriding secretariat, and the potential to grow and develop into a large monopoly. A general secretariat has already been trialled and not proven successful (although it must be remembered that this was a profit-driven model); therefore, an alternative solution should be reached by the Ministry putting more money into the RAs. However, it is also desirable that Government does not become too involved.
Set-up funding should be provided for new boards by the Ministry.
There are divided feelings upon working more closely with Australian bodies; some associations and RAs believe that would lower higher New Zealand standards. It could also adversely affect issues of cultural competency. However, the benefits of working more closely with the Australian boards are cautiously recognised by some professions.
It is strongly felt by some parties, particularly the professional associations, that it is essential for self-regulatory authorities to be able to elect a percentage of their RA’s board. This would improve buy-in from the professions. The cost of elections (as being seen as high) is debatable. However, some smaller boards or professions, as well as multi-disciplinary RAs, are not necessarily in favour of elections, and believe that a vocal minority may promote themselves despite lacking the right skills.
The Ministry should enforce section 7 of the Act more strongly.
Finally, it was acknowledged that the Act is a relatively new piece if legislation, is in the process of “bedding down”, and that it may be too early for major change.

Page last updated: 7 May 2008