The Government is inviting New Zealanders to share their views on health workforce regulation by 11.59 pm Wednesday 30 April.
The consultation is a series of questions, which we are making a submission on.
GPA notes that our submission represents the views of the organisation, and a representative view of our members. However, our members are diverse and have differing opinions on certain points. This submission should not be considered the definitive view of each of our members, and many members will make their own individual submissions.
Members (and anyone else) are welcome to draw from our responses in making their own submissions.
GPA response
How we could achieve patient-centred regulation
Would you be interested in having a say on any of the following?
- changes to scopes of practice (what health practitioners can do) and how this affects patient care
- qualification requirements
- other professional standards (for example, codes of conduct) that impact patient experience
Are there any other things you think the regulators should consult the public on?
General Practitioners Aotearoa applauds the goal of streamlining and creating a patient-first system. However we have significant concerns about some of the proposals in this document, and reject some of the assumptions made.
We agree that there are significant problems with the health workforce. For primary healthcare, this is most keenly seen in the shortage of GPs. This leads to long wait times for many patients wanting to see their family doctor, and difficulty enrolling in a practice as many have closed their books.
We agree that regulation should put patients first, it should be right-sized and future-proofed. In general, we agree regulation should be streamlined and efficient, while recognising that a reduction in regulation does not always lead to achieving these goals, and that well-placed regulation can protect patients, improve the workforce, and lead to better health outcomes and reduced cost in the health system.
We welcome change which would improve the health workforce crisis.
We reject the idea that down-regulating professions will necessarily result in delivering timely and quality healthcare for all Kiwis. Adjustments in regulation should be made carefully, considering the effect on patients’ health outcomes, the health of the population, and the long-term expense of having a less-qualified workforce looking after our patients.
While increasing the workforce is essential, we must not lower standards in the process of addressing the crisis. Airline pilots, drain layers, electricians, and civil engineers do not drop their standards and invite others to do their jobs if there is a vacancy not filled by somebody qualified to do the job. The work of a doctor should be no different.
While patient views on their healthcare and outcomes are essential, we do not believe it is appropriate to invite non-expert public input on the certification process for professions that literally hold life and death in their hands.
We are also concerned about the proposal that healthcare professionals should be removed from regulatory bodies or have their power watered down by government appointees. Healthcare must be appropriately safeguarded by the people who know it best, those who are trained to do the job.
There may well be areas for improvement in the regulatory framework, but in general we believe this is a red herring. The fundamental issue in our area of expertise, general practice and primary healthcare, is a lack of GPs. What we really need to address this crisis is better working conditions, and appropriate remuneration for GPs.
Public feedback should be weighed against expert knowledge and the realities of practice. Most patients (and even many medical professionals working in other specialties) do not understand GP scope of practice or the work we carry out behind the scenes. Most patients see a GP for a 15-minute slot and do not have a view of what really happens behind the scenes to diagnose, treat, get tests, analyse test results, make referrals and ensure those referrals are accepted in a timely manner.
The role of GPs as specialist diagnosticians is often overlooked. Our training and experience in diagnosing complex health conditions and “undifferentiated” symptoms (symptoms that are similar for different diseases and conditions) cannot be replaced. However we do not expect the average member of the public to understand how changes to scopes of practice for different health professionals, qualifications, and professional standards will affect our ability to look after the population’s health.
Are there any health practitioners who are currently unregulated but should be subject to regulation to ensure clinical safety and access to timely, quality care?
We note that physician associates are currently unregulated and do not have a fully defined scope of practice in the New Zealand health system. This is risky, and we are surprised they have been allowed to practice autonymously with little or no requirement for oversight and accountability.
GPA’s position is that rather than regulating physician associates, it would be a better approach to identify skills gaps and retrain foreign-trained physician associates as professions already recognised in New Zealand: GPs, nurses, and allied health.
We also note that while naturopaths and homeopaths claim to treat health conditions, they are not regulated and do not answer to the Health Practitioners Competence Assurance Act.
Do you think regulators should be required to consider the needs of patients and the workforce when making decisions?
Absolutely. Patient outcomes should come first when regulating. Workforce needs are also supremely important for two reasons:
- If the workforce is not looked after, it will erode and quality of care will drop.
- Workers in any industry have a right to good working conditions, and healthcare should be no different.
What are some ways regulators could better focus on patient needs?
By considering the input of professionals and experts who deal with patient needs every day.
What perspectives, experiences, and skills do you think should be represented by the regulators to ensure patients’ voices are heard?
While patient voice is important in the healthcare system, the regulatory body is not the correct mechanism for patient representation.
There is a risk that patient biases might impact policy settings. Many patients, for example, believe that it should be easier to prescribe antibiotics and opioids. Deregulating these could lead to a public health disaster.
We encourage ongoing advocacy work through current representative mechanisms rather than risk potential conflicts with how health professionals are dictated to work. We acknowledge the role the HDC plays in advocating for consumers with other organisations.
Do you agree that regulators should focus on factors beyond clinical safety, for example mandating cultural requirements, or should regulators focus solely on ensuring that the most qualified professional is providing care for the patient?
Regulators should focus on some factors beyond clinical safety.
Cultural requirements, for example, are important for our diverse workforce and patient population. Appropriate mandating of cultural requirements leads to better patient care and health outcomes. For researched information and expert opinion on the importance of cultural safety for the delivery of equitable health care, please refer to the work of our colleagues at Te Ora Māori Medical Practitioners
Cultural safety modules are not complicated or particularly time-consuming. Cultural safety is patient-centred care, and a widely recognised model in developed countries.
Do you think regulators should be required to consider the impact of their decisions on competition and patient access when setting standards and requirements?
It is essential to consider the impact on patient access.
Additionally, most GP clinics are privately owned and operated. As such, regulators must consider the impact their decisions will have on competition in our sector. If GP clinics cannot make a profit, the primary sector will collapse.
Streamlined regulation
How important is it to you that health professions are regulated by separate regulators, given the potential for inefficiency, higher costs, and duplication of tasks? Why?
It is very important that health professionals be separately regulated.
Given the different scopes of practices and the many variances between health care professionals, clear boundary setting helps to give patients confidence that each practitioner is being appropriately regulated for their specific scope.
To help improve efficiency and reduce unnecessary costs, would you support combining some regulators?
We would want to see evidence that this did indeed improve efficiency and reduce cost. This may be appropriate for some groups.
We approve of making savings to better distribute funds where they are needed in the healthcare system, but not if it comes at the cost of patient and practitioner safety.
There is a risk that combining regulators sends the wrong message to patients/consumers around scope of practice and expertise.
Right-sized regulation
Do you agree that these regulatory options should be available in addition to the current registration system?
- accreditation – Yes, for certain professions such as speech and language therapists, nutritionists, naturopaths and homeopaths.
- credentialling – Yes, for low-risk professions, as long as there is strong oversight of credentials, assessments and training standards
- certification – Yes, for certain activities. This is how many GP activities are currently regulated. For example a GP should complete a certification in dermatology before undertaking biopsies and removals of skin cancers. However, care should be taken when the goal is to “increase the number of vaccinators” or similar. Vaccinations, minor investigations and procedures are a good opportunity for GPs to check up on patients who rarely see their doctor. It’s an opportunity for us to check on things like child welfare, family abuse, long-term health conditions and general health. As more and more activites are moved out of GP clinics and into the hands of other vocations, we miss more and more of these opportunities.
- any other options –
Do you think New Zealand’s regulatory requirements for health workforce training, such as the requirement for nursing students to complete 1,000 hours of clinical experience compared to 800 hours in Australia, should be reviewed to ensure they are proportionate and do not create unnecessary barriers to workforce entry?
We think it is appropriate to review barriers and ensure they are fit for purpose in New Zealand’s system. Barriers that are not backed up by data and outcomes should be removed or adjusted to improve workforce entry.
Modern training models are based on competency and skills, not hours. Some people may take over 1000 hours to achieve the required skill level, but for someone else it might take 600 hours.
We should not deregulate simply for the sake of it and we should be careful to avoid introducing underqualified and underexperienced people to the workforce who will add to costs and wait times by making inappropriate referrals or creating worse health outcomes for patients.
We utterly reject the “Scenario D” in this section as being misleading and guiding the reader to a particular outcome. Cultural competency is essential in healthcare in order to provide care for our diverse population, especially those groups who are less likely to engage with the healthcare system and are less likely to get good health outcomes. This is a fundamental part of providing timely, quality care. Experience tells us that patients who feel misunderstood are more likely to mistrust the health system, and are less likely to turn up for appointments and engage with their treatment plans.
Cultural competency is especially important for overseas-trained doctors who do not have an inherent understanding of Aotearoa New Zealand’s cultural landscape.
We also want to caution against the line of thinking that “lower risk” professions could have low regulation. Even supposedly “low-risk” healthcare should be well regulated to ensure good patient outcomes, which contribute to a healthier, less expensive population in the medium-long term.
For clarity, we would like to emphasise that general practice is a high-risk profession. It has a high rate of Health and Disability Commission cases, and high chance of serious health issues for patients who are mismanaged. Deregulating primary healthcare or replacing GPs with non-doctors is an invitation for disaster.
Additionally, GPA members who have moved here from overseas tell us that while the verification process could do with some tweaks, it is not overly arduous or restrictive.
Should the Government be able to challenge a regulator’s decision if it believes the decision goes beyond protecting patient health and safety, and instead creates strain on the healthcare system by limiting the workforce?
Challenges to regulators’ decisions should sit with the courts or other independent bodies.
Government’s role is to regulate processes, practices and criteria that regulators use to make their decisions, not to retroactively challenge those decisions.
Do you support the creation of an occupations tribunal to review and ensure the registration of overseas-trained practitioners from countries with similar or higher standards than New Zealand, in order to strengthen our health workforce and deliver timely, quality healthcare?
We believe a better approach would be for Government or another appropriate body to undertake a systematic review of other countries with high standards. This review would identify which certifications should be considered directly transferable, and identify minimum levels of training, oversight and competency required for those that are not directly transferable. The registration of qualifying health professionals should sit with the organisations that usually regulate each profession (not a tribunal). Government should set an expectation, or possibly regulation, that these transfers and registrations be processed in a timely manner.
Doctors from countries with very different medical systems and cultural practices absolutely need assessment and supervision when beginning practice in New Zealand.
Should the process for competency assessments, such as the Competence Assessment Programme (CAP) for nurses, be streamlined to ensure it is proportionate to the level of competency required, allowing experienced professionals who have been out of practice for a certain period to re-enter the workforce more efficiently, while still maintaining clinical safety and quality of care? If so, what changes should be made?
Yes, we support appropriately streamlining this process.
There are many practitioners who have been out of work for different reasons, and their registration may have lapsed. It should not be arduous to return to work.
Do you believe there should be additional pathways for the health workforce to start working in New Zealand?
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Future-proofed regulation
Do you think regulators should consider how their decisions impact the availability of services and the wider healthcare system, ensuring patient needs are met?
Yes, but these decisions should be considered in the wider context of the workforce: is there a better use of resources in another area that would achieve better outcomes.
We believe that highly-qualified non-doctor health professionals such as nurse practitioners can fill an important role in the health system, particularly in the secondary sector where their specialised training can be put to good use in overwhelmed pathways such as mental health, diabetes and chronic diseases. Nurse practitioners are also valuable in certain roles in general practice, with appropriate scope and oversight. We strongly caution against the thinking that these groups are an alternative to, or replacement for specialist GPs. The only solution to the GP shortage is increasing the number of GPs. We believe the best thing the Government can do to future-proof the primary sector is to encourage registrars to train as GPs, attract secondary sector doctors to retain as GPs, recruit more GPs from overseas, and incentivise our GPs to stay in the workforce longer or return to the workforce.
Do you think the Government should be able to give regulators general directions about regulation? This could include setting priorities for the regulator to investigate particular emerging professions, or qualifications from a particular country to better serve patients’ healthcare needs.
Yes, but these directions should be broad and not encroach on regulator expertise.
We are worried about this document’s apparent de facto acceptance that “emerging professions” will be accepted in our workforce. We believe the Government and regulatory bodies should focus on strengthening the tried-and-true, evidence-backed professions that already exist in our workforce before importing professions from other health systems that work in very different ways. It should not be a given that physician associates will be accepted in our workforce; this decision should be carefully considered. We believe that people trained in professions not recognised in New Zealand should be encouraged to retrain or undergo a certification conversion to a recognised profession such as GP, nurse, occupational therapist or technician.
Do you think the Government should be able to issue directions about how workforce regulators manage their operations, for example, requiring regulators to establish a shared register to ensure a more efficient and patient-focused healthcare system?
We believe a better approach would be investing in the development of a shared register or other shared operations. If the system works well, regulators should opt in to it. Everyone benefits from shared information.
Do you think the Government should have the ability to appoint members to regulatory boards to ensure decisions are made with patients’ best interests in mind and that the healthcare workforce is responsive to patient needs?
We are concerned that Government appointments to regulatory boards introduces a risk of partisan interference in the everyday regulatory process, and a risk of introducing “centralised thinking” to diverse workforces that need individualised solutions. We see the government’s role as setting the expectations and underlying regulations for regulatory boards to follow.