Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill

I move, That the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill be now read a second time. In April of this year the Government announced the launch of the New Zealand Health Strategy, which is all about delivering better care closer to home so that more people can get access to the services they need, more conveniently. Part of that is using all the skills that we have right across the workforce to their fullest extent. We have a highly skilled nursing workforce, highly skilled pharmacists, and many people in the allied health professions are obviously trained to a very high level, but there are a number of functions that, by statute, only doctors can perform. So the purpose of this bill is to improve access to services for the New Zealand public and to increase workforce flexibility.

I will go through a range of the different provisions, but, essentially, it looks at a range of Acts and removes the barriers to patients accessing the healthcare they need. A number of functions previously able to be performed only by doctors will now be able to be performed by an appropriately qualified medical practitioner who is a member of some of those other professions—for instance, the nursing profession. It covers areas such as sick certificates, some clinical assessments, and the issuing of death certificates. The purpose of the bill is to remove legislative barriers so that competent health practitioners can perform a number of statutory functions previously limited to doctors under existing legislation. Barriers to innovative models of healthcare and making the best use of our workforce were identified in a number of Acts, and seven of those Acts were prioritised by the Government for amendment.

The Government also intends to review unnecessary restrictions for statutory functions for health practitioners in further Acts as they are revised. To improve efficiencies in the health system, removal of legislative barriers will reduce unnecessary costs and time for the public, who must often wait and pay to see a medical practitioner. This bill allows the public to be examined, clinically assessed, and, if required, issued with certificates such as sick leave certificates by suitable health practitioners in a much more timely and cost-effective manner. Changes to the statutory provisions in this bill will allow competent health practitioners to use their qualifications, knowledge, and skills for the betterment of consumers.

The bill will improve health practitioner accountability by making practice more transparent. Currently, health practitioners already undertake clinical assessments, but the law requires a medical practitioner to formally authorise the assessments. This double handling is unnecessary and will be addressed by the bill. Delays for consumers in access to care will be reduced. The bill will also allow nurse practitioners with the primary responsibility of patient care to be able to certify the cause of death. This will address the issue of delays for families when doctors are unavailable for certification.

In terms of the work of the Health Committee, it heard submissions totalling 28 from interested groups and individuals, and it also heard 10 oral submissions. Most submissions gave full or qualified support, and I would like to thank those who did take the time to submit, and of course I thank the Health Committee for the work that it put into this bill. As members might expect for a bill of this type, the submissions considered by the committee were largely from professional organisations and individuals with an interest in the nature of the legislative tasks undertaken by health practitioners. On the whole, health professional groups such as nursing, pharmacy, and physiotherapy supported the bill. Most medical group submitters, including some medical colleges, also supported the bill, but a few medical submitters questioned some aspects.

The committee considered the concerns raised. One aspect raised in those submissions was accountability for health practitioner competence. Committee members sought additional advice on the adequacy of the Health Practitioners Competence Assurance Act 2003, to assure themselves that the safety of the public is maintained. The committee was assured that responsible authorities regulating health practitioners have sufficient safety controls. The Health Practitioners Competence Assurance Act includes mechanisms to ensure that practitioners are competent and fit to practise for the duration of their professional lives. I would like to emphasise that the principal purpose of the Health Practitioners Competence Assurance Act is to protect the health and safety of the public. Having a single legislative framework allows for consistent procedures and terminology across the regulated health professions. The accountability regime that ensures health professionals are practising safely is unambiguous under the Act. Those not deemed competent will not be able to perform statutory duties.

Health practitioners must be registered with the relevant responsible authorities and hold a current annual practising certificate. The responsible authority determines the scope of practice for the practitioner. It prescribes the qualification for scopes of practice, and it ensures that practitioners are fit and competent to practise within their scopes of practice. It is also responsible for reviewing practitioners’ competence and, if needed, has the power to suspend a practising certificate. It also has responsibility for referring complaints against a health practitioner to a professional conduct committee or to the Health and Disability Commissioner for investigation or sanctions, as required.

Several submissions requested changes to Acts other than those identified in the bill. These were considered by the committee and several further amendments were made to the bill, including an additional amendment to the Medicines Act 1981. The committee has recommended the bill be passed, and proposed several improvements. The reported-back bill will now amend eight statutes, to enable a wider range of suitably qualified health practitioners to undertake activities currently restricted to medical practitioners. Some additional changes were also made to improve consistency of definitions across the amended Acts and to enhance the provisions of several Acts.

I would like to provide some examples of the bill’s contribution to improvement in the health sector. Amending the Medicines Act 1981 allows regulation-making powers that enable nurse practitioners to supervise designated prescribers, clarifying the current provision in the Medicines Act with regard to the supervision of designated prescribers. Where there is a shortage of medical practitioners available in certain areas, nurse practitioners will be able to supervise designated prescribers. This will enhance training opportunities for health practitioners working towards qualification as a designated prescriber. With the Government agreeing to regulate designated registered nurse prescribers, this supervision will facilitate the delivery of health services in rural and hard-to-staff areas, including nurse-led clinics.

The bill includes improvement to the Misuse of Drugs Act 1975 to allow nurse practitioners and registered nurse practitioners working in addiction services to be able to prescribe controlled drugs as part of the team treating a person for drug dependency. The committee further recommended that designated prescriber pharmacists be allowed to prescribe controlled drugs to a person with a drug dependency when working in drug dependency treatment teams. A further amendment to the bill was also recommended, to add the requirement for compliance with applicable guidelines issued by the Director-General of Health for those treating drug dependency. This change will enhance access to treatment services for drug addictions, and ensure that there are adequate controls of those allowed to prescribe for drug dependency.

To respond to the changing burden of disease in the future, there will be greater emphasis on working in a collaborative fashion right across the various health professions, and partnering with individuals, their whānau, and communities. The health and disability workforce must be freed from statutory barriers in order to be deployed in new ways, to ensure that services are delivered by the right practitioner to meet the needs of the public. This bill will contribute by creating the environment where statutory functions can be delivered by a wider workforce. I commend this bill to the House.

Labour supports this bill. It is a very simple bill, a bill that went through the Health Committee relatively easily with collaborative work across all parties represented within the select committee. But I do want to make a few comments about it.

The first one is that this is a bill that has taken far too long to get on the legislative agenda, because straight after the election of 2014 Treasury and the Ministry of Health advised the new Minister, Dr Coleman, to push ahead with this long-awaited bill to remove the barriers to health workforce flexibility. In fact, it was one of the 12 recommendations made by Treasury to the Minister, and Treasury said that they needed to “identify and remove unnecessary barriers to workforce flexibility by progressing the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill”—the very bill we are debating tonight. This is back in August 2014. Treasury noted that the bill had been under development for several years, and there was frustration at the lack of progress, particularly amongst the nursing profession. In fact, its publication the Nursing Review first reported in April 2008 on the work of an expert advisory group reviewing the health law to remove such barriers so that there could be more innovative practice. So updating this legislation became a priority for those in the profession, but, unfortunately, it went on the go-slow here in the Parliament.

We now have over 50,000 nurses in New Zealand registered with the Nursing Council, and we know that there is a looming GP issue in New Zealand, with around 44 percent of GPs saying they intend to leave the profession over the next 10 years. So we really do need to be developing a very flexible health workforce—those with the skills to be able to undertake work—and allowing them to become more active with their experience. This is what this bill does. We do also know that we have got over 3,000 young doctors revealing the extent of their workload—that some of them are reporting 16-hour shifts for 12 days in a row. We have reports of young doctors falling asleep while driving home, and over a thousand admitting they had made a mistake affecting patients because they were tired. So the need for us to pass this bill, to allow those who have undertaken the training to be able to use it in a much more comprehensive way, is urgent.

The first nurse practitioner—these are nurses who have a very high level of additional training—graduated in 2001, and since then we have got many, many more who have graduated and have been waiting to use their experience. Tonight I would like to just acknowledge one particular person who has been pushing for this for many years, and that is Judy Kilpatrick, who was the chair of the Nursing Council right through the development of nurse practitioners and getting the first nurse practitioner recognised. My complaint, I have to say—if it is a complaint—is the slowness at putting this bill in place, knowing the pressures we have on our health workforce, knowing the need to undertake more innovative practice. We needed to have passed this bill to allow our health workforce to be able to use their skills, as I said.

What the Minister went through in some detail is exactly what this bill will do, and it is about removing the references to medical practitioners in legislation and allowing other suitably qualified health professionals like nurses to perform appropriate tasks, which will allow that flexibility in the workforce, as I said. There are some good examples of things that they could do when this bill is passed: participating in claimants’ individual rehabilitation plans, issuing certificates of proof of illness or injury for sick leave, arranging medical examinations of children or young people, and taking blood specimens from road users are just some of the things that they would be able to do when this bill is passed. This bill is an omnibus bill. It amends seven statutes to increase the range of functions that can be performed by health practitioners under those statutes by changing certain references from “medical practitioner” to “health practitioner”. That will enable us to see far more innovative practice.

I do look forward to the opportunity, when we get to the Committee stage, to ask the Minister of Health questions about others who could be added to “health practitioner”, should they be registered under the Health Practitioners Competence Assurance (HPCA) Act. The first that come to mind are paramedics. Because paramedics are not registered under the Health Practitioners Competence Assurance Act, they are therefore not recognised in terms of the bodies that are covered in this bill. The paramedics have been waiting to have registration under the Act for years, going right back to about 2008. We have paramedics who undertake very, very skilled procedures on the side of the road—highly skilled people. In fact, some of the procedures they are able to undertake are more skilled than those of a GP, but they are not registered under the Act.

One of the things that I would like to see is paramedics become registered so they too can be included as health practitioners, because I can see the role of paramedics being very important in a flexible, innovative workforce—providing services not just at the side of the road but, in fact, in people’s homes and other settings. They, I think, are a group who desperately need to be included as health practitioners and recognised as health practitioners.

I also wonder—and I could not see it, but we will, hopefully, find out with the new Social Security Act rewrite that is taking place now—whether the Social Security Act will be included in this bill. I have gone through it, and I cannot see the inclusion. I see Child, Youth and Family, but I do not see a rewrite of the Social Security Act where nurse practitioners, under that Act, will be undertaking particular procedures. So that is another question that I would like to ask of the Minister.

We do support this bill. We are sorry that it has taken so long—sorry for those who have been waiting for its passage. I sometimes wonder why bills in this House that seem so trivial to many people in the public come before those that could make such a difference in the lives of people and in the operation of our health services, and that get pushed to the back of the queue. This is one of those bills. Go right back to 2008, and we are 8 years on from that first report that came back then from the expert advisory committee, to 2016, when we are now at the second reading of a bill that has taken so long in gestation to get to this stage. I think we need to look more carefully at some of the bills that we have and the priority that is put on them when we are deciding what should be debated and passed in this House.

This might seem a minor thing to those who do not understand the health sector, but it is a major thing if we are going to have innovative, flexible, creative provision of health services, and this bill will help do that, it is said by those who understand, from nurses to those other health professionals. As the Minister said, there were a few in the medical profession who raised concerns, but I do not think they need to be concerned, and neither did the Health Committee. We believe there is enough protection in this bill and within the HPCA Act around competency and around qualification to ensure the safety of the public. So we do support this bill, and we welcome its hasty speed through this House.

I am delighted to take a call after the honourable member Annette King, who has just taken her seat. Once again, it seems that through the work of Health Committee, concord has broken out across the House. All parties, I believe, are in agreement, but I will look forward with anticipation to the contributions from New Zealand First and the Greens. So I am very pleased to take this call on the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill in its second reading.

I want to begin by acknowledging all those who came before the select committee in the weeks prior to talk us through what they saw as the various perspectives on this bill. As has been noted by the last two speakers, including the Minister of Health, this is a relatively simple bill in what it attempts to achieve, but its repercussions are quite significant, I think. If time allows, I might touch on a few of those. I do want to thank all of the submitters who came and spoke, by and large, in support, but, again, I think it is important to acknowledge there were those speakers—I think, in fact, the Royal New Zealand College of General Practitioners was one—that raised some questions, and I think that that has to be acknowledged. I want to thank the officials, obviously, who helped us to bring it back to the House to this stage. Obviously, we have to go into the Committee stage after this and really begin teasing it out.

But this bill is just another example of the Government’s focus, if you will, or intentions to improve healthcare in this country. We often use the phrase, quite rightly, “Faster, sooner, more convenient.”, sometimes even adding in “closer to home”, and there is an enormous amount of examples of how that is actually working. [Interruption] I encourage those on the other side of the House, even the good member who shares my last name, to look at the health targets that were released today—thoroughly good reading, even at 4 minutes to 10 on a Tuesday night.

What this is ultimately doing is allowing the scope of practice to widen or to be transferred between specialties. Often, as I am speaking to constituents or others in the community, the best example is around something like a death certificate. At the moment, the legislation is very clear that a medical practitioner—that being a physician, a doctor—is the one who must do that. This bill, as one example, says that there are actually other health professionals—and we can think immediately of the likes of nurses—who are able to fill out that form. In fact, we will see that through—it is an omnibus bill, so this touches on seven pieces of legislation. This is also going to apply to the likes of death certificates and it is going to apply to the likes of ACC. Basically, it is acknowledging that medical practice changes over time, and that the scopes of practice do broaden.

I think back, particularly, to when I was working in the private healthcare space. I was very conscious in picking the area of dermatology and plastics that what was once an area for specialists alone—so by that I am talking dermatologists, plastic surgeons, general surgeons, and the like—is now actually being done by general practitioners. There is always a little bit of tension in this space, for a variety of reasons, but what we are also seeing is not only our GPs in this space now, but you could imagine in the future that those working, say, as nurses may be able to do this. A good example of that is actually in the endoscopic space, which, again, has usually been in the realm of specialists—endoscopists—but, actually, now there are nurses who would be able to act in this way.

I think it is prudent for this Government and the health profession to look at how it can better coordinate. A word that was also used by the Minister was “collaboration”, and I think this bill is going to help encourage and facilitate that as well. There will be better collaboration. A good example is what is already happening in the pain management zone. In fact, the Government has put money into pain management teams, and the long and the short of that is that it does not matter whether it is an occupational therapist or a nurse or a doctor or a social worker, or whatever—they can actually work together in that space. So I think this is very positive.

I do want to just draw quick attention to the fact that the scopes of practice are maintained by the respective colleges themselves, in coordination with the Ministry of Health—in other words, this is not carte blanche. It does not mean that just any health practitioner is able to do what they wish to do. What this is, is ultimately a chance for those particular colleges and groups to decide what is and is not appropriate for a health practitioner in this modern environment today. So I think it is really important to assure the public that although we are broadening, if you will, the scope of various practitioners and what they will be able to do, there is still plenty of oversight, particularly through the Health Practitioners Competence Assurance Act. Basically, there is legislation already in play that allows and strictly puts forward the way that the scope of practice of these groups is enacted. So that is going to be vitally important that that will continue.

I think, finally—because I am conscious of time—it is one thing amongst many. The select committee made a number of changes, most of them quite small, primarily around something that is just making sure that we describe doctors clinics correctly in a very modern parlance. One of the things we changed, in clause 42B, is to elaborate on the definition of “nurse practitioners”. They will not necessarily have been all that well known to New Zealanders. People just think of nurses, but actually there is a whole range of different equivalents, and nurse practitioners are very important in that space. So I think, with that, I will end my contribution.

Debate interrupted.

Sitting suspended from 10 p.m. to 9 a.m. (Wednesday)