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

It gives me pleasure to rise to take a call on the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. I was not on the Health Committee at the time that this bill was reported; however, I do have a little bit of industry knowledge, and I have been able to read through the report and recommendations of the select committee to the House.

What this bill, in effect, does is it redefines “health practitioners” from what we previously knew as “medical practitioners”, and it allows them to perform some statutory functions under legislation. The obvious example, which is quoted in the legislation, is about nurses and nurse practitioners. The legislation gives some clear definitions and it talks about their competencies. When we look at the way the health workforce has developed over the last 15 or 20 years or so, with technology and with advances in medicine, it has made it important for us to be able to review the practice of particular health professionals to ensure that they are able to do what they are able to do, and also to remove, particularly, GPs from some of the statutory functions that they have usually and normally carried out. There are a variety of responsibilities, particularly for nurse practitioners, that have been defined within this legislation.

What the bill also does is it gives us the opportunity to develop other health professionals. There are programmes to build other competencies into the work of health professionals. If I think back to my own experience in community mental health, it was not so long ago that we developed programmes to ensure that our mental health support workers and support staff actually have some recognised qualifications. It was not so long ago that many of our mental health support staff did not actually have qualifications, and there has been a real programme to ensure that those staff and other support workers are well trained, well experienced, and on a pathway to continuing education. That can only be good, in terms of professionalising our support staff.

As the bill was reported back from the select committee, one of the most significant parts of the legislation is the comprehensive definition of “nurse practitioner”. With an amendment in clause 42B to section 2(1) of the Medicines Act, the definition includes ensuring that a nurse practitioner holds a practising certificate, that they are registered by the Nursing Council of New Zealand under the Health Practitioners Competence Assurance Act 2003, and that they have the relevant scope of practice. So that is now within the legislation: a definition of “nurse practitioner”.

There has been a change in definition with regard to doctors’ surgeries now being called medical centres, which, I guess, are what most of us would go to when we are attending our GPs. There are recommended changes to the appropriate sections of the Land Transport Act to ensure that references that previously would have been to doctors’ surgeries are now to medical centres. There are also amendments to the Mental Health (Compulsory Assessment and Treatment) Act, which will insert within it definitions of “health practitioner”, “primary health care provider”, and “nurse practitioner”.

It is a good bill. It has ensured that nurse practitioners are recognised for the work that they do, as well as other health practitioners. I commend the bill to the House.

It is a pleasure to take a call on this bill. It is a great piece of legislation, and it is removing a whole lot of unnecessary barriers that we currently have. It is an omnibus bill, and it is surprising when you pass a piece of legislation like this how many other pieces of legislation it will affect. But it is really about making the best use of the skills we have in the health industry.

As we know, the way we deliver health is changing. We are going from a focus around those big hospitals, which are extremely important and where we need to send people when they have the most chronic cases of illness, to delivering more things in the community. A lot of our community health providers are very capable, well trained, and able to do some of the jobs that currently, legally, within these pieces of legislation, they are not able to do. So what it is going to mean is that people are going to have a greater level of access to services, and there will be more health professionals out there to do that.

Something that I have come across in my electorate—as you would imagine, it varies far and wide: we have the Hamilton hospital at one end and we have the New Plymouth hospital and a smaller hospital at Te Kūiti, but there is a whole wide range of areas around that rely on health professionals to give them their day-to-day needs. What I am finding is that as we have a shortage of rural doctors—and we know that—something in health that is very important for people, particularly older people, is to trust the person who is providing their care. So they rely quite heavily on the nurses and the people who are in the medical centres to provide that. When they go there they know there is someone they can trust, so even if we do get doctors coming in and out, and it is somebody they do not know, there is actually a set of health professionals there that can help them.

This is all part of the primary care focus. Having worked through some of this on the Health Committee, it is really interesting to me to see the actual bills that are affected by this bill. There are amendments around the Accident Compensation Act 2001: “any health practitioner providing treatment to the claimant”—so, again, it is often just wording, but it makes such a difference because all of these pieces of legislation have to fall in place. There is the Land Transport Act. As the previous speaker said, it is just asking people to go to the medical centre instead of the doctor’s surgery, which is something most of us do not call it any more. Amendments have been made to definitions around the Mental Health (Compulsory Assessment and Treatment) Act, just changing the name of those people who are being dealt with.

I think there are two important issues here within this piece of legislation. They are that the Children, Young Persons, and Their Families Act 1989 is being adjusted to place an equivalent duty on to health practitioners so that it is in line with the duty of medical practitioners to minimise distressed children and young persons when carrying out medical examinations. To be honest, when people go to a medical centre, it is often the nurse or the health practitioner who are the ones who actually calm the children down, because often they are quite scared, particularly if they are going to be having injections and things like that. The other one is the amendments to the Burial and Cremation Act, for the other stage of life. It is my pleasure this afternoon to commend this bill to the House.

It is a pleasure to rise to speak in this debate. It was such a long time ago that the Health Committee heard submissions on this bill that I had to refresh my mind on its content and on the submissions we received.

The way I like to begin second reading speeches is to thank the officials who assisted the select committee and thank the submitters on the bill. The submitters on this particular bill made a very positive contribution indeed. They mainly came from the professional groups that will be affected by the bill, and most of the submissions were of quite a technical nature. I think it is fair to say that, as reported back from the select committee, most of the professional groups that did submit on the bill will be pleased to see the changes being made. Perhaps the medical groups will be somewhat less pleased, as in general they prefer to see no change, but I am sure that, in time, they will come to understand that these changes have been positive for their practice as well.

The health budget is inevitably constrained. No matter how much of the tax take gets put into the health budget, there will always be extra needs that could have been met had there only been some more resourcing, so there is a deep imperative on the Government and on this House to ensure that the resources that we have available to the health sector are used as efficiently as they can be. This bill relates specifically to the resource that is the health professionals, but the same principle applies to the physical resources. Are we using operating theatres as efficiently as we could be? The answer is no, in fact—we could do better in that. Are we using the dollars as efficiently as we could be? We actually do not know, because the only part of the system that we actually do cost-benefit analysis on is the pharmaceutical side. If we had an extra dollar to put into health, we do not actually know whether it would be better to put that into pharmaceuticals or into other interventions. So, in those areas, we could do a lot better at improving the efficiency of our resource use in health.

But this bill, in relation to health professionals, certainly does result in better utilisation of the health professionals whom we have available. The legislation before us and the professional rules that apply to health professionals place limits on the scope of practice of health professions—and that is appropriately so—but those restrictions should be only those that are reasonably justifiable on clinical grounds. They should not go further than that, because if they go further than that—as the existing law does—what it means is that we will have health professionals whose time and skill we are using inefficiently. That means we will not be getting as much health gain from the skill of those health professionals as we could and should do.

We select committee members have had a robust series of discussions with submitters and amongst ourselves to test the changes that were proposed in the bill as introduced. We have made a number of changes that, on balance, we believe make the bill a better bill. Inevitably, there are judgment calls to be made, and I believe that the select committee has made those calls in the right place.

I want to conclude by referring to my own experience as chief executive of the West Coast District Health Board, because I believe it illustrates the pressing need for this reform. I note that nursing organisations, for example, have been clamouring for urgent reform of precisely these rules in legislation, because we have nurses, in particular, unable to practise to the full extent of their skill and knowledge because of arbitrary and inappropriate rules in our legislation. So I am sure they will welcome this bill being taken to the next step.

In an area like the West Coast—pretty much as Barbara Kuriger has spoken about in relation to Taranaki and King Country—many, many people receive their primary healthcare from nurses, and those rural nurse specialists do an absolutely fantastic job. I well remember one of my visits to a rural nursing clinic to follow up on what actually happens on the day that the doctor comes to visit—because the nursing service is supported by a general practitioner who visits. Actually, that general practitioner’s time is principally spent signing forms to, essentially, certify as correct the practice that the nurses had already put into place. So all of the expertise and skill in providing healthcare for patients had been delivered by nurses, and the doctor, who presumably and certainly does have expertise and skill in areas that the nurse does not have, was unable to apply that expertise and skill because all of the doctor’s time had to be spent in needless form-filling required by our current law.

Actually moving beyond that arbitrary and inappropriate restriction on nursing practice will ensure that the nurse is able to provide a full service to the extent of the nurse’s capability, but also that we get to use the doctor’s time more appropriately—a better health gain all around, which surely ought to be the driving principle behind all of our work in relation to health. I commend the bill to the House.

I rise to speak on behalf of New Zealand First on the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. New Zealand First supports this bill. We believe that this is a bill that is going to see some common-sense changes within the health sector. We know that the health practitioners already have the skills, so this bill is an opportunity to ensure that they can use those skills. We need these people to provide the best healthcare for all of us.

The training of health practitioners has advanced considerably, meaning that, as my colleague Kevin Hague said, they are more capable than ever before. I think that in this day and age we have to be quite realistic and say that we have to move with the times and accept some of the changes that are there. We know we have got an ageing GP workforce. We know that about 44 percent of them are going to retire, and that is a huge number, but we still want the same level of healthcare. I was delighted to read in the latest edition of the New Zealand Doctor news online that nurse prescribing got the thumbs up at the GP conference. I thought that was indeed a really good, big step forward.

I would also like to take the opportunity to acknowledge and thank the many hard-working nurses up and down this country. We know they do an absolutely incredible job despite often trying conditions, and we believe that this bill actually recognises their skills and expertise for caring for their patients. We know nurse practitioners have been providing services since 2001. They have got the training to enable them to carry out this role very competently, and no doubt they will be very pleased to see this bill at last progress through the House, because it has taken a long time.

There is one group of health practitioners that actually needs to be included in this bill, and that is the paramedics. We in this House, and New Zealand First in particular, have been calling for the registration of our paramedics. They are the men and women who are often first on the scene for medical emergencies right throughout the country. The skill required to be a paramedic is extremely high. They often have to make complex life or death decisions in a very short space of time, yet they remain unregistered. We believe that many New Zealanders would be shocked to learn of this. New Zealanders, too, are also at risk because at this point in time anyone can set up a paramedic service and Kiwis would not be the wiser. Currently there are four ambulance service providers, and it is quite concerning to read that the skills and qualifications can differ quite widely from one service to another.

We know that the paramedics do a remarkable job under very challenging circumstances, often on the side of the road. Their service is stretched. They answer about 450,000 patient call-outs each year with minimal resources. We believe that as paramedics remain unregistered, they are not receiving the same recognition of their skills as other professionals. We believe that this really does the paramedic service a very grave disservice.

I would like to acknowledge my fellow colleagues and members of the Health Committee, as we carefully reviewed the proposed bill and made some practical changes. We are also grateful to the organisations and the people who took time out to make a submission to the Health Committee, and we considered each submission carefully. We received only 28 submissions, and we received advice from the Ministry of Health. We acknowledged concerns about public safety from the community.

We believe that this bill is a really big step in the right direction. We hope that it is going to ease some of the pressure on our health workforce, which is one of its intended goals. However, it will not solve the issue of an underfunded health system. We are pleased to support this bill, and we look for a speedy passage of the bill through the House. Thank you.

It is a real privilege to take a call in the second reading of this, the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. I know that is a bit of a mouthful, but this is a very good, practical piece of legislation that I think is quite long overdue.

The member Barbara Stewart, who has just resumed her seat, made mention of the 28 submitters on the bill. I think that, with almost no exception, we received very good information from those submitters. Over the years, modern medicine has changed dramatically. I am the son of a registered nurse; my mother practised nursing in the late 1950s. In those days, I recall her telling stories about how nothing happened without the approval of the doctor. The doctor was all-supreme, all-knowing, and all-important in terms of any patient interaction. What we have seen since those days is a change in the way that our medical professionals are trained, and the health practitioners whose roles we are seeking to extend in this piece of legislation are now quite different and more important in terms of providing wonderful service to patients up and down the countryside.

I represent a rural, provincial electorate, and it is in electorates like mine, in the Coromandel, where I think the greatest benefit of this legislation will come to pass. As community health is more and more focused on care in the community and keeping people in their homes, it is more important that our health professionals actually go out into those communities and into the homes. Those communities will be the ones that benefit most from this, because there is a greater role for providers. There are also a greater range of services, and this was made very clear to us by the submitters—that the range of services that health practitioners are required to attend to these days is much wider than it was even a few years ago. The advancement of technology and modern information means that we do need to change these roles. I think that this bill is a very effective piece of legislation. It is a piece of legislation, I think, whose time has come, and I commend it to the House.

I am delighted to speak in support of the second reading of the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. It does not win any awards for the snappiest name, but the name certainly describes the contents of the bill. I remember when the bill was introduced, the Minister said “Its time has come.”, and the Hon Annette King, quite rightly, said: “Actually, its time was years ago.” This is so overdue, as the member, Scott Simpson, who has just resumed his seat, has bravely pointed out to his—it is probably not a career-enhancing move you made there, but it was an honest opinion expressed: that this is well overdue.

We are supporting it because it certainly means now that a lot of the legislation that needs to change to recognise the increased qualifications, the competency, and the ability of other practitioners to perform tasks will keep up with the reality. So much of our legislation is outdated, and I know that other members who have spoken have referenced the fact that this is an omnibus bill simply because it alters so many other pieces of legislation and updates them. Not only is that a good thing—to recognise the valuable contribution that many members of our health system currently make, but they cannot do some things that they are competent and trained to do—but also it recognises the very real cost pressures that we have in our health system, and the workforce issues that we face, as well.

We know that the Government has underfunded our health system in the last 8 years by about $1.7 billion. That is a huge amount of money that the Government has not put into the health system, which it should have put in to keep up with the demographic pressures and the population pressures. We have got an ageing population, we have got huge cost pressures, we have got workforce issues, and instead of recognising that as a package of concerns that is reducing the ability of New Zealanders to get the healthcare that they need—that is the outcome of that—the Government has been short-funding it and tinkering with a lot of other measures that were necessary. But with this legislation it is actually doing the right thing.

We have got about 50,000 nurses in New Zealand registered with the Nursing Council of New Zealand. We have got a looming GP retirement, about—well, not quite half, but nearly 45 percent of current GPs have said that they intend to retire over the next decade. We cannot magically whip up a huge number more GPs to replace those ones who are retiring—that is not possible. A lot of GPs are leaving New Zealand because the health system is so restrictive. They are finding it more satisfying to go overseas. I know a lot of general practitioners decide not to remain operating in New Zealand, because of the costs that the current National Government has imposed, particularly on small businesses. It just layers more and more and more regulation and requirement, and from a National-led Government it is quite a surprise to many of those GPs—in fact, quite a shock.

💬 Hon Simon Bridges: I know—that’s what we expect from you.

The ASSISTANT SPEAKER (Hon Trevor Mallard): Order!

But that is what is driving them to change their voting pattern as well, actually. Thank you, Mr Bridges, for your acknowledgment that this is exactly what you are hearing in your electorate, as well. I am glad that you have confirmed that.

With that short-funding of the health system and the number of GPs who have said that they are going to retire—that is a huge stress on our workforce. Something has to give, and that is the big piece of the puzzle that National is just refusing to acknowledge. There has been a lot of ridicule poured on backbench National Party members recently about the substance of their members’ bills. I want to just say that this Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill was actually the subject of a member’s bill that I drew up some time ago. It was never drawn. I have replaced it because I have changed portfolios and I always have member’s bills that are relevant to my portfolios. But I became very familiar with some of the stupidity of our existing legislation and how important it was to recognise that you do not actually need a doctor to sign a death certificate. You do not need a doctor to sign a medical certificate for Child, Youth and Family. There is a whole range of things that other people in the health system can do, but the legislation restricted them from doing it.

So this is moving the legislation in keeping with the changes that have been driven not only in terms of competency but also in terms of qualification. It was, I think, maybe 2002—it was some time ago—that nurse practitioners were introduced as a new profession. That is a higher level of qualification for nursing than we had ever had before, and now we have thousands of nurse practitioners who are able to do, within their competency, a great deal of things that previously only doctors could do. I remember when midwives were certified to be able to deliver babies. Previously, it had to be signed off by a doctor—a ridiculous situation, and, as Kevin Hague pointed out, it was often just the form-filling that the doctor did, whereas the actual work had been done by a nurse. But somebody had to sign it off according to the law, and, of course, who got the money for it? The person who signed off the form, which is pretty outrageous.

So this bill is making the health system more fit for purpose. It will give it greater sustainability because of the need to have more people practising where they currently are not, but also given the fact that so many of our doctors are retiring. It does need the Government to come to the party in the end and start funding our whole system in a way that recognises the health inflation costs, the demographic changes, and the population growth. There is $1.7 billion of underfunding in our current health system. That is not a way that our health system can thrive and grow. No wonder we have so many people who are not able to get their specialist assessments when they need them.

I have seen it in the media myself, as well as having constituents come to my office—people who are in a lot of pain who need surgery and who are not able to get a referral from their GP and then get in to see a specialist and get that surgery. I saw a case recently in the press where a woman had mortgaged her house in order to get a shoulder operation because she could not get that operation in the public system. In New Zealand in 2016 those sorts of occurrences are just a disgrace.

So I would be very happy if we could have not just a debate on this improvement—and improvement it is—but also a proper debate on how we can ensure that the health system in New Zealand is funded and supported to deliver the level of healthcare that New Zealanders need. I do not think that is asking for too much. We have had it in the past, and it is really only through the miserly behaviour of Bill English—shocking, because he was a former Minister of Health himself, actually—that we have seen not enough money going into the coffers.

In the end, a system will work despite what Governments do, because of the nature of the people. We are so lucky in New Zealand to have, right throughout our health system, amazingly dedicated, passionate people. They will keep our health system going, but there is only so much they can do without the support from central government that they are clearly not getting at the moment. They cannot work so many hours that they are exhausted.

I saw a survey recently where GPs were saying that they often worked longer hours than they should, and something like 10 percent of the GPs who were surveyed said that they had performed actions with their patients that could have done harm, and they had performed them in error because they were so tired. That is a terrible situation for patients who go to their doctor relying on them to be on top of their job, but the doctors have been working such long hours, and have been under such a lot of stress because of the regulatory environment developed for small businesses by the National Government, that they actually make errors. That is something that should be unacceptable in New Zealand. Having said all that, I think that this is a very good bill. I am pleased that it is making progress, at long last, through the health system. I look forward to the final stages of it soon.

I just want to take a short call on this Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. I think a lot of the things that have been said about it this evening have already been covered, but I think it is really important for us to just sort of stop and note that at times things change in society and then legislation needs to catch up.

If we look at the changing nature of medical practice over recent years—whether it is, as a previous speaker has mentioned, the introduction of nurse practitioners, midwives being able to deliver babies, midwives getting prescribing rights for certain medications and the like, or nurse practitioners being able to prescribe medicines—there has been, I think, good progress made throughout the years within these professions to allow more suitably qualified people to be able to perform certain tasks that had previously been able to be done only by doctors. So it is important that our legislation now catches up to that. I think this is a good bill that, obviously, is going to make some changes to seven statutes to ensure that we make the best use of the resources we have available across the sector. I support this bill.

Tēnā koe e Te Māngai o Te Whare. It is my pleasure to speak on the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill in this, its second reading, and to reiterate that Labour supports this piece of legislation.

I would like to just confirm what the stated objectives of this bill are. I am not a member of the Health Committee, but I previously have been. This piece of legislation, having sat on the committee during some of its deliberation, was really interesting. What it seeks to do is to allow health practitioners with the required competencies and knowledge to perform more statutory functions. What this means is that many health professional groups are now capable of performing tasks that were previously the sole domain of medical practitioners, which, essentially, means that nurses are now able to do what doctors used to do. Actually, that was the biggest discussion of the select committee. In fact, the Medical Association, if I put its case forward—that was its biggest issue with this bill. It thought that doctors were, I guess, skilled in certain areas, and it had some concern about transferring that responsibility to nurses. I think some of that discussion may play out in the Committee stage, but I wanted to highlight it because, based on this piece of legislation, the registration under the Health Practitioners Competence Assurance Act will then determine the scope of practice that all health practitioners have, which includes nurse practitioners.

The reason I bring it up is that at the heart of this piece of legislation it is trying to utilise all of the assets that we have in the health system to their full capacity. Now, for example, our nurse practitioners will be able to sign death certificates. In the past that was solely the responsibility of doctors. Some would say that that is a huge change, but what the committee said was that this is actually a practical change, because nurse practitioners do have the skills and they do have the competency, based on their registration, to be able to undertake that specific task.

Nurse practitioners also have the skills to take blood specimens from drunk drivers. Again, that was previously the responsibility solely of doctors. They will also, under this piece of legislation, be able to declare people unfit to drive. At the moment, it is only doctors and optometrists who are competent enough under current legislation to say whether people can or cannot drive. What this piece of legislation does is empower nurse practitioners to make that determination. They are also now able to sign sick leave certificates. Again, under current legislation only doctors can do that. They also now are empowered to prescribe controlled drugs. Again, that is a role that only doctors can perform. They will also, under this piece of legislation, be now empowered to issue a certificate to accompany an application for a mental health assessment. This, again, recognises the particular competencies and skills that nurse practitioners have.

It is interesting to note what we are doing in terms of empowering nurse practitioners, but it is also incredibly relevant if we look at our current health workforce. We have 50,000 nurses in Aotearoa New Zealand; my colleague Adrian Rurawhe has been trying to find out the number of nurse practitioners we have. To be a nurse practitioner, you actually have to undertake a Master’s degree in nursing. It takes an extra 2 years of academic study to qualify yourself to be upskilled—to be competent enough to do all these additional things that I have just read out, based on your qualification.

Within the context of 50,000 nurses, we have 14,333 GPs. I want to continue the discussion that my colleague Ruth Dyson started and, also, that my colleague the Hon Annette King stated in her contribution to the House, and that is that in the next 10 years, 44 percent of those GPs will be leaving. That is 6,306 doctors. So I think that the opportunity that we have to provide more opportunities for nurses to become nurse practitioners is a very good thing, because we are actually futureproofing our workforce to undertake a number of tasks that, historically, only doctors have been able to perform.

I think the reality, particularly for some of our young doctors, is that they have to work up to 16 hours a day. There have been issues in the media lately about that workload and, I guess, their inability to cope, so if we can fully utilise the skills across our health workforce, then, I think, that is a good thing for all of us. Currently there are 3.5 nurses to one doctor, so this piece of legislation makes sense from that perspective.

The other objectives of this bill, as stated in the bill commentary, are to “make it easier for the public to access statutory health services”, “allow the health workforce to use their knowledge and skills”, and to “facilitate innovative services and efficient practice.” In looking at the numbers, again, of nurses versus doctors, I think that in some of our rural communities having nurse-led practices in the future makes complete sense.

From the Labour side of the Chamber, we do support this piece of legislation. I think, just finally, my acknowledgment is really to the Nurse Practitioners New Zealand board. I saw some commentary in the media by Dr Michal Boyd, who was its chair in 2005. It has actually been fighting for the recognition of nurse practitioners for over 10 years now—for them to be empowered to use the skills that they have gained through the qualification of nurse practitioner to undertake many of the tasks that, historically, have only been the responsibility of doctors.

I want to acknowledge all the champions within the nurse practitioner field, who were fighting not only for the recognition of their particular qualification but also for women, because, as we know, the nursing profession is disproportionately a profession that women are engaged in. I think that the fight from the Nurse Practitioners New Zealand association has been beneficial not only for nurses as a profession but also for women, because I think that added responsibility will see, in the future, their ability to lead medical practices. I think that, again, we will see the value of that qualification rise, and, hopefully, the equitable remuneration of that particular skill set or career. I know that was not one of the objectives of the legislation, but from my perspective it is and it will be, and so I hope there are more nurses who put up their hand to do extra study to become nurse practitioners, because, based on the evidence that we have, we are going to need them.

Debate interrupted.

The House adjourned at 6 p.m.