Third Readings

I move, That the Accident Compensation Amendment Bill (No 2), the Burial and Cremation Amendment Bill, the Children, Young Persons, and Their Families Amendment Bill (No 2), the Holidays Amendment Bill (No 2), the Land Transport Amendment Bill (No 3), the Medicines Amendment Bill, the Mental Health (Compulsory Assessment and Treatment) Amendment Bill, and the Misuse of Drugs Amendment Bill (No 2) be now read a third time. This legislation will amend eight Acts to remove references to “medical practitioner” and replace them with the words “health practitioner”. That is going to enable a wider range of suitable health practitioners to undertake certain functions that are currently restricted to only medical practitioners. New Zealand’s health workforce is evolving, and many health professional groups are now capable of performing the tasks that were previously the sole domain of medical practitioners.

The purpose of this legislation is to improve access to services for New Zealanders, and this Government wants to ensure that people receive timely care from the most appropriate health practitioner close to home. That is going to be a very necessary approach if we are going to have a sustainable health system that can provide the services that everyone across the country needs in the long term. These eight bills divided from the original bill align very closely to the New Zealand Health Strategy, which is all about moving care from secondary care out into the community, taking a preventative and early intervention approach, and, very importantly, using all the skills that we have right across the healthcare workforce and deploying them in the most effective manner.

I would like to thank members from across the House for the support that they have given to this omnibus legislation in its earlier readings, and I would also like to thank the Health Committee and those who took the time to make submissions on the legislation. The legislation has had a long passage to this stage of the Parliamentary process. This has ensured that we now have legislation fit for purpose that will make real changes to how people can access services from health practitioners. We have not only enabled suitably qualified health practitioners to undertake statutory duties but we have also used the opportunity to make statutory terms and descriptions much more consistent right across legislation.

I know that a number of members focused on the meaning of amendments for the work of nurses and nurse practitioners in their speeches earlier in the debate. The amendments in this legislation are designed to ensure that all suitably qualified health practitioners are able to undertake certain statutory activities if they have the required training, knowledge, and skills. In some cases, nurse practitioners will be the only suitably qualified group; in other cases, nurse practitioners, registered nurses, or pharmacist prescribers may all be suitably qualified. For other statutory activities, a range of health practitioners may be suitably qualified and the most appropriate and available people to undertake the task at hand. The safety of the public remains secure as the regulatory framework governing health practitioners continues to be managed through the Health Practitioners Competence Assurance Act 2003.

I will briefly sum up the amendments in each part of the original bill. In Part 1, we were dealing with amendments to the Accident Compensation Act. The legislation amends schedule 1 of that Act so that any health practitioners providing treatment to the claimant are given the opportunity to participate in the preparation and costing of an individual rehabilitation plan for the claimant, to the extent that they are willing and able to do so. Examples include physiotherapists or occupational therapists.

In Part 2, we had amendments to the Burial and Cremation Act. This legislation amends the term “doctor’s certificate” to “certificate of the cause of death”. References to “medical practitioner” are amended to allow nurse practitioners to also issue certificates of cause of death, and that is quite a major change. Nurse practitioners are qualified in a similar way to medical practitioners to issue these certificates through their training in diagnosis and their position as lead healthcare providers. I can tell you that certifying death is not as simple as it may sound.

Part 3 amended the Children, Young Persons, and Their Families Act 1989. The legislation amends references to “medical practitioner” to enable a social worker to request suitably qualified health practitioners to examine a child. The legislation also replaces references to “psychiatric hospital” with “hospital” to give it the same meaning as in the Mental Health (Compulsory Assessment and Treatment) Act 1992.

In Part 4, we had amendments to the Holidays Act 2003. Those amendments mean that proof of injury or sickness under that Act may include a certificate issued by a health practitioner rather than just by a medical practitioner—i.e., a doctor. A suitably qualified practice nurse could provide a certificate of proof of illness or injury that would save a sick person both time and money, and, at the same time, would make the best use of the health practitioner’s precious time.

In Part 5, we had amendments to the Land Transport Act 1998. The legislation now amends references to “medical practitioner” to allow health practitioners to undertake duties relating to taking blood specimens and assessing the fitness of people to drive. The legislation is also an opportunity to update the terminology so that references to “doctor’s surgery” and “surgery” are now replaced with a much more common term: “medical centre”. In Part 5A, we had amendments to the Medicines Act 1981—specifically, an amendment to section 105B(d) of that Act, meaning that nurse practitioners will be able to supervise designated prescribers. Nurse practitioners, like medical practitioners, are authorised prescribers. As new prescriber groups are established under the Medicines Regulations, it is important that we have sufficient authorised prescribers to provide the support and mentorship that is going to be needed in order to deliver safe practice.

In Part 6 we had amendments to the Mental Health (Compulsory Assessment and Treatment) Act 1992, and these amendments are going to provide the opportunity to insert a new definition of “nurse practitioner” so that that legislation aligns with other legislation. Section 8B is amended to allow a health practitioner who is either a medical practitioner, a nurse practitioner, or a registered nurse practising in mental health to issue a certificate to accompany an application for assessment. Currently, only a doctor can issue such a certificate. Section 9 of that Act is also amended so that an assessment examination may be undertaken by a medical practitioner or a nurse practitioner who is approved by the Director of Mental Health. Currently, only medical practitioners can undertake that important and very sensitive assessment, so that amendment is a very good example of enabling a suitably qualified person to undertake an assessment examination. Often, the nurse practitioners practising in mental health are not only the people who are most available but may also be the people who have the most knowledge of the history in the current situation of the patient before them.

In Part 7 we had amendments to the Misuse of Drugs Act 1975 that allow specified nurse practitioners, registered nurse - designated prescribers, and pharmacist-designated prescribers to prescribe controlled drugs for the treatment of addictions. The parameters for the new groups to prescribe under that Act are the same as those for medical practitioners, including the need for health practitioners to be compliant with applicable guidelines issued by the Director-General of Health for the treatment of addictions.

The purpose of this omnibus legislation is to reduce legislative barriers so that competent health practitioners can perform a number of statutory functions that were previously limited to doctors only. Changes to the statutory provisions in the legislation will allow competent health practitioners to use their qualifications, knowledge, and skills to the full scope of their practice and, ultimately, will help us deliver better health outcomes for a greater number of New Zealanders. This legislation is also going to help us run the health system in a much more efficient manner and improve health practitioner accountability by making practice much more transparent. The Government intends to review unnecessary restrictions for statutory functions for health practitioners in other Acts as they are revised. This is excellent legislation. I thank everyone who has been involved with it, and I commend these bills to the House.

Labour, as it has throughout this legislation’s progress, supports it at its third reading. I want to begin by saying that I would have thought the Minister of Health could have shown a little bit more enthusiasm about this legislation, which makes quite a significant—

💬 Hon Dr Jonathan Coleman: I used it all on your question today.

You certainly did, Minister. You used it all on the questions today; it is just a shame you never answered any of them. But it is a shame that the Minister did not sound so enthusiastic and sounded a little bored by it all, because, certainly, the Health Committee did not find it boring at all. In fact, I want to begin by saying that the Health Committee took the legislation very seriously. We did a very good job on the legislation, and reported it back once we got our hands on it.

The biggest problem with this legislation is the time that it has taken for it to get through this Parliament and to make the changes that are needed. I have raised this in the first reading, in the second reading, and in the Committee stage, so you will not be surprised that I am raising it again in the third reading. You see, sometimes really good ideas, under this Government, seem to be put on the back-burner and come second, third, or last in some of its priorities. Unfortunately, they are often very good health ideas, and that may reflect the energy of the Minister—I am not sure.

This is legislation that was needed, and has been needed for some time, because of the complexities that we now have in our health system and our need to have a range of health practitioners able to provide a range of services when they meet those competencies. The very first piece of legislation that was going to enable others to prescribe, for example, happened a long time ago—in fact, it happened in 2005, when I was Minister of Health. I introduced something 14 years ago, and here we are making a little improvement all these years later.

So I do say to the Minister, when we have got legislation like this, use your muscle to get it up the Order Paper. I am sure the Leader of the House, if he was approached—being a very approachable man—would listen to him and say: “Yes, this is important.” I think it is more important than some of the legislation we have, and certainly more important than worrying about lost luggage and things like that.

This legislation, as the Minister did say, is from an omnibus bill. It does amend eight statutes and it does increase the range of functions that can be performed by health practitioners under those statutes. In those old statutes, they made reference only to “medical practitioners”—in other words, doctors—so they restricted what could be done by any other practitioner. By amending that and changing it to “health practitioner”, it widens the range of who can carry out those functions. Actually, as the Minister pointed out, health practitioners are carrying out some pretty important functions under this legislation. For example, the Misuse of Drugs Act is being amended so that a qualified nurse can treat addiction patients. Changes to the Burial and Cremation Act will allow nurse practitioners to certify the cause of death. As the Minister said, that is not easy, so you need to have people who are trained in doing it, but they do not have to be medical practitioners. We will also amend the Land Transport Act with this legislation, and it is being amended because at present it states that only medical practitioners—doctors—and optometrists can provide medical reports on a person’s fitness to drive. Then, if you look at the Children, Young Persons, and Their Families Act, it restricts medical examinations of children to medical practitioners whom the court considers qualified for the purpose. So the legislation amends, as I said, eight statutes and allows other health practitioners to undertake those roles.

In a changing health system, those roles, as I said, do require us to use the expertise and training of every health practitioner whom we can use. We can augment the work that is done by medical practitioners when others are involved in the provision of health services, so this legislation widens that ability. It is going to give greater scope and I can see real use for it, particularly in rural New Zealand. It is often hard to recruit medical practitioners there, but in our rural areas we have extremely good nurses with high levels of skill, nurse practitioners, those who are involved in emergency responses, and those who are involved in rural health practice. I can see great use of them to carry out these functions. Imagine if you were in a small town and you had to wait for a medical practitioner to arrive to declare that a person was dead. It is great stress on a family, waiting for that certificate to say that a person has died. Now in that community there can be a person with the appropriate training who can undertake such a function. I think it is going to be very valuable. I notice that the member Barbara Kuriger, who does represent a rural seat, is nodding her head. She understands the practicality of this change, as will many out in our community.

There is one fear I have with this legislation—I raised it at the committee and I raised in other readings of this legislation—and that is what has been said by the Minister, which is that there is no cost to doing this. Well, I think there has to be a cost to doing it, because if a person has greater skills, be they a nurse or any other health practitioner—if they have got greater skills and they have got greater qualifications, they do need to be paid more. They will not be doing it at the same price as a practitioner who has lesser skills. There will be a cost, and one of my worries and fears is that if we think there is no cost, we will fail to fund those practitioners to carry out the role.

One of the problems that we have had with nurse practitioners is that district health boards (DHBs) have not funded those who are qualified to be nurse practitioners, because of the higher costs. Where there could be hundreds and hundreds of nurse practitioners—we have got thousands of nurses who have got Master’s degrees and above in their qualifications not being used because DHBs have to pay more for their skills, and they do not. They have not used that capacity and skill that we have in New Zealand, because of the cost. That is my fear—that we will pass this legislation and little will change. Little will change, even though there are those who have the skill to do it, unless DHBs are prepared to pay for that skill.

We have just gone through a junior doctors’ strike, seeking to ensure that they are properly rewarded but also treated fairly when it comes to rosters and so on. We cannot ask another workforce to carry out the greater duties that we need without ensuring that it too has proper working conditions and the remuneration that goes with it. I just hope that I am wrong, but I have seen what has happened.

The first nurse practitioner was actually registered in Hamilton back in about 2002, and I thought that we would have seen thousands by now. That has not been the case, and it does, as I have been told, get down to money. I hope that at our select committee we do not have to bring this up with the Minister during Estimates hearings and at other times, because he has got it right—I hope I have got it wrong and he has got it right—that there does not need to be any extra money. But one of the things we ought to do is monitor the impact of this legislation over time to ensure that all the things we think will happen by amending these eight statutes actually will happen for the provision of health services in New Zealand.

We do commend this legislation to the House. I am glad that it has finally reached the end of a very long process. I too think the Health Committee is a very good committee, and I am being very objective in this—you know, I could be highly political. But I do think we have an extremely good Health Committee, and I will say of Simon O’Connor, he is one of the best chairs we have had of a select committee.

💬 Grant Robertson: Is he going to get into Cabinet?

I think he should be in Cabinet. In fact, he would probably make an extremely good health Minister. He is informed, he is reasoned, he knows a little bit about it, and he is interested, and none of those qualities, you could—

💬 Grant Robertson: That puts him well in front.

That puts him well in front. None of those qualities our current Minister has. I have just done him to death; he probably will not get a job now. But we support this legislation, and I am very glad it is going through the House.

💬 Grant Robertson: Oh, good timing.

Yes, impeccable timing—serendipitous, even. Thank you to the member Annette King, who has just resumed her seat, for the very kind words. It is a death knell for my career to have the Opposition laud me so strongly. It has been an absolute pleasure to serve this House—this could become a valedictory.

💬 Hon Annette King: Is this your valedictory?

It could be my valedictory. I am very pleased to take a call in this third reading of the bills divided from the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. I think it is important to note that, of course, the original bill has been split into eight bills, as the various aspects that we have looked at, from ACC to the likes of death notices—so that affects the Burial and Cremation Act—begin to extrapolate out.

I thought I would just touch on a couple of points—first and foremost to say thank you, as others have, to everyone who has been involved, to the Minister, who has brought the legislation to the House, and to the Health Committee, which worked very hard on this. Even though there was tongue-in-cheek at the end of the last speech and at the start of mine, the committee actually worked very hard to try to get its head around the various aspects. I think one that really stands out for me was actually the contribution of the member, particularly around mental health and who is the right person or persons to be assisting—how far this should be expanded. But, very importantly, we understood quite early on, particularly through a member’s intervention, that we had to be very clear in this legislation of what facilities were appropriate. The long and the short is that the legislation as initially drafted around facilities was quite broad, so the committee worked efficiently to tidy that up.

Thanks, too, to the officials. I think that although we as MPs work hard, we are very conscious of the work of officials in the background.

There are two other general points I want to make. The first is that we are expanding the terminology from “medical practitioner”—so, again, from doctor—to “health practitioner”, taking in a whole range of other skills. So you are thinking nurses primarily, but you are thinking right across the competencies, such as podiatrists, occupational therapists, and the like. That is the distinction, but I think what is really important to note is that there is a difference, I would maintain, between doctors and the other professionals. They work in a complementary manner.

Some of the comments picked up—sometimes in the select committee; sometimes in the debates—have said they are sort of becoming one and the same. I just want to stress, from my point of view and that of many others too, that there is still a distinction, if you will, between medical practitioners and health practitioners. It is not one simply in legislation but by the various models—clinical, medical, and otherwise—that they make. So this is not making nurses or podiatrists or occupational therapists or other health professionals into doctors; it is just allowing a broader competency, in the same way that doctors within their various professions are broadening their scopes. I have spoken a few times in this House about how general practitioners are now doing the work that some dermatologists, plastic surgeons, and general surgeons are doing—for example, in the same way that nurses are now doing the work of the likes of endoscopists. So there is whole lot of change and flux.

I think it is really important, too, to understand that even though this legislation allows an expansion, there is another piece of legislation in the background, the health practitioners competency Act—I am paraphrasing the name there. The long and the short of it is that all these health practitioners, their colleges, or their associations have guidelines—that might be one word to use for it—of what is and is not within scope. So this is not just carte blanche or a blank cheque for health professionals to do whatever they want. Their colleges and their associations have a very clear list, if you will, of guidelines to say what is and is not possible. It is my understanding that those colleges and the Ministry of Health are working together to update those at the moment.

I will not go on for too much longer because I think we have heard some of the core elements of the legislation being described and I am very sure that people after me will be going through the different stages. Suffice to say, this legislation is about expanding the scope of practice for health practitioners—again, the classic example that has often come up is around the likes of death certificates. At the moment, only a doctor can do that; post this legislation, if it passes into law, other health practitioners will be able to undertake that.

So, yes, this is about health practitioners getting an increase of scope, but, really importantly, it is about this Government and this House—I believe everyone is supporting the legislation—acknowledging that the profession is changing. People in other professions do have the skills necessary, and we are trying to adapt and change to them. Fundamentally, that will continue to build on an excellent health system and make it even better, and so I commend this legislation to the House.

I actually want to start my contribution where the member Simon O’Connor, who has just resumed his seat, has left off, and just talk about, I guess, what happened 14 or 15 years ago, when the conversation in the health sector was about the competencies that someone required in order to do a good job. I remember the conversations that were held when I was working in community health and community mental health about the extraordinary work that nurses, in particular, were capable of doing—that their scope of practice was such and their training was such that they could be engaged in a wide range of health provision. It was at that time that the then Minister of Health was introducing the discussion around the ability to train nurses to take on higher functions and take on the roles as nurse practitioners.

I remember the discussion very distinctly. Nurses were very much in demand because of their scope of practice and their ability to work in such a significant way, and they were being taken to do other work, kind of outside the clinical practice in a way. A lot of them were taking roles as managers of services, particularly health services, and there was a real pressure on the New Zealand health workforce to be able offer a range of services that were at a level that was sufficiently high enough to be challenging for certain practitioners, but were not those duties specifically of a medical practitioner or a doctor—but getting pretty close. I recall the discussions that happened at that time. So it has taken us some time, really, to catch up with the actual practice that is happening in the community—or what should be happening—and this legislation, I think, has brought us to a place where we can now address what is current practice in New Zealand.

I think we have kind of missed an opportunity to futureproof ourselves in terms of what will be future practice for these practitioners with the advent of the advancement of technology. But what this legislation does do is that it actually allows for the scope of practice to occur as it should do. So nurse practitioners are the ones most often quoted, but there is a range of other practitioners for whom we can now encourage a range of career pathways. Specifically, they are going to be able to legally conduct some statutory functions that have been denied to them in the past. We have already heard the examples of being able to sign death certificates.

What they will also be able to do—and this is important in the mental health field—is conduct assessments where psychiatrists or psychologists are not available to conduct those assessments. That is really important when we have situations—say, for example, the police may have picked someone up, or someone has become unwell and is having an episode and they are unable to get to a psychiatrist or a psychologist quickly. Health practitioners will be able to conduct those assessments and be able to have people into treatment relatively smoothly and quickly.

There are some other examples—for example, the assessment of children with regard to health practitioner roles within the care environment for Child, Youth and Family, and one or two other aspects of their job.

The report back from the Health Committee—and I do want to commend the work of the select committee. It often has very complex issues to deal with, and this was also relatively complex legislation. The report back from the select committee recommended some changes: defining what a nurse practitioner actually does, which includes what type of practising certificate they must hold and that they are governed under the Nursing Council and the Health Practitioners Competence Assurance Act; changes in terminology from “doctor’s surgery” to “medical centre”; and various other things, particularly under the Mental Health (Compulsory Assessment and Treatment) Act—the ability to actually be the provider of those assessments.

The previous speakers have actually outlined the significant parts of this legislation and how it amends the eight pieces of principal legislation. I do not think there is much more that I need to contribute to this debate. We are happy for the bills to be passing into legislation and we commend them to the House.

It is a pleasure to take a short call on the legislation arising from the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. It is the third reading. We have enjoyed going through this process as a Health Committee. It is going to be really good legislation, which is going to help us to deliver better, faster, and more convenient healthcare to patients. We actually heard before about rural New Zealand, where we can, effectively, use the skills of the workforce. We do have a lot of nurses out there who are well and truly capable of taking on further roles and further work, but at this point in time, before enactment of this piece of legislation, the law is not in a position to enable them to do that. The legislation is going to help not only our rural communities but all other communities tremendously. Changing to health practitioners, rather than having everything being done by medical practitioners, is going to give us a lot more scope and a lot more ability to do things in our communities.

We are working really hard to fulfil National’s election promise to encourage younger nurses to stay in the country after graduation through the voluntary bonding scheme, which pays off student loans for nurses, medical and midwifery graduates who agree to work in hard-to-staff communities and specialise for 3 to 5 years. I think this is going to be a really good process for that in terms of enabling them to do what they are fully capable of doing.

As our healthcare changes, the way we deliver health services changes as well. I have spent a bit of time since I have been a member of Parliament on the mobile surgical buses, looking at the specialist services on some of those mobile buses—which we had in Parliament while we were discussing this bill, as a Health Committee. They play a greater role in terms of bringing health services to us, and it just means that those nurses in our communities are able to specialise further and help provide more services for our communities.

I also want to commend the work that has been done by the Health Committee under our more than capable chair, Simon O’Connor. We are a very good committee. We actually work extremely well together. We are focused on what is going to provide better things for our future in our communities, and it is my great pleasure this afternoon to have the opportunity to commend this legislation to the House. Thank you.

Debate interrupted.

The House adjourned at 6 p.m.