About regulation

What is regulation?

The Government regulates groups of workers or services where it believes the public needs protection. Occupational regulation is a way to protect the public from the risks of an occupation being carried out incompetently.

One way of doing this is passing an Act of Parliament such as the Health Practitioners Competence Assurance Act (2003) (HPCA Act). The HPCA Act currently covers 16 groups of health practitioners. Several more groups such as counsellors and anaesthetic technicians are seeking coverage.

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Why would the ambulance sector need regulation?

The main reason to possibly regulate any health profession, including ambulance officers and New Zealand Defence force medics is to increase public health and safety, minimise risk and/or improve the delivery of services.

Currently there are five main operators and a number of smaller companies in the sector and there are no compulsory national standards and protocols that apply across the sector.

There are no nationally recognised qualifications for clinical personnel working in the sector, although the service providers have been working closely together on bringing this about.

Some clinical personnel are able to perform invasive procedures and administer drugs under standing orders and could cause harm if they are not fully trained and competent.

Any clinical personnel attending any accident or an acute medical event will have to make decisions about treatment and manage life threatening cases. If the decision making and management is not robust, the public could potentially be at risk.

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Why do some people talk about registration and others about regulation?

The HPCA Act regulates health professions, which, if covered by the act, have to follow the rules it sets out.

If you are a clinical person from a health profession covered by the HPCA Act you would have to be registered. You become registered when you name is added to the list of people practicing under the scope of practice of your health profession. This list is called the register.

The register is a document that sets out information on all the practitioners covered by the regulatory group. This includes things such as their name, scope of practice and qualifications and if they have a certificate to practise, which is called an Annual Practising Certificate (APC).

By law it must be available to be public to view.

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What does the government take into account when considering regulation of a health profession under the HPCA Act?

The New Zealand Government assesses that regulation of some type is required if:

  • significant harm to consumers or third parties is possible
  • existing means of protection from harm are insufficient
  • intervention by Government is likely to improve the outcomes
  • there is market failure which industry cannot remedy
  • when the industry is unable to regulate itself because of the costs involved.

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Are the public at risk?

Some clinical personnel do perform invasive procedures and may dispense drugs. Many have to assess a patient in the critical period immediately after an accident or acute medical event. These situations mean there is potential for ambulance officers and NZDF medics to cause harm if they are not fully trained and competent.

An assessment of concerns and complaints related to clinical and competence issues across the sector is difficult to compile as there is no central database or national sentinel or adverse event reporting.

However, a review of complaints about ambulance services to the Health and Disability Commissioner (HDC) from February 2004 to April 2009 noted that 46 complaints were made and of these 25 related to complaints about the appropriate standard of care. In most of these complaints, the HDC took no further action.

There is currently little to prevent new providers of ambulance type services who may not practice using the same standards as current providers setting up in New Zealand and this could potentially pose a threat of harm to the public.

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Would all ambulance officers and NZDF medics be covered by regulation and need to be registered?

There are two main options:

Regulating those at Intermediate Life Support and Advanced Life Support only

Ambulance officers and NZDF medics working at ILS or ALS have to make the most serious clinical assessments and judgments. They also have to perform invasive procedures, make clinical judgments and provide drugs under their delegated Authority to Practice. These activities potentially make them the most likely to pose ‘a risk of harm to the health and safety of the public’ because there is potentially more in what they do that could go wrong.

Regulating all clinical personnel practicing at Basic Life Support, Intermediate Life Support and Advanced Life Support

On the other hand, it could be argued that all clinical people in our sector, whatever level they practice at, potentially pose a ‘risk of harm’ to the health and safety of the public because they all have to make clinical assessments and decisions. If decision making and patient management is not robust this could pose a risk to the public.

It is possible to argue that the qualifications at Intermediate Life Support and Advanced Life Support levels means that those practicing at these levels have more knowledge and experience to base their clinical decisions on than those working at the Basic Life Support level.

If regulation under the HPCA Act goes ahead, personnel from all ambulance services in New Zealand, large and small, would be covered as well as medics from New Zealand Defence. Any other clinical person wanting to continue to use the titles and terms which would be protected by regulation would also have to apply to be registered.

Whether the profession thinks Ambulance Officers, Emergency Medical Technicians, Junior Medics, AO2s, BLS2s and Paramedics practicing at BLS level should be regulated is something that needs to be discussed as part of this consultation process.

Due to the variety and level of training and the limited scope of practice at First Responder and current Primary Care levels, it is unlikely that people at this level would be regulated.

This would not have any impact on the way they work because, in an ambulance, they already work with others who have a delegated Authority to Practice which is similar to working with somebody who would be registered, with an Annual Practicing Certificate.

Regulation is unlikely to affect those working at Primary Care level because this Practice Level is being phased out.

Both volunteers and paid staff could be covered by regulation. It would depend on your Practice Level described above, rather than whether you are paid or volunteer.

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What happens overseas?

Regulation of ambulance services or regulation of the people in the ambulance sector differs in various countries overseas.

In the United Kingdom ambulance personnel are covered by health practitioner regulation, similar to the HPCA Act.

In Australia there is state regulation of ambulance services in New South Wales, Victoria and South Australia.

Currently there are major changes in health regulation in Australia with the development of a national practitioner regulation, rather than the former model of state practitioner regulation. There are no plans at this stage to include ambulance officers in the new systems for regulating health practitioners, though this could happen in the future.

In states in Canada such as British Columbia, paramedics are regulated and have a licence to practise; in other areas they work under delegation.

In the United States licensing of paramedics is a state responsibility and this varies across each state; emergency services are also regulated.

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What happens in relation to regulation of other health professions New Zealand?

In New Zealand, currently 16 groups covering 21 groups of health practitioners are regulated under the HPCA Act and several other groups are currently seeking coverage.

In 2003 when the HPCA Act was introduced into Parliament, it brought together all New Zealand’s regulated health practitioners under a single piece of legislation (rather than the 11 previous separate Acts).

The practitioners currently covered by the HPCA Act are chiropractors, dentists, dental hygienists, clinical dental technologists, dental technicians and dental therapists, dieticians, medical radiation technologists, medical practitioners, medical laboratory scientists, midwives, nurses, osteopaths, occupational therapists, optometrists and optical dispensing physicians, pharmacists, physiotherapists, podiatrists, psychologists and psychotherapists.

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Is there support for this type of regulation within the sector?

In 2008, Ambulance New Zealand organised a survey of those involved with the provision of ambulance services to give information on the HPCA Act and measure the level of interest amongst clinical personnel of becoming registered under the HPCA Act.

Over 500 responses were received, though there has been concern that the survey was not widely circulated.

However the results showed that, of those that replied, most clinical personnel supported registration in some form, with 5% being opposed and 3% stating they were unsure.

37% of those replying thought all clinical personnel should become registered and 55% thought only those at a certain practice level should become registered. Of those wanting registration at a certain practice level, 70% thought the appropriate level for registration was the Intermediate Life Support level (ILS)1 and above.

Another study by Jackie Clapperton on The Feasibility of Establishing Emergency Care Practitioners in New Zealand asked paramedics about this concept and about regulation. 97% of individuals replying (116) and all organisations that were asked (15) said that Advanced Paramedics should be ‘professionally registered’.

1The levels used in this report are First Responder, Basic Life Support (BLS), Intermediate Life support (ILS) and Advanced Life Support (ALS) are the terms used in the sector standard number NZS8156:2008 published by Standards New Zealand.

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