Paramedic Registration in New Zealand: Where are we up to?

By Sean Thompson – Chair Paramedics Australasia (NZ) and member of New Zealand Paramedic Registration Working Group

Sean Thompson headshotCAVEAT

This article is based on formal and informal communications between the author, Paramedics Australasia’s New Zealand chapter, the New Zealand Paramedic Registration Working Group, Ambulance New Zealand, Health Workforce New Zealand, the National Ambulance Sector Office, the Hon. Mr Peter Dunne, and the office of Minister of Health Dr Jonathan Coleman. The information herein is correct to the best knowledge and understanding of the author at the time of writing of 31st August 2016. Details may change as the process towards regulation and registration progresses.

The author expresses his sincere thanks to all concerned for their information and insight.

“Paramedic registration” refers to the registration of paramedicine and as a term is not intended to denote a specific authority to practice level.

A LITTLE HISTORY

Paramedic registration was first mooted in New Zealand 25 years ago. Several other professions had already been registered for many years. The Medical Practitioners’ Act of 1867 saw doctors in New Zealand gain registration (1) while the Nurses’ Registration Act was passed into law in 1901 (2). 25 years ago paramedics would have required an “Ambulance Bill” to be passed by government; an idea still promoted by some paramedics today.

In 2003 the landscape of health professions changed dramatically when the Health Practitioners Competence Assurance (HPCA) Act was passed into law. This brought together all of the health professions under a single piece of legislation.  The idea behind this was to consistently achieve the Act’s principal purpose of protecting the health and safety of the public by providing mechanisms to ensure health practitioners were competent and fit to practise their professions.  In doing so, the Act aimed to balance “the demands of public safety against allowing practitioners sufficient involvement in the regulation of their profession”(3). The government of the day wanted all professions to come under a single regulatory body. However individual professions proved too powerful so approximately 14 different professions were individually recognised under the one Act. The Ministry of Health expressed reluctance to allow new professions to come under the HPCA Act but today we see 22 health professions regulated under 16 Responsible Authorities (4).

Paramedic registration has been actively pursued since 2006, predominantly led by Ambulance New Zealand, the representative body of ambulance services. Over this time there have been advances and set-backs, including the delay in assessing Ambulance New Zealand’s application in 2011.  The Ministry of Health was unable to progress the application at the time as it was about to embark on a second strategic review of the HPCA Act.  There has been debate about whether paramedics should be regulated under the HPCA Act as New Zealand ambulance services are seen to have a high standard of self-regulation.

Currently ambulance services are the delegated portfolio responsibility of Hon. Peter Dunne. If paramedicine does become a registered medical profession, paramedicine will come under the jurisdiction of the Minister of Health Dr Jonathan Coleman who, as Minister, is the only one who can make the final recommendation to regulate paramedicine.

Ministers Dunne and Coleman both consider that Ambulance New Zealand’s application can proceed to the next stage of the consultation process.  The next step at time of writing is targeted consultation with the sector and the wider stakeholders. Out of this consultation process the Ministry of Health will need to assess whether regulating paramedics under the HPCA Act is possible and practical, and that the benefits clearly outweigh any potential negative impacts of regulation.

Paramedicine is currently closer to registration than at any other time in New Zealand’s history.

TIMELINES

Health Workforce New Zealand (HWNZ), the Ministry of Health business unit that manages the process for regulating health professionals, is developing a consultation document on whether to regulate paramedics under the HPCA Act.  HWNZ has drawn extensively on the 2011 application as well as the detailed work completed by Ambulance NZ and Paramedics Australasia’s submissions and publications in formulating this paper. HWNZ aims for the consultation process and targeted stakeholder feedback on this document to be initiated before the end of 2016. Feedback will be sought from the Responsible Authorities (RAs) responsible for registered medical professions, as well as from other groups including Paramedics Australasia.

The process for a profession to become regulated under the HPCA Act is lengthy and is outlined on the Ministry of Health’s website (5).  After targeted consultation takes place, the Minister of Health will decide whether to seek Cabinet agreement about his decision regarding paramedic regulation.  If Cabinet decides to regulate paramedics, the Minister of Health will make a recommendation to the Governor-General to issue an Order in Council.  At this stage, it is not known how long it will take for the Government to make a decision on whether to regulate paramedics.  The process to assess Ambulance New Zealand’s application, and the process to develop the statutory framework under the HPCA Act, may take one to two years.

RESPONSIBLE AUTHORITIES (RAs)

The Ministry of Health wishes to ensure that costs of regulation are minimised and administrative duplication is avoided where possible and it has encouraged RAs to work to reduce administrative costs and share resources.  New professions are added to existing RAs where this is the most suitable option.

Several RAs have been considered as partners for paramedicine and all RAs have been consulted with by Ambulance NZ.  The Medical Council was an early consideration but appeared too costly and with a differing scope of practice. Joining a more generic or even a more specialist RA was considered but there was little synergy between paramedicine and these other professions and limited desire by these RAs to join with paramedicine.

The process for considering new health professions under the HPCA Act includes determining suitable cost effective governance arrangements.  Details regarding how the paramedic profession could be regulated are still being worked through and will be communicated to the ambulance sector by HWNZ as soon as decisions are finalised.

The Nursing Council has been working with Ambulance NZ and HWNZ for a while now and has worked actively to research and support paramedicine’s inclusion as a profession under the HPCA Act.

The 2003 HPCA Act has undergone a significant review in the last few years and the recommendations arising from this review were accepted by the Government in late 2015.  These recommendations do not impact the process or criteria for considering new health professions for regulation under the Act and the bill to formally amend the HPCA Act is currently being drafted.

WHO WILL BE REGISTERED AND WHY?

Approximately 1000 paramedics are proposed to be included in the initial registered cohort and would include paramedic level and above.  Ambulance New Zealand’s application for regulation does not include 78 percent of the St John and Wellington Free Ambulance workforce that practise as First Responders and Emergency Medical Technicians.  The reason why this group has not been included is because they are primarily a volunteer workforce and it is the Ministry of Health’s assessment that they provide relatively lower risk emergency care, compared to paramedics and intensive care paramedics.

There has been vigorous discussion as to which practice levels should be registered and the registration of Emergency Medical Technicians (EMTs) and First Responders (FRs) has divided opinion. There is a good argument for regulating all ambulance officers, regardless of qualification.

They fulfil the requirements if the HPCA Act as they:

“deliver a health service”, and

“this health service poses a risk to the public”.

Their inclusion can also be argued if:

“it is in the public interest to regulate”, and

“if existing regulatory mechanisms do not address these health and safety issues”, and

“if regulation is possible and practical to implement”, and

“if the benefits of regulation outweigh the potential negative of regulation.” (3)

Some of the reasons EMTs and FRs are proposed to be excluded from registration under the current application are:

  • There are more than 650 EMT volunteers in New Zealand and the cost of paying this registration would be significant.
  • Enforcing EMT registration and the associated requirement of Continuing Professional Development (CPD) and minimum clinical hours may cause some EMT volunteers to leave and may also be an impediment to new EMT volunteers joining.

Developing a single national competency framework will be one of the first tasks of the RA. All practice levels, including EMTs, will be included in this framework. EMTs will be regulated under the same framework as registered paramedics and ICPs but EMT adherence to the standards of the framework would be managed by their employer. This would likely improve on current safeguards for EMTs as ambulance services will adhere to a national framework rather than their own. This new nationalised EMT regulation may address the HPCA’s concerns where “existing regulatory mechanisms do not address … health and safety issues”(3).

Any future decisions about whether to regulate EMTs will be up to the RA.  If paramedics are regulated under the HPCA Act, the RA could also consider in the future regulating FRs and/or EMTs.  This could be achieved by the RA introducing new scopes of practice under section 11 of the HPCA Act.  Section 14 of the HPCA Act would require the RA to consult with affected parties before a new scope of practice was added.

FEES:

One of the first questions asked is always “how much will registration cost?” For the registered paramedic there will be two compulsory fees:  registration fees and annual practicing certificate fees.  Fees for other regulated health professions depend on a range of factors, such as the size of the profession and the number of complaints investigated.  The fees that RAs charge range from $110 for nurses and $1,124 for chiropractors.  Ambulance NZ and the Ministry of Health is considering the costs of registration fees and annual practicing certificate fees for paramedics and will provide this information in the consultation document.

It is normal for professionals under a newly registered profession to pay their own registration fees, however the annual practicing fee is typically negotiated into collective employment agreements after the first one to two years of negotiations.

As both St John and Wellington Free Ambulance are registered charities, the government would be expected to consider this in the cost that is passed on to paramedics and services. Registration will be an extra cost that is not currently funded for.  The outcomes of the Horn Review of ambulance service funding are still yet to be determined.

INDEMNITY INSURANCE

Currently ambulance services hold indemnity insurance which covers paramedics and the services. Under registration, paramedics would be strongly advised to have their own personal indemnity insurance. It is likely that the RA, the professional body, unions and private insurers will all step in to offer insurance at reduced cost or included in their members’ fees. An unsubsidised indemnity insurance fee could be in the region of $100 – $300 per year depending on level of cover.

COMPETENCY FRAMEWORK

Currently practice standards are employer-led. Under registration they will be led by the RA.

One of the first tasks of the RA will be to agree on a nationally standardised competency framework. The framework will cover all qualification levels with Paramedic and above being externally moderated and EMT and below moderated by the employer. The RA will need to approve each ambulance service’s systems as achieving the requirements of this framework at all of the qualification levels.

Paramedicine will need to develop a Code of Practice. Ambulance services and the Paramedics Australasia professional body already have codes of practice so developing a national Code will be quite straightforward.

FURTHER CONSIDERATIONS FOR PARAMEDICS UNDER REGISTRATION:

Registration will present a major change for paramedics.  They will be individually accountable for practice as a registered health professional and individual errors may put their registration at risk.

Paramedics will need to complete an annual portfolio to show continuing professional development and a percentage of paramedic portfolios will be audited each year. Some CPD will be provided by the employer but paramedics will be expected to source the remainder to meet the requirements to attain and retain registration.

Registration will give the professional paramedic broader career options and with it will come an anticipated increase in workforce mobility.

Suitably qualified non-clinical staff, such as academics and managers, may be able to register as a paramedic as well. They will likely have stipulations or limitations included in their registration, similar to Authority to Practice endorsements for current paramedics. It will be up to the RA to determine whether interns can receive provisional registration.

CONSIDERATIONS FOR AMBULANCE SERVICES UNDER REGISTRATION

Registration may bring extra costs. Currently ambulance services hold indemnity insurance which covers paramedics and the services. Ambulance services will still need to have indemnity insurance but this insurance will become focussed on protecting the Services from paramedics themselves. The monitoring of impaired paramedics may impose a cost, as will the likely longer time on unpaid leave for paramedics under investigation.

There is no legislative requirement under the HPCA Act for health services to provide RAs with adverse event reports.  RAs can only investigate individual health practitioners under audit, or when a complaint has been made.

Registration will not affect staff salaries, however unions may determine that there is a connection and argue for this in negotiations.

As both St John and Wellington Free Ambulance are charities the government will need to reasonably consider this in the costs passed on to paramedics and services. If ambulance services are to pay paramedics’ registration, there would be a significant cost. Increased staff turnover should also be anticipated due to increased mobility of qualifications. Paramedics who are unable to attain and maintain the standards mandated under registration may elect to pursue alternative career options.

CPD costs may actually decrease. The employer would provide a portion of CPD through guideline rollouts and service-wide training requirements; however the individual paramedic will need to source additional CPD to complete their annual requirement.

There are approximately 40 paramedic and ICP level volunteers in New Zealand.  The Ministry of Health will seek the sector’s views during the stakeholder consultation phase about whether registration fees for volunteers should be paid for by ambulance services.

SUMMARY

The focus of the registration debate needs to be upon public and professional protection.  The primary purpose of the HPCA Act is “to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professions” (3).  There will be significant changes for paramedics under registration and the impact both professionally and financially should not be underestimated.

Whatever shape registration takes, it needs to be communicated clearly, with paramedics being supported and informed.  The regulatory system must be safe for the public and elevate the profession of paramedicine. We need a functional system that minimises cost and bureaucracy and ensures that paramedics and ambulance services can provide out of hospital medical care to our patients in a rapidly evolving field of medical care.

References

  1. Jones G. A personal and informal perspective of events during my time as Chief Executive/Secretary/Registrar from 1986 to 2000 [Internet]. Medical Council of New Zealand. 2002. Available from: https://www.mcnz.org.nz/assets/Forms/MedicalCouncilofNZHistory.pdf
  2. Maclean H. Nursing in New Zealand: History and Reminiscences A Summary of Nursing History and Legislation in New Zealand [Internet]. 1932. 265 – 267 p. Available from: http://nzetc.victoria.ac.nz/tm/scholarly/tei-MacNurs-t1-back-d1-d2.html
  3. New Zealand Ministry of Health. Health Practitioners Competence Assurance Act [Internet]. New Zealand Legislation. 2003. Available from: http://www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html
  4. New Zealand Ministry of Health. Responsible authorities under the Act [Internet]. 2015. Available from: http://www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act/responsible-authorities-under-act
  5. New Zealand Ministry of Health. Regulating a new profession [Internet]. 2016. Available from: www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act/regulating-new-profession

About Paramedics Australasia (New Zealand) and the New Zealand Paramedics Registration Working Group

Paramedics Australasia (NZ) is the professional body representing paramedics in New Zealand. Along with the New Zealand Paramedic Registration Working Group we represent New Zealand paramedics and actively work to research and understand issues of professional paramedicine, including paramedic registration. Paramedics Australasia (NZ) and the NZPRWG are key stakeholders targeted for feedback in the registration consultation process. We promote paramedicine and paramedics, independent of any other employer, union, institution or body. As such our advice is regularly sought by ambulance services, politicians, unions, private providers, the media and others.