By Sean Thompson
The author, Paramedics Australasia’s New Zealand Chapter, and the New Zealand Paramedic Registration Working Group have met with various participants and authorities on the issue of paramedic registration and regulation. This article is based on formal and informal communications and is correct to our best knowledge at the time of writing of 23 November, 2016. Details may change as the process towards regulation and registration progresses.
‘Paramedic registration’ refers to the registration of paramedicine and as a term is not intended to denote a specific practice level.
Paramedic registration was first mooted in New Zealand 25 years ago. At that time paramedics would have required an ‘Ambulance Bill’ to be passed by government; an idea still promoted by some today.
However in 2003 the landscape of health professions changed when the Health Practitioners Competence Assurance Act (the HPCA) was passed into law, bringing all health professions together under a single piece of legislation. The Act’s intention was to achieve its primary 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. It aimed to balance “the demands of public safety against allowing practitioners sufficient involvement in the regulation of their profession”.1,2 The government of the day wanted all professions to come under a single regulatory body. However, individual professions proved too powerful so 14 different professions were individually recognised under the one Act. The Ministry of Health (MoH) was reluctant to allow new professions to come under the HPCA but today we see 22 health professions regulated under 16 Responsible Authorities (RAs).3
Paramedic registration has been actively pursued since 2006 in New Zealand, predominantly led by Ambulance New Zealand, the representative body of ambulance services. New Zealand ambulance services are seen to be effective at self-regulation and this has led to the lack of urgency by Ministers to progress regulation.
Under the current government however, paramedics are closer to regulation than at any time in the past. Health Workforce New Zealand (HWNZ), the business unit of the MoH that oversees regulated medical professions, is currently completing a consultation document and targeted consultation with the sector and wider stakeholders is planned to occur before the end of 2016, with Paramedics Australasia named as one such key stakeholder. Out of this consultation process the MoH will need to determine whether regulating paramedics is possible and practical and that the benefits of regulation clearly outweigh any potential negative impacts.
Who will be registered and why?
Around 1000 paramedics and intensive care paramedics (ICPs) are proposed to be included in the initial registered cohort. 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 (FRs) and emergency medical technicians (EMTs). The majority of this group are volunteers and the MoH believes that EMTs and FRs pose a lower risk compared to paramedics and ICPs.
The registration of EMTs and FRs has divided opinion in New Zealand and there is a strong argument for regulating all ambulance officers, regardless of qualification. They fulfil the requirements of the HPCA as they:
“deliver a health service”, and
“this health service poses a risk to the public”.1
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 negatives of regulation”.1
When registration is confirmed, one of the first tasks of the RA (the body which has oversight of paramedicine under the HPCA) will be the development of a single national competency framework. All practice levels, including EMTs and FRs, will be included in this framework. EMTs and FRs will be regulated under the same framework as registered paramedics and ICPs but EMT and FR adherence to the standards of the framework would be managed by their employer. This would likely improve on current safeguards as ambulance services must adhere to a national framework rather than their own. This more robust nationalised EMT and FR regulation may address the HPCA’s concerns where “existing regulatory mechanisms do not address … health and safety issues”.1
The process for a profession to become regulated under the HPCA is lengthy.4 After targeted consultation has taken place the Minister will seek Cabinet agreement about his decision regarding regulation. If Cabinet decides to regulate paramedics, the Minister 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 paramedic regulation but the process to assess Ambulance New Zealand’s application and the process to develop the statutory framework under the HPCA should take one to two years.
In the interests of cost saving the MoH has ruled out a separate and independent RA for paramedics. Several RAs have been considered as partners for paramedicine: The Medical Council was an early consideration but this was not pursued due to cost and differing scopes of practice. Joining with a more generic or even a more specialist RA was considered, but little synergy with paramedicine was found and these other professions had limited desire to join with paramedicine.
The Nursing Council (NC) is the most likely RA and has actively investigated and supported paramedicine’s inclusion as a profession under the HPCA. The Paramedics Australasia New Zealand Chapter is in active discussions with Carolyn Reed, Chief Executive of the NC and the NC is open in their support of paramedicine in the transition to becoming a regulated profession.5
What would paramedicine under the Nursing Council look like?
While there are significantly more nurses than paramedics in New Zealand, the NC is clear that it has no desire to assert any control over paramedicine. Its aim is to support paramedicine and ensure efficiency by providing ‘front and back office functions’. The NC already does this for several other RAs including osteopathy, occupational therapy, podiatry and midwifery.
Boards and representation
The NC has presented several scenarios of the structure of paramedicine within the NC RA to the MoH. The MoH has previously stated that it does not want any new boards to come under the HPCA so this would mean that paramedic representatives would need to sit on the Nursing Council Board. This scenario is arguably inefficient. With 40,000 registered nurses and 1000 registered paramedics, paramedic Board representatives would spend a significant amount of time hearing registration issues not directly related to the profession they represent.
A preferable approach is to have a Paramedicine Board sit in parallel with the Nursing Board, under the umbrella of the Nursing Council. While this goes against the MoH’s desire of ‘no more boards’ it is argued that this is the most efficient and cost effective solution.
The Paramedicine Board
A Paramedicine Board would have about five members made up of representatives with a paramedic background plus members of the public. This Board will take initial responsibility for developing a competency framework and determining the standards required of registered paramedics to ensure they attain and retain these standards and competencies.
The RA and the Paramedicine Board will need to approve each ambulance service’s systems as achieving the requirements of this framework at all qualification levels as well as ensuring that tertiary education providers produce graduates of an expected standard.
The Board will need to develop a Code of Practice. Ambulance services and Paramedics Australasia already have codes of practice so developing a national code should be straightforward.
Cost is a hot topic. Under the NC model, the annual registration fee is projected to be under $500 per registered paramedic. Usually there is an initial administration fee of around $285 to get on the register but if employee details are simple to transfer electronically from St John and Wellington Free Ambulance to the NC, the NC would like to waive this fee for these staff if possible.
It is normal for professionals under a newly registered profession to pay their own annual registration, however annual fees are typically negotiated into collective employment agreements after the first one to two years of negotiations.
Currently ambulance services hold indemnity insurance which covers paramedics and the service. Under registration, paramedics would be advised to have their own indemnity insurance. It is likely that the professional body, unions and private insurers will all step in to offer insurance at reduced cost or included in their membership fees. An unsubsidised indemnity insurance fee could be in the region of $200–350 per year depending on level of cover and possibly qualification.
Further considerations for paramedics under registration
Registration will present a big change for paramedics. As registered health professionals they will be individually accountable for their practice and individual errors may put their registration at risk. The employer will still manage the majority of staff errors, however, significant fitness to practice and legal issues would be referred to the RA for review. For paramedics referred to the NC there a strong focus on such investigations being a rehabilitative process for staff; either assisting staff with returning to work or encouraging staff to consider alternative employment. Where a paramedic is in breach of the law, the NC’s legal team would be engaged.
Paramedics will need to complete an annual continuing professional development (CPD) portfolio and a percentage of 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.
Suitably qualified non-clinical staff such as academics and managers should be able to register as well. They will likely have stipulations or limitations included in their registration, similar to Authority to Practice endorsements for current paramedics.
Registration will give the professional paramedic broader career options and with it will come an anticipated increase in workforce mobility.
Considerations for ambulance services under registration
Currently ambulance services hold indemnity insurance which covers paramedics and the services. Ambulance services will still need insurance but this will instead become focussed on protecting services from the paramedics themselves.
The majority of adverse events will still be managed by ambulance services with only the most serious going before the RA. Complaints from patients against a paramedic will be assessed by the Health and Disability Commissioner first, and then be referred back to either the employer or the RA.
Registration will not affect staff salaries, however unions may determine that there is a connection and argue for this in negotiations.
Increased staff turnover should be anticipated due to increased mobility of qualifications and new career openings with professional recognition. There will also be some paramedics who struggle to attain and maintain the standards required under registration and decide to leave the profession.
This increase in workforce mobility has been experienced in the United Kingdom (UK) where of the 22,000 registered paramedics, only 40% work in frontline National Health Service (NHS) ambulance services.6,7
Registered paramedics in the UK have moved more easily into other areas of employment within the NHS and with private medical providers and it is hypothesised that this will happen in New Zealand, and Australia.8 This is arguably part of the reason for the UK’s current paramedic staffing shortage.
There are approximately 40 paramedic and ICP volunteers in New Zealand and the MoH intends to seek the sector’s views on whether registration fees for volunteers should be paid for by ambulance services.
The focus of the registration debate needs to be on public and professional protection. The primary purpose of the HPCA is “to protect the health and safety of members of the public by providing mechanisms to ensure that health practitioners are competent and fit to practise their professions”.1 There will be significant changes for paramedics and employers 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.
About the author
Sean Thompson is Chair of Paramedics Australasia’s New Zealand Chapter and sits on both the New Zealand and Australian Paramedic Registration Working Groups. He is a BHSc paramedic degree lecturer at Whitireia New Zealand and an intensive care paramedic with Wellington Free Ambulance.
- New Zealand Ministry of Health. Health Practitioners Competence Assurance Act [Internet]. New Zealand Legislation. 2003. Available at www.legislation.govt.nz/act/public/2003/0048/latest/DLM203312.html
- Tunnage B, Swain A, Waters D. Regulating our emergency care paramedics. N Z Med J 2015;128(1421):55–8.
- New Zealand Ministry of Health. Responsible authorities under the Act [Internet]. 2015. Available at www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act/responsible-authorities-under-act
- New Zealand Ministry of Health. Regulating a new profession [Internet]. 2016. Available at www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act/regulating-new-profession
- Reed C. Personal communication 17 October 2016.
- National Health Service. NHS Hospital and Community Health Services Non-Medical Workforce Census 30 Sept 2014 [Internet]. 2014. Available at www.hscic.gov.uk/catalogue/PUB16933/nhs-staf-2004-2014-non-med-tab.xls
- Rate of paramedics leaving ambulance service nearly doubles [Internet]. National Health Executive. 2015. Available at www.nationalhealthexecutive.com/News/rate-of-paramedics-leaving-ambulance-service-nearly-doubles
- Paramedics Australasia. The case for national registration of paramedics [Internet]. 2014. Available at www.paramedics.org/advocacy/registration/the-case-for-national-registration-for-paramedics/