Substitution of regulated health professionals such as doctors and nurses with unregulated health professionals such as physician assistants gives rise to concerns around patient safety and accountability issues: Yes

With the well-documented workforce shortages and increased workload pressures in Aotearoa New Zealand’s primary care sector (and the health sector overall), we are seeing an increase in the unregulated health workforce, and the impact that this workforce has made within general practices and with patients. The unregulated workforce are people working in health who do not have a qualification that comes under the Health Practitioners Competence Assurance Act 2003.¹

Within my practice in central Wellington, alongside the specialist general practitioners (GPs) and nursing teams, we have a primary care practice assistant. The other unregulated health roles that we are seeing within practices have varying titles and include physician assistants, healthcare/clinical assistants, vaccinators and kaiawhina.

I have spoken a lot about the importance of ‘Team GP’ and working together to provide patients with the best possible care over the course of their lives. This is the option that I believe benefits patients best – a team approach rather than the outright substitution of regulated health professionals with unregulated health professionals.

The keyword in this moot is substitution. Substitution in maths means

the replacement of a term of an equation by another that is known to have the same value in order to simplify the equation. (Dictionary.com)

Substitution in everyday life, like the typewriter for the computer, or the paper prescription for the ePrescription, is usually a sign of progress and improvement. Substitution in health care should meet both these definitions; substituting regulated health professionals with unregulated health workers does not.

Having a diversity of skills, knowledge, education and experiences within a practice is how we ensure our patients can get the very best of care within their community. We are seeing more complex and changing health needs of our patients, and how we address these needs is a constantly evolving and progressive process, and one that we work hard to manage.

The advantage of having a strong model of multidisciplinary care does work to the key principles of improving equity and access to health care that we are all focused on achieving and providing to our patients and communities.

Those working in regulated health workforces such as specialist GPs or rural hospital doctors, nurses, nurse practitioners, pharmacists, midwives, clinical nurse specialists and physiotherapists are a part of their relevant professional organisations and must show their ongoing learning and competence when applying for their annual practising certificates (APCs).

Unregulated healthcare workers, although taught to carry out their roles, do not work under regulations managed by a professional body and may have variable skills. As the saying goes, ‘we don't know what we don't know’.

The patient safety and accountability issues that arise when shifting tasks from regulated health professionals to the unregulated sector are many. Two of the key ones are: do the public understand what they are consenting to? and who is providing the oversight?

The understanding of the public of who they are seeing and what the skill set of the health worker is, is a basic right within our Code of Health and Disability Consumers Rights.² It is everyone’s duty (the person delivering the care, the receptionist booking the care, the service employing the staff) to ensure that patients are fully aware of who they are seeing and what their skills are, otherwise we risk patient rights and safety.

The supervision of the unregulated workforce falls to the employers and the regulated health professionals who work with them. This can be mitigated to some extent by strong boundaries, guidelines and policies; however, confidence can become misplaced, roles can expand, and supervision can reduce. As with all supervisor roles, there is not often any recognition of the burden of being a supervisor or remuneration available. The risk is that supervision is lacking, boundaries are crossed, and patient safety is at risk.

Being part of a regulated workforce protects not only the patients by reassuring them of our competence and our standards for providing care, but it also protects those of us who are part of a professional body or medical college, as we have clear regulations and guidelines to work to that also assist with our purpose and ethos of the workforce. Whatever task we are doing, there are rules and regulations on who is responsible for the outcome.

Being part of a regulated workforce also allows the appropriate response to be applied to any risks or issues that arise. Having clear regulations and guidelines to adhere to ensures that the level of intervention applied is measured, and over time as data, capabilities or needs change, so too can the regulations and guidelines of our workforce.

Working with an unregulated workforce to expand the care available in an affordable way is important, but this does carry risk that needs to be identified, considered and mitigated.

Substitution of one for the other is not progress and puts patient safety at risk.