All change

Responses to the changing needs of healthcare have seen many roles and responsibilities expand and develop. Dr John Marwick, a GP and member of MPS’s educational faculty in New Zealand, assesses the impact of the Medicines Amendment Act

New Zealand has recently seen a number of new health practitioners and extended roles for existing practitioners. Demonstration pilots are underway for physician assistants (PAs – sometimes called physician associates) and primary care practice assistants. Some nurse practitioners and clinical nurse specialists have extended into roles previously the domain of doctors such as surgery, anaesthesia, and diagnosing and treating acute and chronic conditions.

Nurse practitioners and optometrists have joined midwives in the group of non-medical practitioners who are authorised to prescribe, and some other nurses and pharmacists have been added as designated prescribers in particular services such as diabetes care.

There’s quite a lot to think about.

The Medicines Amendment Act 2013, passed in November last year, added nurse practitioners and optometrists to the list of authorised practitioners who can prescribe medicines that lie within their scope of practice – putting them on the same footing as doctors, dentists and midwives. The Act also introduced delegated prescribers: a new class of prescriber who would be able to prescribe under delegated authority from an authorised prescriber.

The other relevant piece of legislation is the Health Practitioners Competence Assurance Act 2003, under which health practitioners are registered and regulated. This law is designed to protect the public by letting them know that a registered practitioner is safe to practise. It prevents unqualified people from claiming that they are registered practitioners but, apart from a number of restricted activities specified under an Order in Council (Ministry of Health 2014b), it doesn’t prevent any unregistered practitioners from practising and offering health services.

Under this law new practitioners such as physician assistants (PAs) and primary care practice assistants are not required to be registered so long as they don’t carry out a restricted activity like a surgical or operative procedure “below the surface of the skin”.

New practitioners

At present new practitioners and new roles are still at an early stage. PAs are well-established in the US and more recently have been introduced in Canada, Netherlands and the UK. In Australia pilot programmes for PAs have been completed and some training programmes started but, as in New Zealand, there is some opposition and few PAs are currently practising. In New Zealand two US-trained PAs were part of a trial that started in Middlemore Hospital in 2010. A second phase is now underway in Gore, Hamilton and Tokoroa. These new pilot sites incorporate primary care and rural settings although the number of PAs is still in single digits. The PAs – who again are US-trained generally with a two or three-year postgraduate masters-level degree – work in a team setting under supervision from a medical practitioner.

A primary care practice assistant is responsible for clinical and administrative tasks, including such tasks as blood pressure and weight measurements, treatment room preparation and reception duties. A report (Adair, Adair, and Coster 2013) on the 2010-11 pilot of this role in a number of Auckland and Northland general practices found financial and care benefits for patients and practices. At present approval is being sought for development of a NZQA Level 4 qualification and then part-time training programmes will be offered to develop more practice assistants.

Non-medical prescribing

Forms of non-medical prescribing have been happening for some years. In various hospital and community settings standing orders have been used to allow nurses to administer or supply specific medications and so improve access often in cases where there is no doctor immediately available. Such orders are issued under specific regulations. They do not allow nurses to write prescriptions for a pharmacist to fill nor to issue prescriptions that have been ‘pre-signed’ by a doctor. Anyone considering issuing standing orders or supplying medicines under such an order needs to be familiar with the requirements and guidelines for their use (Ministry of Health 2012).

Under the Medicines Amendment Act 2013 mentioned above, since 1 July 2014 there are now four groups of “authorised prescribers” – practitioners other than doctors who will be able to prescribe medicines so long as they are practising within their scope of practice. These practitioners are dentists, midwives, nurse practitioners and optometrists. Like doctors these practitioners carry responsibility for their own practice whether they are working alone, in a hospital or clinic, or as part of a team that is giving care to patients. It is their responsibility to ensure that prescribing, like any other aspect of their practice, is safe and appropriate; so long as they work within their scope of practice they will not be restricted in which medicines they can prescribe.

The Medicines Act also now allows for two other classes of prescriber: designated and delegated prescribers. Before the latest changes most nurse practitioners, certain nurses working in diabetes services, some pharmacists and some optometrists were designated prescribers. These prescribers are designated by way of Regulations issued by an Order in Council, and approved by the relevant responsible authority (for example the Nursing Council) which specifies the qualifications and training required. They are then allowed to prescribe for certain types of patients from a list of medicines designated in the Regulation. As with authorised prescribers, designated prescribers will be responsible for their own practice and for ensuring that they stay within the parameters of the relevant Regulation.

 Delegated prescribing is the third class of prescribers that was allowed for under the Medicines Amendment Act. In order for any new group of professionals to be allowed to become delegated prescribers (and thereby accept delegated prescribing from a doctor or from a non-medical authorised prescriber) the regulatory body for each professional group would need to make an application to the Minister of Health in support of the change.

If and when any new health professionals become delegated prescribers then the prescriber will be responsible for ensuring that their own prescribing is within the relevant Regulation and the details of the delegated prescribing order. The authorising prescriber (perhaps a medical practitioner) will carry responsibility for ensuring that their delegated prescribing order is properly given according to the Regulations.

Vicarious liability

Under section 72 of the Health and Disability Commissioner Act 1994 there can be situations where a healthcare provider (eg, a DHB or a medical practice) is vicariously liable for the actions or omissions of a person who is employed or acting as an agent. Thus, if a medical centre or an individual doctor employs a nurse or another healthcare practitioner, they can be held vicariously liable for the other practitioner’s actions or omissions. It is a defence under this section of the Act that the employer has taken “such steps as were reasonably practicable to prevent the employee from doing or omitting to do that thing”.

In an article on vicarious liability (Paterson 2005), the previous Commissioner stated that: “Although medical centres will not ordinarily be held liable for lapses in care or communication by an individual practitioner, if the lapse was attributable to poor systems or inadequate protocols at the centre, or if there is no evidence that the centre took reasonable steps to ensure that the practitioner was competent (eg, by credentialling on appointment and conducting ongoing peer review and practice audit), the centre may be held vicariously liable.”

Implications

New roles are being developed in many countries around the world as governments everywhere seek to address workforce pressures and shortages. They offer new opportunities and challenges. In general, medical groups support the idea of expanding roles within team approaches but are concerned about fragmentation and other risks when new practitioners work independently. On the other hand, nursing and other professions involved in such expanded roles often support the new clinical responsibilities, but argue that their practitioners are well-trained and capable of independent practice when this is appropriate for better patient access.

Medical practitioners should always treat healthcare colleagues – whether doctors or from another profession – courteously, respectfully and reasonably and respect their skills and contributions.¹ They should be mindful of the importance of careful communication with any other professionals who are treating the same patients as they are. Shared patient records, which will develop further over coming years, will be helpful for ensuring that the patient is always at the centre of care. Inter-professional rivalry will not be helpful.