Monday, January 27, 2014

Paramedic Registration in NZ - A double edged sword?

Paramedic registration in New Zealand has been on the sector 'to do' list for some time now. While it now looks inevitable within the next few years, and many in the industry are hailing it as an empowering thing, I cant help but reflect on the concerning parts that may also come with it. I am skeptical, to say the least, of the proposed benefits associated with registration and while I recognise that it will be a step forward and undoubtedly provide greater opportunities for paramedics I really feel that many paramedics are not fully aware of all the implications that registration will bring. This is my take on it.

New costs just to do the same job

Government Registration essentially means we will have to 'pay' for the privilege to do what we currently do now for free and it will also come with total personal liability for doing it.Individuals will need to have indemnity insurance and pay for an annual practicing certificate as well as possibly association with the governing body and ongoing education.Practicing cerrtificates are set to be in the region of between $600-1500 per annum with the main ambulance services already saying they will not pay for this.

Learning on the job may take on a whole new meaning

Practicing pre-hospital medicine, like other areas of medicine, has always included that very component - practice! That means, that like doctors, sometimes we get it wrong, and just like doctors the outcome can even have serious consequences. I personally believe the current scheme of working under an approved protocol and essentially practicing under the license of a Medical Director(s) has provided a more positive learning environment without the pressures of being subject to an external industry body watchdog and the possibility of fine and censure. We have in the the industry recently moved away from a punitive approach to one of learning and improving where it is finally safe to admit you made a mistake so everyone can learn from it. Registration will potentially set that back, as the risk of reporting an error could mean a large fine or even the end of your registration and job.

All health practitioners are currently subject to the Health & Disability Commissioner (HDC) Act Code of Rights in New Zealand, ensuring quality of healthcare in the sector. This includes paramedics and there have even been some investigated by this body for mis-demeanors in the past. This consumer watchdog gives our customers an avenue to complain and have an independent investigation carried out. Although there is no punitive punishment associated with an investigation, other than a recommendation for improvement from the commissioner, past investigations have resulted in positive changes to the industry. Where criminal liability was found, this has been passed onto the police for prosecution.

Registration will change this situation altogether. As well as being subject to an HDC investigation, paramedics who are under investigation will need to also potentially face the disciplinary panel under the Health Practitioners Competency Assurance Act. They will possibly need to hire a lawyer to defend themselves and may face fines, censures or even de-registration. Even an unjustified complaint from a consumer or their relative may see a paramedic face the stress of this tribunal - something that cannot currently occur as non registered health professionals.

It may become a barrier for student practice

Currently student paramedics are able to carry out skills on the road under supervision of a qualified practitioner. Invasive skills such as IV therapy, IO, intubation, LMA, drug administration etc aassociated with it. How would a qualified paramedic now feel about allowing a student to practice those skills under their registration! Who carries the can if they stuff up? Will you face disciplinary action - fines or censure if it goes wrong? Would you want to take the risk? Potentially it could mean students simply can't practice these skills on the road because staff are unwilling to risk the potential adverse consequences if it went wrong and this would potentially have a significant impact on the future training of trainee paramedics.

A barrier to volunteers or those wanting to progress

Approximately eighty percent of the paramedic workforce in NZ are voluntary and we are absolutely reliant on some of these volunteers in very remote areas. With the introduction of additional personal responsibility and cost of registration this may dissuade volunteers from providing their services, or at least have the effect of a barrier to gaining higher qualifications (the proposal was for registration only for paramedic level and above). What if a significant amount of current volunteer paramedics simply opt to lower their ATP to non-registered EMT level because of the extra cost and responsibility that registration will bring. What impact will this have on our ability to provide sufficient clinical skills across NZ? Has any workforce planning being carried out around this potential situation?

Annual proof of competence and practice will be part and parcel of the registration process, but what happens if this prevents a significant number from gaining registration, or causes them to become de-registered? Competence and de-skilling has always been a challenge, particularly for remote and rural areas and while this is being addressed more now than ever before it is unlikely that it will be solved by the time registration appears. This could further impact the numbers of volunteer staff obtaining paramedic qualifications.

Now I hear what you are saying - if you cant make the grade you shouldn't be doing the job and that makes sense. However the fact remains, we are totally reliant on a volunteer workforce across the country and some of these people are old, potentially with low experience levels, low workloads and will find it challenging maintaining their competency. By insisting on registration we will either force these people into a lower, unregistered skill level or force them out of the industry altogether. This will leave a coverage gap where previously it was covered and potentially add costs where previously there was none. While we may consequently have better clinicians as a result, we may also have a severe shortfall of them. If you were a volunteer paramedic and suddenly had to fork out over $1000 per annum in practicing certificates and education with the possibility of facing fines, censures and other costs if you made a mistake would you want to continue doing it?

A recent published study by the NZ Paramedic Industry body, looking into paramedic attitudes towards professionalism (including registration) showed many in favour of registration, as many of the pro's are blatantly promoted (see here) but I wonder how many think about the down sides or actually question whether the pro's will actually eventuate? These are some of the proported benefits of registration out forward and my (skeptical) view of them.

Registration will increase respect from other registered professionals

The notion that simply being registered will somehow automatically increase respect from industry colleagues is an interesting one. If this were true, all registered health professionals would be well respected by each other but I know this simply isn't the case. I have heard many GP's make scathing remarks about physiotherapists, osteopaths and chiropractors - all registered professions that dont necessarily garnish the respect of the medical fraternity. It only takes bad publicity of a few poor practitioners to bring the industry into question. Midwifery too has had it critics yet these professionals too are registered and for the most part do a wonderful job in a very challenging environment. So registration alone does not make an industry instantly respected. That comes from publicity, publications and collaboration, something the industry has made huge inroads with and as a result we are more respected now than ever before, although much more could be done. Simply being registered does not itself entitle an industry to be respected.

Registration will increase competence

The requirement for an annual practicing certificate will undoubtedly require  proof of competency, likely through continuous clinical education, similar to GP's, although this is likely only to be needed at Paramedic and above. This is definitely a positive thing but also something that is currently in place in NZ. All ST John and WFA ambulance staff are currently required to undertake annual continuous clinical education modules. The fact that paramedicine is now a university degree based system is also leading to increased competency. Simply becoming registered however does not guarantee competency. If this were the case then there would be no HDC complaints against incopmetent practitioners yet we see published complaints involving poor competency across many different registered health professionals. Continuous education increases competency. Registration by itself does not.

The public will be more reassured by registration and it will rid the industry of cowboys

I have to say that for the most part the public still has a very poor understanding of what paramedics actually do. The fact we are constantly referred to as ambulance drivers, even by other healthcare professionals demonstrates that our job and skills are, on the whole, unappreciated and misunderstood. Simply being registered will make little difference. To many we will simply be registered ambulance drivers. What is needed is a huge ongoing public education campaign to teach the public what we actually do. This was one of my aims for writing my book priority one.

The notion that the public will only want to be treated by registered paramedics makes me laugh. If I am in intractable pain with broken legs in the middle of the road I really wont care whether the paramedic treating me is registered or not. Although registration may prevent rogue operators from calling themselves paramedics, they will likely still have a shirt or reflective vest with Medic on it and the public will still be none the wiser.

With a split qualification system (BLS, ILS, ALS) and the aim of only registering paramedic at ILS and above, we will end up with basically a two-tiered system of ambulance officers - registered vs non-registered - on par with Registered Nurses vs Enrolled Nurses but both groups will essentially be doing the same job from the public's perspective. If you asked the general public what the difference was between an enrolled nurse and a registered nurse most would be unable to tell you. I believe the same will stand for paramedics. If an ambulance turns up I doubt the public will demand to know whether the ambulance officer is registered or not, just like they generally have no idea what BLS, ILS or ALS means. All they care about is an ambulance has turned up!

In a similar fashion, those who are labeled cowboys in the industry will still continue to be cowboys. They may no longer be able to call themselves paramedics but that won't stop them wearing a sign saying 'Medic' or 'First Aid' nor will it stop anyone needing first aid from seeking it from them. They will likely be practicing at BLS and so be bellow the level of registration anyway. Besides, has anyone actually quantified this issue? How many rogue practitioners are out there? Is it really such a huge issue that registration is needed to get rid of them all or are we only talking about a fraction of people here?

It will be easier to work overseas with registration

Countries who currently have registration (UK, USA, Canada, South Africa) still require an individual to re-register in that country. Simply having registration in one country does not mean you can automatically get registration in another. Even in Australia, it is possible that individual states may set up their own registration process meaning that paramedics may have to register in individual states to practice there, similar to the way Australian state Police forces work. This is seen too in medicine where doctor registration in one country is not automatically accepted in all countries. On top of this, most providers also have their own Authority to Practice (ATP) system so there will likely still be two hoops to jump through. What has made a difference is the degree programme with reciprocating countries respecting each others qualifications but it may or may not apply to registration.

We do have the advantage of learning lessons from the UK registration process and a good comparisons of some of the pro's and cons can be found here

Whatever the outcome, I know we have to embrace the fact registration is coming and will be here to stay. I just hope that the industry goes into this with their eyes wide open, with realistic expectations and a budget to meet the increased costs that undoubtedly will tag along with it. Although I am playing the devils advocate role here and am probably very much a lone voice, I hope I have balanced the debate to some degree and made people more aware of some of the implication that may follow. I dont claim to be right I simply want a robust debate on the issue.

Feel free to leave your views, comments, responses below.