sou · GYB365 · 2010-10-13 00:00:00 — This is evident from communication which the Government has forwarded to us. Since the Swedish drew attention to this just under 10 years ago, the number of private health-care practitioners has increased substantially. However, it is possible for individuals to apply for special appointment by . When someone receives a special appointment to practise a pro- fession in the health-care sector, this should be scrutinised just as carefully as when a licence to practise is granted. From 1 January 2011, will have access to information from the Registry on certain offen- ces which have led to the imposition of sanctions other than fines. The purpose of this is to allow applications for a licence to practise to be assessed and to assist the Board in its supervisory activity with regard to health-care professionals. In our view, this direct access should also apply to the Board's assessment of applications for special appointment. We also consider that the county councils should have the right to request extracts from the Registry to allow an assessment to be made of whether a person should be granted a special appointment for a pre-registration post or a locum tenens post. There is a need to review the regulations which enable the county councils to employ doctors without a licence to practise. The present-day system of special appointment is appropriate and meets the need to enable doctors without a licence to practise to work in the health-care sector under certain circumstances. It has not been evident during our work that these special appointments cause any problems or pose any danger to patient safety. In dealing with such special appointments to practise a profes- sion, county councils and should have access to information on what offences have led to the imposition of a sanction other than fines. should review the regulations which enable the county councils in certain cases to issue special appointments to practise the profession. Our remit has been to conduct a broad inquiry into why too few specialist nurses are trained in relation to the needs of the health- care sector and to present proposals for ways in which more can be trained. The term specialist nurse is generally used to mean a nurse who has obtained a degree as a specialist nurse. There are degrees at pre- sent in 11 specialties: 8.health care for children and adolescents 10.care of the elderly All these training programmes provide 60 university credits, with the exception of the district nursing specialisation, which provides 75 credits. Licence to practise as a nurse is required for qualification to specialist training, and the student has to have completed an in- service part of the training programme (VFU) as well as indepen- dent work in order to be able to gain the degree. Anyone who has completed the specialist nurse training programme is entitled to the protected specialist title. Central government is responsible for the specialist nurse training programme and funds it, including the in- service element which takes place in particular in care organised by county councils or municipalities. Nurses with a licence to practise can also receive continuing pro- fessional education in ways other than by obtaining a specialist nur- sing degree. Many nurses choose to make a detailed study of ophthal- mic care, diabetes care, pain, asthma, allergy, diabetes, rheumatism etc. However, this type of continuing professional education does not lead to a specialist nursing qualification and does not give entitle- ment to use of a protected title. Both a degree in specialist nursing and other continuing professional education of nurses can take the form of commissioned training, which means that a county council or a municipality orders a training programme from an education and pays for it. What is the demand for and supply of specialist nurses? It is not possible to state in absolute figures how large the gap is between the supply of specialist nurses and the need for this type of skill in the health service. The need depends on a number of relative factors, such as what targets different care units have with regard to manning levels. is there any regulation of how many of the nurses in an organisation must have specialist training. According to report NPS 2010, one in every two nurses today has specialist training. It is also apparent that the county councils consider it difficult to recruit specialist nurses, particularly in the operative, psychiatric, intensive care and anaesthetic fields. Why are too few specialist nurses being trained? There is no single reason why a sufficient number of specialist nurses are not being trained. Views also differ on what needs to be done for more people to train. It is stressed that there is no demand for spe- cialist nurses in the health-care sector and that they do not receive higher pay or new duties. If the training does not lead to changes with regard to duties, responsibilities, pay etc., it is reasonable to assume that this has an impact on the level of interest in undergoing further training. In the same way, the possibility of training in paid employment would probably have an impact on the level of interest among nurses in continuing professional education. Pay and other terms of employ- ment are, however, regulated between the employers and unions. As the specialist training of nurses is a state higher-education programme, the question of whether the training can be provided within paid employment must also be decided by the employer and the indivi- dual nurse. In addition, it is the responsibility of the health-care provider to direct and distribute the work so that different duties are performed by staff with the right skills. A requirement for a certain propor- tion of nurses in a care unit to have specialist training would signify a special solution which is not compatible with the regulations in general. The obligation of the healthcare provider to ensure that those who work in the organisation have the right skills for their duties is also highlighted in the Government bill Patient and Super- vision (2009/10:210) for a new Patient , which comes into force on 1 January 2011. The same requirements to be met by the health-care provider are contained in (SOSFS 2005:12) on management systems for quality and patient safety in health care. The level of interest among nurses in undergoing specialist training probably also depends on the range of training programmes available and where in the country they are held. Given the present-day rules on higher education institutions, there are extremely limited of meaningfully influencing the training provision in these institu- tions. They determine where in the country the training takes place, whether the training is provided on a full-time or part-time basis, whether it is arranged on the Internet and so on. Some people are of the opinion that the specialist training of nurses ought to be formulated in the same way as the specialty training programmes for doctors. This would, however, mean that the training of specialist nurses becomes an in-service specialisation programme and no longer a higher-education training programme. It would consequently become more difficult for specialist nurses to be admitted to training at postgraduate level. This ought there- fore to be investigated in a wider context, where the in-service specia- lisation programmes or specialist training programmes of the profes- sions are reviewed at the same time. The most important question to ask in order to discover why too few specialist nurses are being trained is: Do the 11 specialties actually meet the needs of the care sector today and in the future? The principal sign that this is not the case is that health-care provi- ders buy commissioned training in areas other than the 11 with spe- cialist training. In our view the training therefore needs to become more flexible, with institutions of higher education being allowed to organise training programmes within the specialisms which are in demand in the health-care sector. Nurses who undergo specialist training will consequently also be in demand in the care sector, while more flexible training can more easily track the development of knowledge in health care. A problem on which everyone concerned is agreed is that there are shortcomings in the dialogue and collaboration between insti- tutions of higher education and health-care providers. The health- care providers cannot describe their need for specialist nurses, and the specialist training programmes are not designed in accordance with the needs of the health-care sector. Cooperation on in-service training (VFU) must also improve. for Higher Education has conducted a re- view of specialist nurse training, which was presented in the report Specialist training of nurses – what kind of qualification? (2010:5R) in 2010. The proposals presented in the report, together with our analysis, ought to be able to provide a basis for continued dis- cussion of the issue of the design of training for specialist nurses. If a new, more flexible training programme is introduced, it is important that the provisions on protected title for specialist nurses are In our view there should continue in the future to be a protected specialist title for specialist nurses, which is linked to the field within which they have obtained their specialism. for Higher Education should be instructed, in cooperation with and in consultation with the Autho- rities and Regions, to investigate and propose forms of coopera- tion between the health-care sector and the institutions of higher education and mutually between the institutions of higher educa- tion with regard to the training of specialist nurses. Activity related to the health-care sector We have been asked to present proposals which make it clearer to the general public what is and is not counted as part of health care. According to our terms of reference there is a risk of confusion and of misleading information in the type of activity usually known as alternative and complementary medicine (ACM). A risk of confusion often arises when practitioners of various types of treatments use titles and descriptions in their marketing of methods which allude to traditional health care. There is no clear answer regarding what ACM is. A description often used is that employed by the Cochrane Collaboration. This organisation describes the area of alternative medicine as all the forms of health care that exist outside the politically dominated health-care sector in a particular society in or in a particular culture during a particular historical period. It is not possible to give a precise figure for the number of people employed in alternative forms of therapy in , but in 2007 just over 25 500 people were working in the sectors which encompass alternative forms of treatment. There are also a number of organisa- tions and associations which organise practitioners of various alter- native therapies in . Register of alternative therapists To make it easier for people to make conscious choices on what form of care and treatment they wish to receive, we propose that a register should be established for those who practise alternative therapies and who are not health-care professionals with a licence to practise. Registration would, however, be conditional on the practi- tioner being a member of a professional organisation in the area of ACM. These organisations should also be included in the register. Registration should be voluntary. A mandatory register might lead to incorrect expectations that central government in some way vouches for the registered practitioners and the therapies they employ. Those professional organisations wishing to be included in the register should be non-profit organisations whose principal purpose is to organise professional practitioners of alternative therapies. The professional organisation should also be of a certain size. A suitable basis might be for the organisation to have at least 30 members. Pro- fessional organisations play an important role through the know- ledge gathered in them and the close cooperation that often takes place with training coordinators. To be included in the register, the organisation must have statutes enabling it to receive complaints, to exclude members and to set requirements for particular training for its members. Practitioners of alternative methods of treatment must have basic general knowledge of the human body and its various organs, pathology and regulations in the field of health care. The principal purpose of requiring such basic knowledge is that the practitioner has to know whether he or she should take on a patient or refer the patient to the health-care sector. The profes- sional organisation also has to have rules on marketing and require- ments and require its members to hold insurance which, among other things, compensates for any injuries caused by treatment. Registra- tion should be financed by an annual fee paid by the members of the register. We propose that the should admi- nister the register and approve those organisations which fulfil the requirements to be allowed to take part. is the administrative authority for consumer issues and is responsible for the rules on consumer protection being respected and consumers having access to information which enables them to make choices and for strengthening the position of consumers in the market. Under the Marketing Act, traders must not make false claims about their own qualifications. In a recent review of the Act, it was proposed that a new chapter should be introduced on the treatment and care of people. In our view, a register which makes it possible for consumers to make conscious choices among practitioners of alternative therapy methods is a good match for the Agencys area of responsibility. Alternative therapies are also used in the health service and supple- ment or are fully integrated into established health care. They are also covered by the rules governing the organisation, which means that patient safety is maintained. The register we propose should only contain practitioners of alternative therapies who are not health-care professionals with a licence to practise. The reason for this is to further clarify the difference. It should, however, be possible for health-care professionals to switch between working in traditional health care and operating outside the health service as practitioners of alternative therapies. This creates a need for staff with a licence to practise to cede their licence to practise, but also be able to regain it. The register must be readily accessible. This means that it must be on the Internet. An information portal containing objective and scientific information about the various therapies offered should also be linked to the register. A national information campaign should be conducted at the time when the register is introduced to make it generally known. A register should be established for those who practise alter- native therapies and who are not health-care professionals with a licence to practise. Anyone wishing to register must be a mem- ber of a professional organisation in the area of ACM which has been approved for inclusion in the register. should administer the register. A national information campaign should be conducted when the register is introduced. Restrictions on the right to take certain measures There is no general ban on undertaking professional activity in the area of health care. However, the opportunities to do so are limited by the regulation that exists on authority to practise professions in the health-care sector, provisions on exclusive right to practise pro- fessions, protected titles, skills as a European doctor and specialist skills. The principal rule is thus that it has to be permitted for anyone to operate in the area of health care. Activity related to health care is currently only regulated through the restrictions contains in the Professional Activities in the Health and Care Field Act (1998:31, LYHS). It is stipulated there that anyone who is not a health-care professional must not: -treat infections diseases which are notifiable under the Com- municable Diseases Act, -treat cancer and other malignant tumours, diabetes, epilepsy or -pathological conditions in connection with pregnancy or child- birth, -examine or treat under general or local anaesthetic, by injection or under hypnosis, -use radiological methods, -supply written advice or instructions for treatment without per- sonal examination, -try out or supply contact lenses or -treat children below the age of 8 years. The Riksdag has adopted a resolution to remove the ban on selling contact lenses with effect from 1 January 2011. The new Patient also comes into effect on that date. The provisions of the Professional Activities in the Health Care Field Act will then also be contained in this Act. A wish has been expressed at the meetings and hearings we have held and through written communications we have studied for changes in the restrictions which exist at present with regard to the use of alternative methods of treatment. The wishes expressed are for the ban on treating children below the age of eight years to be removed, alternatively for the age limit to be raised to 15 or 18 years, for pregnant women to be allowed to receive alternative therapy and for mental diseases and treatment by psychotherapy to be in- cluded in the enumeration of diseases which must not be treated. The argument behind prohibiting treatment of children below the age of 8 years is that while an adult has the option of discon- tinuing treatment if it leads to an exacerbation or does not produce any results, children are dependent on the assessment of their parents and the therapist. When children start school they undergo regular checks, which should enable it to be discovered whether they are receiving incorrect or harmful treatment. In , presented a report on efforts made by the Government and government agencies in the past five years to put the UN Convention on the Rights of the Child into practice. On 12 2009 of the Child presented its conclusions after examining the report. The Com- mission expressed concern that prohibits the use of ACM for examination, treatment and care of children below the age of eight years and for pregnant women and women during childbirth. is one of the few countries not to permit treatment of children below the age of eight years. This must, however, be viewed in connection with the fact that there are a large number of countries (19 in Central and Southern Europe) where it is totally prohibited for anyone other than health-care professionals to give such care and treatment. With regard to the treatment of pregnant women, our view is that there are already ways today of treating certain less serious complaints which may be related to pregnancy. The risks of people with mental diseases being treated outside the health-care sector have been discussed in many contexts. How- ever, there are no studies showing which methods are harmful or which conditions are associated with risk in treatment by alterna- tive methods. This also makes it very difficult to indicate and specify which mental diseases would be covered by a ban on treatment. The same applies to the use of psychotherapy. It has now become apparent during our work that such treatment do not pose particularly significant risks. It is also difficult to specify which methods would be prohibited. There is a ban at present on using protected titles in marketing in a way that incorrectly gives the impression that the activity is performed by someone who has a licence to practise. This ban provides some protection for those who seek help with mental problems and wish to receive psychotherapy. In the framework of our inquiry, we have not had an oppor- tunity to analyse the need to add new somatic diseases for which treatment is banned or to remove any of the rules which at present limit the options for treatment. Such a review also requires the assistance of and other expertise. should be tasked with reviewing which somatic diseases should be subject to a ban on treatment, whether the age limit for children should be amended and the options for treating pregnant women. for supervision of alternative and complementary medicine is responsible at present for supervision of certain activities, including those related to health care. If anyone is convicted of an infringement of the rules limiting the options for care and treatment, may prohibit him or her from undertaking such activities for a certain period, or permanently. also moni- tors whether anyone who is not authorised to do so uses protected titles or titles which may be confused with such protected titles. Supervision of activity related to health and care is other- wise exercised within the framework of general consumer legisla- tion. We do not propose any strengthening of supervision in the area concerned. Under our terms of reference, we have been asked to review the provisions relating to protected titles, as there may be a risk of these being used in a misleading in activity related to health care. A protected title may only be used by the person who has a licence to practise. may anyone who does not hold a licence to practise use a title which may be confused with a protected title. The marke- ting of health-care services and related activity is only regulated today by the Marketing Act. Incorrectly claiming that a product or service is capable of curing diseases, functional impairments or deformities always represents improper marketing. The Act in itself provides scope for taking action against marketing which is misleading in relation to the trader's qualifications. With regard to how important it is from the point of view of patient safety that the person seeking care is not misled about the practitioners skills, we propose that the protection of titles should be expanded so that it also applies to the marketing of activity. As at present is responsible for supervision of the use of pro- tected titles, we also consider that such a ban on marketing should come under the Board's supervision. Protection of titles should be expanded so that it also applies to the marketing of activity. should be responsible for supervision. The Professional Activities in the Health and Field Act (LYHS) contains provisions both on health-care professionals and on what restrictions apply to those who practise alternative and complementary medicine. In our view, a combined law on alternative therapies would contribute to clarifying what is regarded as health care and what is not. The provisions on what restrictions apply to those who practise alternative and complementary medicine should be transferred from the Professional Activities in the Health and Field Act to separate piece of legislation which also contains the rules on the register which we propose. Specialist training programmes for dentists We have been asked to investigate and present proposals on how specialist training programmes for dentists should be regulated. The specialist training programmes are continuing professional education which takes place during employment. This training has to be under- taken at a clinic approved by . There are eight specialties at present: -paediatric dentistry (dental care of children and adolescents) -orthodontics (development and growth of the face, jaws and dentition) -periodontology (diseases and defects in the tissues surrounding the attachment of the tooth to the jawbone) -oral surgery (diseases and defects of the oral cavity, jaws, face and adjacent areas) -endodontics (pathological processes in the pulp of the tooth) -oral prosthetics (deformities and tissue loss in the jaws and face)