Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill — First ReadingText is incorporated into the Bound VolumeHealth Practitioners (Replacement of Statutory References to Medical Practitioners) Bill — First Reading[Sitting date: 23 July 2015. Volume:707;Page:5310. Text is incorporated into the Bound Volume.]Health Practitioners (Replacement of Statutory References to Medical Practitioners) BillFirst ReadingHon Dr JONATHAN COLEMAN (Minister of Health): I move That the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill be now read a first time. I nominate the Health Committee to consider the bill. This bill will amend seven statutes to enable a wider range of suitably qualified health practitioners as defined under the Health Practitioners Competence Assurance Act 2003 to undertake certain functions currently restricted to medical practitioners.In response to changing health care needs the manner in which our services are delivered is changing. The emphasis is shifting to delivering new models of care and better services to patients closer to the communities in which they live. In response to this the health workforce is evolving. Many health professional groups are now capable of performing tasks that were previously the sole domain of medical practitioners. In the future health care will be delivered by multidisciplinary teams in an integrated team environment. Health professionals will be supported to practise to the full extent of their skills and to engage in collaborative evidence-based practice that delivers high-quality interventions for patients. Expanded scopes will be more common and innovative practice will be encouraged.These trends in health care service delivery will have significant benefits for patients. Such benefits include improved patient experience early access to preventative healthcare and where necessary early intervention and a greater availability of health care services closer to people’s homes. In addition patients will have a sense of a continuum of service delivery where health practitioners have a common understanding of patients’ health care needs and are able to make more timely and appropriate interventions than at present.Current legislation does not support the new direction of the health care workforce. The amended statutes will enable health practitioners with the required competencies and knowledge to perform certain statutory responsibilities lawfully under those statutes. There are currently seven statutes that allow only medical practitioners to undertake certain functions. Other practitioners are unable to perform them. This bill if approved will enable more health practitioners to undertake some of the functions currently limited to doctors. More services could be delivered in the community rather than in hospitals and patients’ access to services will be improved.The bill will not pose an increased risk of harm to the public. Each health practitioner is required under the Health Practitioners Competence Assurance Act 2003 to perform only those tasks that are within their scope of practice. Scopes of practice and the qualifications that practitioners must obtain in order to perform tasks within each scope of practice are set by the relevant responsible authorities that have been established under the Health Practitioners Competence Assurance Act 2003 such as the Nursing Council of New Zealand the New Zealand Psychologists Board and the Pharmacy Council of New Zealand.Although the bill has been a long time in the making the amendments are a welcome change as they recognise and enable a greater range of health professionals to work together to deliver safe and timely services to the people of New Zealand. I am advised that although the initial work to identify legislative barriers originally considered the potential contribution of nurses given the significant role that nurses play in health care service delivery the proposed amendments will also enable the potential contribution of other regulated and suitably qualified and experienced health practitioners particularly in the primary care context.I would like to provide some examples of where this bill can make a real contribution. The Holidays Act 2003 allows only medical practitioners to provide proof of sickness. The Accident Compensation Act 2001 limits who can participate in claimants’ rehabilitation plans. The Land Transport Act 1998 states that only medical practitioners and optometrists can provide medical reports on persons unfit to drive. The Children Young Persons and Their Families Act 1989 restricts medical examinations of children to medical practitioners whom the court considers qualified for the purpose. Amendments under the bill will extend these duties to appropriate health practitioners other than doctors such as nurses with the appropriate knowledge skills and training. The Government relies on competent suitably qualified health professionals in the health sector and supports expanding the role of nurses pharmacists and others to improve health service delivery.This bill will contribute to making the best possible use of our available health workforce. By enabling more health practitioners to undertake the functions currently limited to doctors there will be real benefits to patients and their families. Changes to the Mental Health (Compulsory Assessment and Treatment) Act 1992 will allow health practitioners other than doctors to request patients under their care to have further assessment or treatment by their medical practitioner when required. This change will enable health practitioners involved in mental health care to more easily refer patients under their care for medical help. The amendments to the Misuse of Drugs Act 1975 will enable suitably qualified nurses to treat drug addiction where unfortunately there is a growing need.The passing of this bill will also mean that nurse practitioners caring for patients will be able to certify the cause of death under the amended Burial and Cremation Act 1964. That change is especially important in rural areas and in aged-care services. Currently where there is not an available medical practitioner to certify the death there may be unnecessary delays for family and whānau to be able to move their family member from the place of death for burial. This bill means that current arrangements for certifying death will be more in line with what happens overseas. For example in the United States registered nurses have been able to sign death certificates since 2004.I would like to acknowledge the contribution made by the nursing sector in the creation of this bill. The Ministry of Transport the Ministry of Social Development the Ministry of Business Innovation and Employment the Accident Compensation Corporation the Police the Ministry of Justice the State Services Commission and Treasury have also been involved in the development of the bill so you can see that there has been quite extensive and wide input. I commend this bill to the House.Hon ANNETTE KING (Deputy Leader—Labour): I rise to support on behalf of the Labour Opposition the Health Practitioners (Replacement of Statutory References to Medical Practitioners Bill. I am pleased it is going to the Health Committee. Where else would it go? It is a committee that is made up of some very good members and it is very well chaired by Simon O’Connor. So we look forward to having more work at that committee; we are underworked at this stage. What this bill does as you have heard from the Minister is it amends a number of Acts to increase the range of health professionals who are able to function in certain roles that are currently carried out by medical practitioners.I want to begin by saying that I really welcome this change. It has been very very long in the making. The first nurse practitioner was introduced into New Zealand in 2002 13 years ago. The reason I know that is that I was the Minister of Health who brought in the first nurse practitioner. And what is a nurse practitioner the listening public might ask? A nurse practitioner is a registered nurse practising at an advanced level in a specific role who has a Master’s-level education and is recognised by the Nursing Council of New Zealand. We have literally thousands of nurses now with Master’s-level qualifications and above.Back in 2002 it was very much part of what we as a Labour Government wanted to do. I would just like to recall something that I said at that time. I said that nurses provide consistently high-quality health care to New Zealanders but there is considerable potential for them to contribute even more positively through responsive innovative and collaborative health services. I said that nurse practitioners will have an important responsibility in advocating health promotion and disease prevention and part of their role will be to encourage self care. But they also have the skills to consider a wide range of health services that may suit individual patients. I then went on to talk about the Primary Health Care Strategy because diversifying our health workforce—a high-quality workforce—with a focus on better health for the whole population and reducing health inequalities was the very very basis of the Primary Health Care Strategy. Fundamental to that was ensuring that people got the right services in the right place from the right practitioner.So we have had for many years the ability for nurses to be able to carry out a much more broadened role. On 12 September 2005 I actually announced the first prescribing rights for nurse practitioners. That was 10 years ago and the Cabinet of the day under the Helen Clark Government approved new regulations to allow nurse practitioners the ability to prescribe a range of prescription medicines and controlled substances. It took 6 years of work to get to that position and it allowed something like a hundred nurse practitioners to start prescribing.Since then there has been one big long wait for anything else to happen. And so I note that in the Cabinet paper on this bill I received from the Minister some time ago it was back in October 2011 that Cabinet did approve a number of changes to widen the range of health professionals who could undertake the functions that are currently carried out by medical practitioners. We are 5 years on and this has not been concluded. The work has taken this long by this Government. So important was it to have an extension of the role of health professionals that it has had to wait 5 years to be introduced today.You see the rhetoric on health is all very well from the Government but the follow-up and the follow-through just do not match.The role of different health practitioners could enhance our ability to provide health services particularly in rural and provincial New Zealand. Last week my colleague David Clark and I visited all the small rural hospitals in Otago and in part of the Southland area. We went to Timaru to Ōāmaru to Maniototo to Queenstown to Clyde and to Clutha.We spoke to those people who work there on the ground and heard at first hand what they said.One of the things that they need—desperately need—is a workforce suitable to provide the health services that they need. They mentioned the need to have nurse practitioners able to carry out a wider range of services. It is often hard to staff those areas with GPs with doctors. It is very hard at times to get the right staff in the right place but a nurse practitioner with broadened skills with the ability to prescribe and to carry out a range of functions would enhance their ability to provide those health services.One of the things the Minister said in his speech about this bill—he said that the Government wants services closer to home. Well that is the very fundamental principle of the Primary Health Care Strategy. It is the fundamental principle of a good primary health service. Services closer to home—there would not be a member in this House who would not want their family to have services that could be provided as close to home as possible. And we could provide so much more in those communities with the right health workforce and a real commitment to closer-to-home services.So what happened when we went to Queenstown? We got the example of how services closer to home by the right health professional are not happening. They have just seen three out-patient clinics in their town—a town of 30000 that rises to 90000 in the season—losing out-patient services. And that is the kind of message we got where we went. The services are not provided closer to home often because of the lack of a health workforce often because of the lack of commitment and often because the rhetoric does not match the action. So I am delighted that now there is going to be a greater range of health professionals able to provide health services and able to prescribe. I have to say again that it has taken far too long. We should not have waited this long if we really cared about providing those services to our communities.I then looked at the regulatory impact statement that was provided for this bill. I note that it was done by the Ministry of Health and one of the things that it did say in it was there was going to be no cost—there was going to be no cost to this. Well I have to tell you perhaps there is no additional cost to business in theory but if we are really going to expand the role of nurse practitioners and other health professionals there is a cost because they cost more. You cannot pay a nurse practitioner who has a masterate in higher qualifications extra training and the ability to prescribe the same as you would pay a practice nurse. Unfortunately the money that goes with a nurse practitioner has not flowed through to district health boards and there are too few nurse practitioners in New Zealand right now. So there is a cost and will that cost be picked up and provided for by the Government in its health budget or will it be told to take it out of the budget it has already got? If that is the case regardless of this extension to the role of nurse practitioners and other health professionals there will be little that happens unless the money follows to pay for them.One other thing that is in the regulatory impact statement is around the consultation. It said that overall the sector was in favour of the amendments that the Minister of Health is making in this bill. It said it would improve efficiency reduce some of the workload burden on doctors and enable professionals to use their skills more. The submitters came from the Nurses Organisation. They were very supportive of the change and they have been supportive since 2002—very patient and have waited a long time.But unfortunately there were groups that opposed it. And unfortunately I say again the groups that opposed it were medical practitioners. We have these old demarcations that still exist. If we are to have a fully operating primary health team it is not a matter of who has got what; it is how you can give the best service to the patients that you are attending to. That means using all the skills—the pharmacist skills the nursing skills the nurse practitioner skills and the skills that exist in the community—to provide an excellent service to patients as close to home as possible. So I still think we have got some battles to go through in terms of that old demarcation. We do support this bill. I see it is supposed to be passed by December. In the Health Committee I can assure you that the Labour Opposition will be ensuring it is passed by December.SIMON O’CONNOR (National—Tāmaki): I would like to thank the honourable member who has just taken her seat the Hon Annette King for what was an excellent contribution and also for her very kind words and compliments. I am always a bit worried though as my colleagues might be when Labour is giving me accolades and what that might signal. But no I am very pleased to work on the Health Committee with the Hon Annette King. In fact in beginning with this bill I want to acknowledge the entire Health Committee and the work that it is undertaking across a whole range of topics at the moment. This will be another one we add to it as we discuss the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. I thank the Minister of Health for introducing this into the House.I think genuine questions have already been raised around the timeliness—why has it taken so long? I think there is a hint of it in the last few minutes of the Minister’s speech when he noted all the various groups that had to be engaged and consulted with from the likes of the nurses unions through to the Ministry of Business Innovation and Employment obviously the Ministry of Health and a whole lot of other groups. Although this is a relatively simple bill it is a bill that has significant implications. So I thank the Minister for bringing it to the House and although it is predictable that it would come to the Health Committee I think it is something we are looking forward to being part of.This bill is very similar to a number of others that we have had of late. In the committee we are just finishing up the work on the Radiation Safety Bill and we finished work a while back on a bill that looked around the use of solaria and around contact tracing. What links all of those together is that they are playing into the Government’s focus in this space around health care that is sooner faster and more convenient and that this is ultimately about inefficiency and the updating of the statutes. This has been something that has required a long time in coming but in this space we are also trying to be responsive to the changing nature of health care in New Zealand.The terms “medical practitioner” and “health practitioner” are often used interchangeably but they are actually quite distinct terms and I might take the liberty to go through it a little bit for the edification of the House and for those listening but also to put it into context. A medical practitioner as currently defined is effectively a physician or a surgeon. We would classically just think of that as someone who is a doctor or a specialist. So your GP your dermatologist your plastic surgeon your general surgeon and your vascular surgeon—that is whom we are talking about. One of the examples that the Minister used a little bit earlier was around the use of death certificates. Part of this bill is actually going to reword what they are called but at the moment you need a medical practitioner—in other words you need a physician or a surgeon—to sign off on that document. We are saying that actually there is another group of people who can be involved and those people we call health practitioners.You will excuse me if I have to read this part because health practitioners are those who fall within the ambit of the Health Practitioners Competence Assurance Act of 2003 that very well-loved and well-known Act I am sure. Section 5 of that Act defines a health practitioner as a person “who is or is deemed to be registered with an authority as a practitioner of a particular health profession”. So obviously a doctor a physician or a surgeon falls within that but there is a whole range of other groups that fall within that. Just to give some examples—I do not intend to go all the way through them—midwives would fall under the definition of a health practitioner. Obviously that is the profession and it sits under the Midwifery Council. You have occupational therapists. They are health practitioners and come under a therapy board there. Those working in optometry osteopathy pharmacy physiotherapy—again these are people we are quite innately aware of who work in the health space.So primarily what this bill is doing is saying people within these professions within the correct scope of practice can actually begin to help us in the health care space. Again using the death certificate as an example why should it only be a physician and surgeon who can sign one when in fact we can ask as the bill suggests a nurse to have that power? A big part of that for those of us who have worked in the health care sector is that we know that it has changed we know that there are a number of people now who practise within the health space whose core competencies or scopes of practice are such that they can do things that we may not have thought of in the past.The best way to illustrate this is the change from the tertiary to the primary care sector. So when we talk in health about tertiary care we are talking about specialists. Think about elements say of dermatology plastic surgery. Think of the likes of endoscopy. Now they are primarily being done by specialists. If you had a skin cancer in times past you would pretty much if not exclusively go and see a dermatologist a plastic surgeon and a general surgeon to get that done. But actually the scope of practice of general practitioners over time has increased. Their skill levels have increased the technologies and the advances have increased so that you can now go to a general practitioner to have that done. It can now be done in the primary care sector. There are advantages to that not only financial but also it is just more convenient. So again if you have got a lesion you can go to your GP. He or she will take it out rather than having to send you down to a specialist.To further illustrate what has happened it is actually nurses now who are able to begin to act in this area. We still have some steps to go but nurses also have the necessary skills to work within this space. I think the Hon Annette King alluded to that and the great work that she introduced years ago as the Minister of Health to allow nurses the scope to expand. The same is happening in the endoscopic space—do not think about this too much but it involves cameras going down one of two areas. Again it has always been the domain or primarily the domain of specialists but actually now nurses can be trained to do this service. Again it can be done more cheaply and that is a real win for the taxpayer but it is also again more convenient. You can go down to a local surgery wherever your nurse or GP is and if they are suitably trained you can obtain their skills.So that is just an illustration of I suppose the background of why we can update these definitions through this particular bill why we are saying it is quite safe and prudent for us to allow health practitioners to work in a space that was traditionally just medical. So I think that is a positive. I think it is prudent and something I have certainly heard out in the community.It was alluded to earlier that some were doing a bit of a trip to the rural health practices—something I have been doing as well. In fact I was down at Gore Health recently and hearing about what they call a physician assistant. It is effectively a person who acts as a doctor in all but title. A physician assistant is a role that has been around—I think—about 30 years in the United States and we are trialling it here in New Zealand through the health workforce. It is a postgraduate level degree. Obviously it is not a doctor’s degree as we would understand it here in New Zealand but a person who has postgraduate training in a very particular clinical space and is able to do probably about 80 percent of what we think a doctor could do. That is being trialled in Gore Health.Again how do we increase the workforce and get them involved? So how that is going to manifest itself—it will be in a number of areas: one quite key one is in that multi-disciplinary area. Here are two very quick examples. We already know that within ACC if you need help obviously you are going to have a GP involved. You may be seeing a specialist if say you have got a back issue. You are going to be seeing an osteopath probably around that if not an orthopaedic surgeon. You are going to have occupational therapists involved and so forth. A lot of the paperwork at the moment still must be done by the medical practitioner. We are saying that we can make some changes through this bill that will provide that the lead person who is helping you through ACC can sign some of those documents.Similarly one of the announcements in the Budget was around the introduction of pain teams. In other words for those people in our community particularly in the orthopaedic field who are in pain we are going to bring multi-disciplinary teams together—nurses occupational therapists doctors. At the moment and without this bill only the doctor can sign off on forms. Through this bill it will actually be the lead provider in those pain teams. So it may be that the occupational therapist will be enabled to do the documentation required.So I think it really fits in as I said at the start to services in health that are sooner faster and more convenient. I think it is what New Zealand wants and I say that with some confidence not only as the chair of the Health Committee and obviously from going out in the community but from the fact that so far we have heard—I wait for the other parties but I am pretty sure—that we have got widespread support in the House. I can see nodding from New Zealand First. I know Labour is going to support it and the Greens. I assume therefore that everyone is going to support this bill. We as the New Zealand Parliament see that this is something important something that Kiwis will understand and will find appropriate which will make for better health care for them.Chris Hipkins: Why is it taking so long then?SIMON O’CONNOR: Finally the most excellent Chris Hipkins wonders why it is taking so long. Well we do have about eight other speeches to go. We can always just forgo those and go to the vote and call it a close for a Thursday. Thank you very much.Dr DAVID CLARK (Labour—Dunedin North): It is a delight to follow that member Simon O’Connor who has been praised by the Hon Annette King as a good sound member and in fact as a sound leader of the Health Committee. I think what we have observed there in that speech is that following Annette King is something that many people should do. It is something wise people do everywhere. Actually the member said he followed the Hon Annette King to Gore Hospital not long ago and he might do well to advise the Hon Jonathan Coleman to also follow the Hon Annette King because where the Hon Annette King goes there the health officials follow.I have to say that there have been many stories recently that have been broken in this House about what is going on in the health system. The Minister clearly did not know about the North Shore stuff we heard about in the House today about the staffing shortages there and the crisis and the challenges of meeting the medical need and the real struggle that is going on behind the scenes. He had no idea. The Hon Annette King was informing the public and I can bet you—not you Mr Assistant Speaker—I can bet the people at home bottom dollar that the health officials will be jumping as a result of Annette King’s words today.It was no different when she announced about a week ago the loss of orthopaedic accreditation in Dunedin at the hospital there. And it was not a couple of days either side of that when she announced the loss of accreditation of intensive care training in Auckland. The Hon Annette King is the one who is driving the health portfolio right now. She does not collect the salary; I think she could be a bit disappointed about that. The Hon Jonathan Coleman is still carrying the lunch box around with the silver plate on it and collecting the salary but he is not driving the officials and he is not driving the health portfolio. The visionary here is actually the Hon Annette King and this bill today is somewhat late in coming. The Hon Annette King put a very similar but better one into the ballot 6 months ago. The Hon Annette King is once again well ahead of the Government—Grant Robertson: Visionary.Dr DAVID CLARK: Visionary some would say. In fact along those lines we observe that it was the Hon Annette King who introduced the first nurse practitioner in 2002—2002. In fact beyond that in 2003—and I have a speech here from the Hon Annette King that describes some of the things that nurse practitioners could be doing which we are going to make happen today. This is from a speech in 2003. Twelve years on the Government is catching up. It is no wonder that everybody else in this Parliament thinks it is about time this happened. Twelve years ago the Hon Annette King was saying “Nurses provide consistently high-quality health care to New Zealanders but there is considerable potential for them to contribute even more positively through responsive innovative and collaborative health systems.”Sue Moroney: That’s leadership.Dr DAVID CLARK: That is leadership. She said: “Nurse Practitioners will have an important responsibility in advocating health promotion and disease prevention. Part of their role will be to encourage self-care but they will also have the skills to consider a wide range of health services that may suit individual patients. The vision for the Primary Healthcare Strategy includes developing a high-quality workforce a focus on better health for the whole population and a reduction in health inequalities.”Of course we know that under this Government things have been going in the opposite direction but we do congratulate it on finally 13 years down the track putting through some legislation that will enable these further steps that the visionary Hon Annette King suggested way back—way back—in 2003. It is cost effective as the Hon Annette King noted further on in that speech. It has more of a community focus and the nurse practitioner concept is one that is now proven. It is one that we know brings cost-effective efficient health care to New Zealanders. So this bill is a long time in coming a very long time in coming. It makes a lie of the mantra of the Government that says “faster sooner more convenient” and I noticed that even Simon O’Connor was struggling to remember that mantra in his speech. It did not roll off the tongue and I do not think it would roll off the tongue of many New Zealanders.The Hon Annette King’s bill interestingly if we note does suggest a few extra things that could be achieved and maybe they will be put forward as amendments later in the process. Maybe they will be discussed at the select committee. For example there is the recognising of the role of a nurse practitioner in legislation properly: amending the Adult Adoption Information Act 1985 which would enable a nurse practitioner to provide information on medical grounds; allowing for the provision of genetic counselling; amending the Civil Aviation Act to enable a nurse practitioner to conduct medical examinations; amending the Education Act to enable a nurse practitioner to certify whether a child is well enough to go to school; and so on. It is visionary stuff.A bill was put in the ballot 6 months ago when Annette King’s frustration at the lack of Government progress became clear. She decided: “Well let’s try to do it ourselves.” The Government could have adopted it then in fact and we could have had it in law by now. But this is a Government that has been dragging its heels. It seems a little distracted by other issues and is failing to realise really the urgency of change and the savings that are possible in our health system to deliver better provision of health care for New Zealanders. We can think of examples recently: $140000 TV screens $260000 sun decks New York apartments that cost $11 million hair straighteners and so on. The Government is distracted by these issues rather than focusing on sorting out a health care system that would really benefit all New Zealanders.As the Hon Annette King mentioned in her speech she and I did a tour through many rural hospital areas recently and we heard from the people running those hospitals how useful it would be to have more nurse practitioners and how useful it would be to have that flexibility in the rural health workforce to help deliver the services that are needed. Of course part of that requires this kind of enabling legislation that makes it possible for those jobs to be there and of course for the training of the workforce.We travelled down through Timaru. We visited Timaru Hospital which is considering interestingly amalgamation with Ōāmaru Hospital because of the crisis with funding. Ōāmaru has been threatened with a 5 percent funding cut in its hospital because of the underfunding of health services by this Government—a 5 percent cut after having had its funding frozen previously. We visited Maniototo Hospital where its struggle is to actually deliver services into the future with any kind of certainty in its rural community because the buildings are earthquake prone it has a rating base of 1800 people and a trust runs it because the Government was not keen to provide the health care services there. In Queenstown we heard about the lack of availability of services there for a population of 30000 people that swells to 90000 in the tourist season. At Dunstan Hospital there is another model there and further on in Clutha there is another model there where they are doing more integrated services delivery.In all of those areas we heard how much more benefit we could get out of having this more flexible health workforce that was trained in a contemporary way and overall I guess the feeling is that this Government is dragging its feet. I have to say that the communities we spoke to across the Otago region were very concerned about the cuts in funding in real funding during this Government’s tenure. That has meant that there are service cuts proposed in all of those rural areas. Several of those hospitals have accepted funding cuts next year. They have had their funding frozen previously and they have accepted funding cuts in the coming year.So it is amazing that it has taken so long to get this bill on the Order Paper when the need is so great in the health workforce. We do have Annette King to thank for her leadership in this area and for introducing those nurse practitioners with the master’s qualifications recognised by the Nursing Council to conduct a range of activities that they are entirely able to conduct to create a modern health workforce that is responsive and financially sustainable.I for one look forward to the Hon Annette King not only nominally driving the officials in the health ministry but actually also having that title of Minister of Health. I hope that time will come sooner rather than later. We also heard I have to say in Otago that the halcyon days of health were under the Hon Annette King. Public audiences told us that. They are still looking back to the brief time when Annette King was Minister of Health. They are looking forward to her being health minister again as am I and then we will know that we will not only get this kind of positive progress but get more of it faster sooner and more conveniently for the people of New Zealand.BARBARA KURIGER (National—Taranaki - King Country): It is a real pleasure to stand up here on behalf of the Health Committee this afternoon and speak on this piece of legislation. Actually it is about seven statutes and it is about correcting all of those in order to be able to let our nurse practitioners operate in a way that will be really really useful for our society. You know we have heard a lot about Mrs King today and her introduction of nurse practitioners. I actually think the introduction of this piece of legislation is extremely exciting and it really is only the beginning of a number of things that we can do in this area. Some of those have been outlined today in terms of how we may be able to expand on this in the future.Really it is about primary care. It is about people being able to get access close to home to their health services and as we have heard about this afternoon it is really really critical in our rural areas not only for people to be able to get care closer to home but actually for our nurse practitioners also to be travelling closer to the people. So this Government is dedicated to developing this pattern further and investing in areas that will allow care to be delivered this way. This bill is a key step in actually helping us to enact what we are working on. I welcome the change along with the committee and I welcome this opening up of a whole range of things to nurse practitioners.What it is doing is removing the legislative barriers that we currently have to innovative practice and that is why I find it quite exciting. Since I have been a member of Parliament which has been only a short few months I have actually been tracking around and looking at various health services in my electorate particularly in relation to rural ones. I had a really really fantastic experience where I watched an operation on the Mobile Surgical Unit bus. It actually travels around the country on a 5-week cycle and the nurses from the various health boards actually participate in the area when the bus comes to that area. So there is an opportunity for nurse practitioners to get more involved in terms of the scope of their work and be able to do more and help people closer to where they live.When we are talking about health we also talk about things like telehealth and Skyping health. I think this is really important. Our Rural Broadband Initiative is really going to help us to bring those nurse practitioners even closer to where people live once they have the ability to work with that equipment with the rural broadband rolling out across the electorates. We also heard the member David Clark talking about buildings and about some buildings perhaps losing services and not being up to scratch. But I am really heartened by places like Te Awamutu where we had a building that was pretty old and dilapidated that was being used for midwifery. Now that building has actually closed down and there is a core group of midwives who have started their own business and they are putting a purpose-built building in. So although in rural areas we can no longer live close to a big hospital in a lot of situations we can make purpose-built buildings.I have just recently been out at the chamber of commerce in Raglan where it is talking about building a purpose-built health centre. From that aspect we can have all sorts of nurse practitioners and all sorts of people who will come into the community and be able to work on that which saves people travelling long distances. The other thing that excites me a lot about this is that we currently have a lot of nurses who are travelling long distances to get to specific locations to do the job. The patients are also travelling long distances to those specific locations to get their medical help. If we can actually allow some of those nurse practitioners to do things closer to their home and also closer to their patients’ homes then it certainly is going to give us faster primary health care because it is going to save a whole lot of people having to travel around. I really welcome that change.The other reason that I welcome that change is that we have got 40000 nurses who are working around the country. Recently I was asked to speak and open the Rural Nurses Meeting. There are a huge number of rural nurses who are living in our communities. Actually I found out that the average age of those rural nurses is 55 years of age. There are a lot of women who are out there who are actually taking huge pride in the work they do but cannot take any further steps in their careers because of being limited because they are not able to undertake some of the duties that we are trying to open up for them today. So I think in terms of those particular people it is going to give them the opportunity if they do not already have the nurse practitioner qualification to be able to then go and get extra qualifications. They will then be able to build their own careers while they are actually still living close to home. For a lot of them I would not say that that is necessarily close to home where their children are. In some cases they actually have grandchildren in their communities. So it gives them an opportunity to be able to continue their careers for quite a long time.So really it is about a more flexible workforce. It is about people being able to be accessed from all around the community. We would actually love to have more doctors out in our rural communities and that will be part of the scope of hoping that we can work more closely with them to get them out there. But this step will actually give them a whole range of people that they can work with and it will be able to open up the scope of what we do in some of our rural places. In all that I have read related to this change in this piece of legislation it is a low risk to public safety. These nurse practitioners are very very capable people and it would really engage those people to have far better ability in our rural communities.What is really important for me is access to health and I think that since I have been on the Health Committee—and I do enjoy being on the Health Committee. It is a group that works extremely well together and we have a great collective of people and skills. A lot of what we talk about is that access to health—people’s access to primary care. Doing this in terms of what we are trying to do today will make it easier for the public to access timely and effective treatment. What we have also got is that if people cannot access timely and effective treatment people will actually go and start self-diagnosing themselves.Barbara Stewart: Which they do.BARBARA KURIGER: They are doing it now.We have actually got a wonderful initiative going on at the moment in our rural communities where we have got a doctor who used to do a TV series called Doctor Global. His name is Dr Tom Mulholland and he has bought an old ambulance and he is actually going around rural communities. He is doing health checks. He is doing blood pressure checks. He is doing diabetes checks. He goes out into rural areas like Whangamomona. He has been at Fieldays. He is travelling the country. A lot of those people would not actually get up and go to the doctor and he has picked up a few reasonably serious health situations just from those checks where he can sit in the community. It is quite amazing. You can sit for 3 hours in a community hotel where he comes in and everybody takes their turn. It is quite a supportive attitude where people are supporting each other to get these health checks and they are actually looking after each other.He is a qualified doctor and if we can get more people even out there being able to do those basic specific checks and health can come to the community rather than the community going to health then we are going to have a far better society. So I am supporting this bill and I am looking forward to being part of its passage.EUGENIE SAGE (Green): The Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill is certainly a useful bill which the Green Party is pleased to support. It will change the relationship between New Zealanders and medical and health professionals. That is because it amends seven statutes to increase the range of functions that health practitioners can perform by changing references in the law from “medical practitioners” to “health practitioners”. That means that health practitioners can perform certain statutory responsibilities quite lawfully such as issuing certificates of the cause of death rather than medical certificates.As Barbara Kuriger noted this is certainly going to provide recognition of the range of skills that nurse practitioners have developed provide for more professional development and increase flexibility across the health system. It is a fact that we rely on health professionals very considerably for their knowledge and their skill and the bill recognises that both the medical and the wider health profession have evolved with time. We have now got new technology more advanced training techniques. Health practitioners particularly nurse practitioners are upskilling and diversifying their knowledge base and they are now capable of performing tasks that previously were solely the domain of medical professionals. The fact is that nurse practitioners have done this only to find that the law actually stymies them carrying out work so this bill is overdue.It will allow for a more flexible and efficient use of the health workforce and that is particularly important because of the deepening shortages in particular parts of the country—in rural areas for example. Because we have got a nationwide shortage of GPs who are available to work in rural areas when they go and make a visit to some areas they often find that a large chunk of their time in small communities may be taken up with quite laborious administrative tasks such as signing certificates for ACC for Work and Income. They are for the people whom the local rural practice nurse will often know much better and those nurses will be in a better position to sign those certificates.So the bill with the changes to the seven statutes will allow health practitioners to participate in ACC claimants’ individual rehabilitation plans and to take blood specimens from road users. And where an employee is required to provide to an employer proof of sickness or injury that person will be able to get a certificate from a registered health practitioner rather than from a medical practitioner which is currently the case.One of the interesting things in the bill I think too is the widening of the ability for the signing of certificates for the causes of death which at the moment is able to be done only by a medical practitioner.I think there may well be a concern by some that some sectors of the health profession may not have the competence and the necessary skills to sign off cause of death but there had been extensive consultation before the bill was introduced including with the Law Commission.I would draw people’s attention to the Health Practitioners Competence Assurance Act because that makes it quite clear that health practitioners can perform only activities that they have got the expertise and capability to do.You cannot have people going beyond the functions that professionally they are identified as being able to do within the scope of their practice.So I think that the Health Practitioners Competence Assurance Act is a very important safeguard for people who may be concerned that some health professionals may be less responsible than medical practitioners.Certainly within that legislation you have responsible authorities that regulate health practitioners in any particular profession.They identify the scope of the practice and they identify the activities that each class of practitioner is deemed competent to undertake.That said we still look forward to the submissions to the select committee from professional organisations and colleges nurse practitioners and others to establish that the bill establishes flexibility in the right places and to the right degree and that there is overall support for the changes that the bill provides. But it is a very timely piece of legislation. I note Labour members’ comments about it being overdue but it certainly will provide a practical recognition that nurse practitioners have significantly diversified their skills.They play a hugely important role in the health system and the current law in these seven statutes by restricting their ability to take on roles where they have got the competence is overdue for reform. We support the bill. Thank you.BARBARA STEWART (NZ First): I was busy watching the time to see whether or not I would manage to get a turn before 6 o’clock because this is one of the bills that I had hoped would go to the Health Committee next week so that we could start work immediately on it. It is my pleasure to support this bill. New Zealand First definitely supports this bill. This bill actually makes common-sense changes to a whole range of Acts that are currently in force. The current legislation is very narrow. It sets out a whole range of functions that can be carried out only by medical practitioners in order to protect New Zealand’s health and safety. It is really great to hear from the Hon Annette King that nurses are in favour of these changes.As the bill points out in the explanatory note the training of health professionals has changed drastically over time. New technologies and treatments have been developed and the workforce has adapted and diversified. Many groups are now capable of performing the tasks that were previously solely the domain of medical practitioners. Extending the scope of tasks that are able to be completed by other health practitioners will hopefully free up our medical practitioners so that there are more doctors appointments available treatment can be faster treatment can be more timely and treatment can be at a place of the patient’s choosing to a far greater extent than what it actually is today.In New Zealand First we believe that this bill puts into practice the process of respecting what our nurses actually do in the roles that they have. The skills and the training that they have and the work that they do under extreme pressure really make it essential that their competency is recognised in the terms of this bill. Of course as has been previously mentioned this is a change that may increase the number of nurse practitioners which is a very positive thing. We will be supporting the bill. We will be looking forward to the nurses coming and submitting on this particular bill.We know that the definition of practitioners under the Health Practitioners Competence Assurance Act was quite narrow. It is appropriate for some professions. We know that there are 22 professions in New Zealand that are regulated by the Health Practitioners Competence Assurance Act. We assume that the public make assumptions as to what professions are actually covered by the definition. We know it covers nurses. Nurses are the most prominent health practitioners in need of having their roles extended and this is something that we support. It also covers psychologists. This is quite appropriate because we know that psychologists should be available to examine young people particularly if it is deemed appropriate by the courts. It must cover pharmacists. We know that they have got an increasing role in diagnosing and prescribing in the community and many people find it far more useful and convenient to actually go to their local pharmacy. They are right there on the spot.But one of the unregulated professions that we would like to see included in the bill is the paramedics. Paramedics frequently work unsupervised and they often make lifesaving or life-changing decisions right on the spot at the side of the road in terrible circumstances. The skills needed by these paramedics are highly advanced and the interventions they make can save a life. Yet because they are not recognised under the Health Practitioners Competence Assurance Act there are no universal standards for the skill sets or the capabilities that define what a paramedic should be able to do or what they cannot do. Because of this there is a loophole in the law that we have been seeing. Anybody can call themselves a paramedic anybody can set up their own ambulance service and no one would be any the wiser.If an ambulance comes we assume that these people are competent. We know that the current existing ambulance services train their paramedics to a high standard and they deliver a very high standard of care to the about half a million patient call outs that they attend on an annual basis. But unfortunately paramedics would not be extended the same respect or acknowledgment of their skills as those professions that are regulated. We believe that this is something that we really need to have a look at even during the select committee process.We know that paramedics take their patient to a hospital. When they get to the hospital the doctors or nurses take notice of their diagnosis and treat that patient accordingly. We think that it would be really appropriate to have paramedics included somehow in this particular legislation. It is something that I will be following up when it comes to the select committee. We are quite happy to ensure that paramedics are given the courtesy that they need. They take blood samples outside of the hospital and on the side of the road which is far more appropriate than the role of a doctor waiting until the patient actually gets to hospital.Just to finish before 6 o’clock New Zealand First supports this bill. We will be looking for some changes during the select committee process which we hope the Health Committee will listen favourably to. We look forward to working further on this bill and ensuring that it passes speedily through the House. Thank you.CHRIS HIPKINS (Senior Whip—Labour): As there are about 30 seconds left to go before the House rises I seek leave for the House to rise 30 seconds early so that the next speaker will have their full allocated 10 minutes.PAUL FOSTER-BELL (National): We have no objection to that course of action.The ASSISTANT SPEAKER (Hon Trevor Mallard): I think what I will now say is that the debate is interrupted and set down for resumption next sitting day and the House stands adjourned until 2 p.m. on Tuesday 28 July.Debate interrupted.