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: 18 August 2015. Volume:707;Page:5918. Text is incorporated into the Bound Volume.]Health Practitioners (Replacement of Statutory References to Medical Practitioners) BillFirst ReadingDebate resumed from 23 July.JACQUI DEAN (National—Waitaki): The Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill I am assuming enjoys wide support through the House. On the face of it it looks like a pretty sensible bill. As I have been reading the bill for the first time this evening it seems on the face of it relatively in concept quite straightforward. What this omnibus bill does do to a number of statutes is to bring legislation into line with current practice. Once again it is another statute that is being brought to the House that is modernising legislation to make it fit for modern times and so it is with this bill.Medical practitioners or medically trained practitioners including general practitioners have for many years been the medical personnel who have had statutory duties under a number of pieces of legislation. Of course current practice has changed now. For example we have a much higher level of competency and training in a number of other health professionals—nurses in particular and other health practitioners as well.As I often do I will refer back to my large rural constituency where health services are delivered increasingly away from the base hospital and towards where the local population lives. That is a laudable move by this Government and it is working particularly well for the people who live in my communities. We are getting health services closer to where people need them.Another component of the delivery of those health services is to allow those highly trained health practitioners to now deliver some of those roles that have been the province so far of medical practitioners. So if I can simplify the omnibus bill rightdown in many instances the changes in this bill proposed for the statutes to which it refers are to change references from “medical practitioner”to “health practitioner”. “Health practitioner”is not just a term thought up by some officials in the Ministry of Health. Health practitioners are required to have competencies and knowledge as you would expect and the ability to perform a number of tasks.I am just going to go through some of the statutes that are covered in this bill. There are a number of them of course as this is an omnibus bill. It is interesting for those of us who are in this business that an omnibus bill may be introduced to the House if the amendments to be effected to each Act are of a similar nature. Of course in this case this bill as it is applied to those statutes recognises the increasing skill levels of health practitioners. I will refer to the Accident Compensation Act. What the amendment to that Act will do is make reference to a health practitioner rather than a medical practitioner in clause 7 of schedule 1. What that means if you go to schedule 1 is that ahealth practitioner leading the coordination of treatment or rehabilitation of the claimant for ACC must now be given the opportunityto participate in the preparation of the individual’s rehabilitation plan. Again that is using wisely the enhanced skills of health practitioners.Under the Burial and Cremation Act which is an older Act of Parliament—from 1964 and probably due for renewal—a “doctor’s certificate” which is required by that Act is going to be renamed a “certificate of cause of death”. References to “doctor” in that piece of legislation will be replaced by references to “medical practitioner”.And so it is with the Children Young Persons and Their Families Act. This one is our very important Act for vulnerable children in particular in the New Zealand legislative system. So in that legislation there is an equivalent duty to minimise distress to children and young persons when carrying out medical examinations and that duty goes on to health practitioners so that it is in line with the duty of medical practitioners who do the same thing. So the benefits there—and I am looking forward to the select committee consideration of this bill—are that the focus under this Government goes on yet again to what is good for children. A health practitioner who may have an existing relationship with the child under care now has the ability to undertake procedures and medical examinations rather than it just being confined to those of the health practitioner.The bill also amends the Holidays Act the Land Transport Act—and I am not going to go into each piece of legislation. There are other members who I know are very keen to speak to those particular Acts. I know that my colleague Scott Simpson is particularly keen to focus on the Holidays Act and the Land Transport Act in his initial contribution so I am going to leave those up to him.I just want to finish my contribution with a couple of comments on our health workforce because of course this omnibus bill once it is passed will have a large impact on health professionals in New Zealand. I will just note that it is this Government that is investing in the training of health professionals which is why it is appropriate for us to be able to make these changes in the way health services are delivered to New Zealand. Although this is a simple bill on the surface it has wide-reaching implications and I commend it to the House.JENNY SALESA (Labour—Manukau East): Labour supports the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. This Government has been going on about increasing the focus on primary and community - based care and improving and implementing new models of care to ensure the sustainability of Vote Health part of which involves nursing and ensuring that health care workers carry out a wider range of functions. And yet it has taken 7 years to get this bill on to the Order Paper—7 years. This delay has been frustrating for the nursing profession which has been promised more support for increasing its scope of work in legislation for many years.Labour supports this bill but I wonder why it has taken the Government so long to get cracking on this legislation which is needed to enable nurses and other health practitioners to contribute fully within our health system. The Government has been told for years that it needs to remove the barriers to innovative practice by removing legislative references to medical practitioners when certain health professionals like nurses are perfectly capable of undertaking this work. The National Nursing Organisation body has reported that nurses have long been frustrated by the models of care in primary health care and that they do not make the best use of their knowledge and skills as well as they should.Treasury and the Ministry of Health have both urged the Government to speed up this bill and to remove the barriers to extending nurses’ roles within the current health workforce. There has been a constant chorus from the Government about an increased focus on primary and community - based care and I am really pleased that this bill is actually being read for the first time.Can I just acknowledge that 13 years ago the first piece of nurse practitioners legislation was introduced to this House in 2002 by none other than the Minister of Health at that time the Hon Annette King. The first prescribing rights for nurse practitioners were announced 10 years ago in 2005 again by the Hon Annette King. Now here we are 5 years further on finally looking at a partial response by the Government.The Hon Annette King has continued her visionary work in this area and has had a Nurse Practitioners Bill in the members’ ballot since last December. That bill would amend a total of 21 pieces of legislation that would have provided for nurse practitioners to perform an even wider range of tasks to take the pressure off our doctors for the benefit of all of us here in New Zealand. The Government should have stopped its dilly-dallying in this area and simply adopted the Hon Annette King’s bill in 2002. It would have been law by now. Labour supports this bill.SCOTT SIMPSON (National—Coromandel): I am delighted to take a call in this first reading of the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill in the name of the very good and competent Minister of Health Dr Jonathan Coleman.The previous member Jenny Salesa was obviously receiving some kind of incentive or reward for mentioning a former health Minister in the last Labour administration Annette King because I suspect that probably every mention received a chocolate fish or something along those lines. I counted about five or six mentions. Of course some of us have been involved in the political system long enough to remember that when that member was the Minister of Health we had people lined up in corridors under fluorescent tubes for days on end at North Shore Hospital waiting to get a place in a hospital. It was a shocking and dreadful shambles. So this Government has been busy reforming health making health more efficient and getting it so that for instance New Zealanders no longer have to travel overseas to receive cancer treatment as they did during the time of the Hon Annette King’s administration. This bill particularly is of importance because it is reflective of the changes that have been occurring for a long number of years in our medical and health systems.My late mother was a registered nurse. She practised her nursing at Waikato Hospital. I well recall the many stories that she used to tell of how in those days the most important things that nurses seemed to do was to starch linen and make beds and do everything that was ordered literally by the doctors who were like gods if you like in our medical system. The nurses did the menial tasks and the doctors and the senior medical physicians really did sort of administer a regime that was strict and controlled. Their judgment was never questioned—their judgment was always the be-all and end-all of any medical intervention. Things have changed a lot since the days that my mother was practising nursing at Waikato Hospital.Andrew Bayly: And for the better.SCOTT SIMPSON: And indeed as my friend and colleague Andrew Bayly says for the better. And much for the better because these days there are so many aspects of our health interventions and procedures that can be done by very competent skilled and well-trained people in the medical profession who actually are not general practitioners or doctors as such but they do have the registration and the current education and training to ensure that they can provide all sorts of services and support for people needing that from our health system.This bill I want to make very clear as I understand it makes absolutely no increased risk of harm to the New Zealand public with the scope of practice being set in every instance that this bill envisages by the relevant responsible authority and the professional accountability of each practitioner to be responsible for their actions and their deeds. So although we are moving forward in this area there will be no lowering of standards or lack of protection for members of the public.It is an omnibus bill and it effectively amends seven statutes which enables a wider range of suitably qualified health practitioners as defined under the Health Practitioners Competence Assurance Act 2003 to undertake a wider range of functions than they are currently able to do and that are currently restricted to medical practitioners.This Government has spent a lot of time in its 7 years of Government in ensuring that our health dollars go further and that we get better results because under the last Labour administration we had a doubling of health spending but a reduction in actual results for New Zealanders and that of course needed to change and it needed to change in a significant way.I am very proud to be part of a Government that has worked diligently both during the time of the Hon Tony Ryall—during his administration as the Minister of Health—and that is now being carried forward by Dr Jonathan Coleman in his areas of portfolio responsibility.This is a Government that is completely committed to delivering much higher-quality services for all New Zealanders no matter where they live. A previous speaker in this debate my colleague Jacqui Dean who like me represents a provincial rural electorate—these are matters that are of concern to constituents in seats like the Coromandel because often the bricks-and-mortar hospitals are actually quite a long way physically from where the patients are. So the increasing focus is upon ensuring that people can receive the benefits of health and medical advice and intervention in their own communities or indeed in their own homes.What this bill seeks to do is to provide a much greater role for community health providers like our nurses and our pharmacists. Nurses and pharmacists of course have an ability to operate neatly and easily within communities—local communities—often in places that are geographically isolated and some distance away from base hospitals. So by making these changes and by ensuring that we have a greater role for for instance pharmacists and nurses there will be a better supply of health benefits to a wider range of people in our more far-flung rural and provincial communities. This is a Government that is just as concerned about supplying good public services to people in the provinces as it is to supplying them to the cities.This National-led Government of course has put a very big emphasis on increasing the number of doctors and nurses within our health system who are now able to be working within our broader communities. They are working hard to ensure that better services are provided to a much wider range of people. We have now over 3000 enrolled nurses registered to practise across all areas of our health sector. There are 3000 enrolled nurses—Chris Bishop: How many?SCOTT SIMPSON: 3000 Mr Bishop and that is a large number of capable talented professionally competent nurses who can do a whole range of things that have previously just been the protected preserve of the medical practitioners. We now have a total of more than 40000 nurses. So the 3000 enrolled nurses make up the total of 40000 nurses working in New Zealand’s health system and they of course perform a very vital role. So the changes under this legislation will allow this highly skilled workforce with the appropriate knowledge training and professional background to treat and look after patients within our communities and I think that that is a very good step. It is something that has probably been in the wind for a long time but we needed to make sure that it was the right time to introduce this legislation.As a member of the Health Committee I am very much looking forward to a thorough and diligent investigation of this legislation. I know that committee members on the Government side will be doing that and I hasten to add that the Health Committee is a very collegial committee. I know that with the support of Labour members who have indicated that they are going to support this bill through the House I think that we will ensure a very good select committee process under the capable chairmanship of Simon O’Connor.One of the things that has been most obvious over the last few years is that in many other countries health spending has been cut and services to health have been cut. That has not occurred in New Zealand. I am very proud to be part of a Government that has—during the very toughest of economic times when there has been enormous global financial pressure—in every single one of its seven Budgets increased health spending and increased the effectiveness of services to New Zealanders who require the use of our health system.This appears to me to be a very good bill. I am looking forward to the scrutiny that the select committee will give it and I commend it to the House.Hon RUTH DYSON (Labour—Port Hills): I noted the words of the member Scott Simpson who has just resumed his seat when he said that he was going to do a thorough rigorous and diligent perusal of this bill at the select committee and I commend those wishes. I wish he had done half as much of that on his attack—unfounded ill considered and factually wrong—on the former Minister of Health the Hon Annette King. That member should look up the facts before he starts attacking other members of this House because what goes around comes around and it will be his turn very very soon.When we were elected to lead the Government in 1999 we had a total of 43 radiation therapistsin New Zealand—43. Is that enough radiation therapists to service the needs of New Zealanders who have cancer? I will give you a clue. The answer is either yes or no and it is not yes. The answer is no.What does a Government do if someone presents at a hospital or at a doctor’s with cancer but there are no trained staff available to treat them? Should we send them home? Should we send them to the backblocks of Coromandel where Mr Simpson comes from? Shall we send them home or shall we pay for them to go to Australia—where they will get their treatment—until there are enough trained staff in New Zealand? So what is the answer—what is the answer? Scott Simpson has not got a clue. He has just demonstrated that. There were 43 radiation therapists when his party left Government in 1999 and within 3 years that number had doubled—[Interruption]The ASSISTANT SPEAKER (Lindsay Tisch): Order! Now I want the House to settle down. We do not have comments like that. Speaker’s ruling 48/2 refers to that. We will not have that again.Hon RUTH DYSON: Thank you very much Mr Assistant Speaker. This bill is another contribution to being able to ensure that we can provide health services to people who are in need of them. But before I get back to the specifics of the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill—that has got to win the award for the longest title of a bill so far this year—and to support the legislation can I add another warning to Mr Simpson. Just 9 or 10 months ago his Minister of Health received exactly the same warning about the shortage of trained staff able to treat New Zealanders with cancer as the previous National Government had received in the late 1990s and he ignored it. The then Minister of Health between 1996 and 1999 got the warnings in writing from the Ministry of Health saying: “You will not have enough trained staff to treat cancer patients in New Zealand. There will be a crisis.” That Minister of Health did nothing and that is exactly what Tony Ryall and Jonathan Coleman have been doing in the last 2 years. There were exactly the same warnings in writing to the same Ministers and they have been ignoring it.Hon Member: What a load of rubbish.Hon Annette King: We will table it.Hon RUTH DYSON: We will certainly table it Mr—I cannot remember his name—whatever.It is not very usual with the current Government that Labour is able to support legislation. For example earlier this evening we had a couple of hours of debate about how National is proposing to sell off our State housing stock. It tried it in the 1990s and it is doing it again now. Those members have got all sorts of magical words that they are weaving around it but in the end they are hocking off a significant asset putting some of our most vulnerable individuals at risk—The ASSISTANT SPEAKER (Lindsay Tisch): Order! That is not part of this debate.Hon RUTH DYSON: So we could not support that legislation but we are able to support the bill that we are debating at the moment. It has taken an awfully long time—7 years—to bring this bill to the House.I could give the Minister of Health and his predecessor some advice. They should have just looked in the members’ ballot because Annette King has already got a member’s bill in the ballot that does considerably more than this. This amendsonly six or seven pieces of legislation. Annette King’s member’s bill without the resources of the huge Ministry of Health amends 21 pieces of law in exactly the same way as this health practitioners amendment bill does. In fact there are 59 pieces of legislation that need amendment in this way and we have managed to get only seven out of this current Government. They are good moves; we certainly support them. But why has it taken the Government so long and why is it such a shonky little bill? It is not nearly robust enough—seven legislative changes instead of what the Ministry of Health recommended which was changes to 59 pieces of legislation.So how does this issue come about and why are we debating the bill? Well the issue comes about because years and years ago the only people who had the training to enable them to do some jobs in the health system were doctors. They were the only people who got the training. Over the last few years particularly since Annette King was the Minister of Health and we had the introduction of extended scopes of work and new titles—for example nurse practitioners—we know that now nurse practitioners as one of a few examples are trained and are competent to deliver their scope of work but they are not allowed to within the law. There are some things that they are trained and are competent and able to do but the law forbids anyone but a medical practitioner from performing them. That is just because the statute never caught up with the practice and that is what we are fixing today.I hope that during the select committee process there will be some pressure put on the Ministry of Health and indeed on the Minister to get the rest of the legislative changes on to the floor of Parliament because it is clear that all parties agree with these changes. I imagine—I have not heard from Mr Seymour from ACT. It is fabulous to have your presence with us tonight unusual though that is in the Chamber. But I am hoping that even Mr Seymour will be supporting this legislation. It is certainly sensible.So I do not know why we have not got all 59 needed legislative changes included in this bill. I do not know why when there was a priority of 10 identified in the regulatory impact statement that we ended up with only seven and I certainly do not know why it has taken 7 long years to get to this state. I know that it does not assist with training the additional cancer specialists whom we are short of but I do know that it will help relieve the huge—and predicted to be increasing pressure—that we have on our doctors. This will enable competent qualified trained “other” health practitioners—and they are described in this legislation as health practitioners sensibly in my view to avoid future extensions of scope that might allow other than nurse practitioners the ability to perform these tasks.It does not explain why we have not covered off all the necessary changes. But the ones we have got in this bill are changes to the Accident Compensation Act which are primarily around a health practitioner having input into a rehabilitation plan and to the Burial and Cremation Act which will allow a qualified person other than a medical practitioner to certify that someone has actually died—David Seymour: You’ve run out of steam.Hon RUTH DYSON:—and I hope that they do not take too close a look at the member who is interjecting.There are amendments to the Children Young Persons and Their Families Act for medical examinations of children and to the Holidays Act so that a health practitioner can testify that someone is actually too unwell to be able to go to work—they might be too busy on public business across the road to be able to go work but you do not need a health practitioner to be able to do that. Also there are amendments to the Mental Health (Compulsory Assessment and Treatment) Act—changes to that and changes to the Misuse of Drugs Act.So as I said at the beginning this is a bill that we strongly support. It is long overdue. It is short in terms of the breadth of legislative changes that are needed which were recommended by the Ministry of Health and without any explanation were not presented to us. I look forward to its progress in the House.Dr SHANE RETI (National—Whangarei): It is a pleasure to stand and speak positively and affirm this bill the Health Practitioners (Replacement of Statutory References to Medical Practitioners) Bill. Fundamentally and substantively this bill is administrative renaming the term “medical practitioner” as “health practitioner” thereby increasing the scope and the number of people who can be engaged. The purpose of this will be to increase efficiencies in the health system and it will do so in several ways.First of all health practitioners will be able to deliver better end-to-end service without having to do segments of care then have a medical practitioner intervene and they then complete their care onwards. So end-to-end care is better preserved.It also prevents skill dilution. When you have highly skilled practitioners who have to undertake sometimes labour-intensive repetitive work you get what is called skill dilution. They lose their career path and they lose interest. They move out of what they are doing. So a bill like this also prevents skill dilution.Most important what it also does is that it allows more clinical people to do more things. I think this is useful in resource-depleted areas particularly. One of the things that this bill will do is amend the Accident Compensation Act 2001. This allows a health practitioner leading the case to be involved in individual rehabilitative plans. Many times that practitioner may actually be a physiotherapist a podiatrist or maybe even a chiropodist. The health practitioner is also able to prescribe various aids and appliances. So the theme here is that the health practitioner with the most knowledge is able to contribute and I think that is the way that it should be.The Burial and Cremation Act 1964 is also amended. Particularly it allows nurse practitioners to complete certificates of causes of death. This is a very important function. The certificate of cause of death is very important for epidemiological studies. It gives us some sense of trends of death and trends of disease over time. It is actually also very important for closure for patients. I have often found that when they have got their certificate of death in their hand they can look at it and in amongst their grief that episode of sadness reaches some level of closure. New section 46B in clause 9 addresses this and talks about how a medical practitioner or a nurse practitioner can complete a death certificate.If I could just go over some of those clauses—first of all it applies to a person who dies of an illness so if you succumb due to an accident you go to a coroner’s inquiry. It also says that the death has to be a natural consequence of illness and the section also says that a health practitioner has to reasonably consult with any other health practitioners who have been involved in the last illness.There are some safety clauses in this section as well. A health practitioner or a nurse who attended the person may refuse to give a certificate of death if a previous practitioner cannot say: “Yes I think this was due to illness.” Another safety clause is that a medical practitioner or nurse practitioner must not give a certificate of cause of death unless they have taken into account previous medical records and the circumstances of the death and of course they have examined the person’s body. The final safety clause in this section is that the certificate of cause of death must not be given if a death must be reported to the New Zealand Police or to a coroner. So I think there are a number of safety clauses there.When you do a certificate of death it is actually quite a time-consuming event. You need to coordinate with the funeral director to be at the funeral parlour. So you coordinate schedules you go in and the very first thing you need to do is to certify that the person is dead of course. There are a number of ways clinically to do that. What you then do is you complete some documentation that asks whether this person had a notifiable disease or any sort of disease that the funeral home might need to know about or that the public needs to know about. You are then asked whether they had a pacemaker because if they are going to be cremated you cannot do that because pacemakers explode under cremation. Then you actually do the certificate of cause of death. In my experience this takes probably 30 to 35 minutes and sometimes three-quarters of an hour and to have this done by an appropriately qualified person I think is a really good thing.New section 46B also specifically talks about nurse practitioners and our colleagues across the House have talked about them today. These are indeed highly trained professionals many of whom actually have prescribing rights as well. In fact just on Friday I tried to persuade the Tāmariki Ora nurse in Nelson to become a prescribing nurse practitioner with Te Piki Oranga the service she was with and we have tried to enlist nurse practitioners up into some of our resource-depleted areas in Northland. Nurse practitioners really do have a high scope of practice. They are registered with the Nursing Council in a registered scope of practice they have had a minimum of 4 years of experience in specific areas of practice they have actually completed a clinical Master’s and they have passed an assessment panel as well. When I looked at the Nursing Council website a few days ago there were actually 116 nurse practitioners.We have just talked about the Burial and Cremation Act and it strikes me that there are three registered nurse practitioners who might especially benefit from that Act. These are nurse practitioners with scopes of practice—there are only three of them—in palliative care. The three of them come from Auckland Canterbury and Southland. Auckland and Canterbury may well be well served by medical practitioners in other services who can complete certificates of cause of death but I am pretty sure that Southland would be very pleased to have a nurse practitioner who can complete some of this documentation.This bill also amends the Children Young Persons and Their Families Act 1989. Health practitioners are able to prescribe and undertake medical examinations. The duties of care are also amended so that health practitioners are aligned with medical practitioners.I am always sort of interested in what health policy we enable and how many people it might actually touch—is it a few or is it many—and I think it is actually the amendments to the Holidays Act 2003 where this legislation may actually touch the most New Zealanders. When we look at the efficiencies that this bill creates—let us take your standard practice and how we actually complete a sick note. The patient comes in you then consult with them and what most of us would generally do is then show the patient through to another room and the nurse completes the sick note. They then will be required to come back to you for you to sign it and then it is complete. Well that could be 45 to 50 minutes for a patient—that is a lot of time. What could happen here now with the work flow is that they could be seen and diagnosed by a nurse practitioner or an appropriate health practitioner. The sickness certificate could be done and that could all be completed in 15 minutes. This is particularly so if the nurse has high skills in some of the more frequent things that we see sickness notes for like a urinary tract infection for example. This can often be point-of-source tested in the surgery. The patient does not need to see the doctor but can see an appropriately—The ASSISTANT SPEAKER (Lindsay Tisch): I am sorry to interrupt the honourable member. The time has come for me to leave the Chair.Debate interrupted.