Health Professions Council
Scope of Practice Review
I. EXECUTIVE SUMMARY – POLICY ISSUES
The Health Professions Council (Council) was appointed by the Minister of Health in 1991 to advise the minister with respect to applications by unregulated practitioners for designation as self-regulated health professions. In December 1994, the minister expanded the mandate of the Council. The Council was asked to review the scopes of practice of 15 regulated health professions and to review the legislation under which 10 of them were self-regulating. (See Appendix A for list of professions.) The Council was given Terms of Reference (see Appendix A) which provided the criteria to be applied in the reviews of both scope and legislation. The scope review had four areas on which the Minister of Health requested recommendations: scope of practice of each profession, reserved acts, supervised acts and title restrictions. Because of the parameters of the Terms of Reference the Council did not consider issues such as the cost implications of the recommendations, or the impact on education and training facilities or labour relations. These are clearly important but they did not fall within the Council’s mandate. Nonetheless, these issues will likely have to be considered should the government decide to implement the new regulatory model discussed in this report.
B. SHARED SCOPE AND RESERVED ACTS The Terms of Reference set out the framework for an entirely new way of regulating health professions. Heretofore, each regulated profession had an exclusive scope of practice which prohibited others from practising within its scope of practice unless permitted to do so by statute. The new system consists of non-exclusive scope of practice statements and reserved acts. Scope of practice statements describe in general terms what a profession does and how it does it. On the other hand, reserved acts, defined as those "tasks and services involving a significant risk of harm," need to be restricted, and may only be performed by professions to whom they are, on a non-exclusive basis, assigned, and so long as those performing them are acting within the scope of practice of their profession. The Council developed a list of such activities, the Reserved Acts List, and in its review of each profession determined which of the reserved acts it was qualified, as a profession, to perform. The list underwent revision from time to time in the course of the review process. (See the discussion on "The Shared Scope of Practice Model Working Paper", page 46 of written report and the current list of reserved acts on "Reserved Acts", page 4 written report.) The scope of practice of each profession together with the reserved acts assigned to that profession are set out in the Executive Summary – Professions section of this Report.
C. SUPERVISED ACTS A third issue directed to the Council was to recommend if and how activities otherwise restricted could be performed by individuals under some form of supervision or delegation. The Council considered this issue and developed a set of protocols under which reserved acts could be performed in certain restricted circumstances by both regulated and non-regulated individuals who would otherwise not be permitted to perform these acts. (See the discussion "Supervised Acts" commencing on page 57 of written report.)
D. RESERVED TITLES
Reserved titles are titles reserved exclusively to a health profession. Reserved titles afford a means for consumers to identify the different types of health care providers, to distinguish the qualified from the unqualified and to differentiate those practitioners who are regulated from those who are not. Titles must adequately serve the public in describing the practitioner and the services being provided and must distinguish the practitioner from others performing services outside the jurisdiction of the regulatory body. The Council considered this issue on title restrictions and made recommendations for each health profession. (See the discussion "Reserved Titles" commencing on page 59 of written report.)
E. OBJECTIVE From the outset, the paramount consideration was the public interest, both with respect to the scope review and the legislative review. As a corollary to that, the mandate of the Council clearly expressed the desirability of increasing public choice of health care services with the function of government being to ensure, as far as possible, that the choices available were within safe parameters. (See the discussion "The Scope of Practice Review Process" commencing on page 41 of written report.)
F. PROCESS The Council consulted broadly in its review process. Each individual profession was consulted with respect to its own review as well as that of all the others. Responses were sought from professional, academic and educational bodies, organizations representing employers and employees, and governmental authorities across the country as well as from public interest and consumer groups. Literature was reviewed from not only Canada but also the United States and Europe. In particular, the Council availed itself of the research and reports emanating from similar reviews in other provinces, notably Ontario and Alberta as well as Manitoba. In certain instances, to deal with specific activities which were beyond the expertise of the Council and staff, professionals were engaged to provide information and research, mainly respecting the degree of risk in certain of the reserved acts under contemplation. Finally, after a preliminary report was published with respect to each profession, public hearings were held to allow interested parties to comment on the preliminary report and make further submissions. (See the discussion "The Process of the Scope of Practice Review" commencing on page 42 of written report.)
II. EXECUTIVE SUMMARY – ISSUES OF GENERAL APPLICATIONThis section of the Executive Summary sets out the Council’s recommendations in full. A general discussion of each recommendation is contained in the section of the report commencing on "Discussion oF Issues "page 45 of written report.
The Health Professions Council recommends that the following reserved acts be enacted by the Minister of Health and Minister Responsible for Seniors:
(See the discussion "Reserved Acts" commencing on page 46.)
B. SUPERVISED ACTS The Health Professions Council recommends that a provision be enacted by the Minister of Health and Minister Responsible for Seniors which sets out the duties of a health professional and his or her regulatory college when delegating a reserved act. The provision should require the following:
The Health Professions Council recommends that this provision apply to all professions within the new regulatory model. As a result, the Health Professions Council will not include individual recommendations for supervised acts in the summary of recommendations for each profession. (See the discussion "Supervised Acts" commencing on page 57.)
C. MEANING OF THE TERM "ORDER" The Health Professions Council recommends that the following definition be adopted by the Minister of Health and Minister Responsible for Seniors for the term "order": An "order" is a prescription for a procedure, treatment or intervention. It can apply to an individual client by means of a direct order or to more than one individual by means of an indirect order:
(See the discussion "Reserved Acts on Order" commencing on page 52.)
D. THE SOCIETY ACT The Health Professions Council recommends to the Minister of Health and Minister Responsible for Seniors the implementation of the recommendations of the Royal Commission on Health Care and Costs (the Seaton Commission) that:
(See the discussion "The Society Act" commencing on page 60.)
E. REVIEW OF THE COUNCIL’S RESERVED ACTS LIST The Health Professions Council recommends that a process be established by the Minister of Health and Minister Responsible for Seniors for the Health Professions Council to provide ongoing review and consideration of additional issues related to the new regulatory model, including the following:
(See the discussion "Review of the Council’s Reserved Acts List" commencing on page 62.)
F. ACCESS TO LABORATORY AND DIAGNOSTIC FACILITIES The Health Professions Council recommends that the legislation governing access to laboratory facilities be reviewed and modified by the Minister of Health and Minister Responsible for Seniors to ensure access for health professionals who are deemed by the Minister of Health and Minister Responsible for Seniors to be trained and educated to utilize test results. (See the discussion "Access to Laboratory and Other Diagnostic Facilities" commencing on page 63.)
G. REVIEW OF RESERVED ACTS GRANTED PRIOR TO THE SCOPE OF PRACTICE REVIEW The Health Professions Council recommends that the Minister of Health and Minister Responsible for Seniors review all reserved acts granted through regulation prior to the Scope of Practice Review to ensure that they are consistent with the current Reserved Acts List. (See the discussion "Review of Reserved Acts Granted Prior to the Scope of Practice Review" commencing on page 63.)
H. DELEGATION PROTOCOL – DELEGATION TO UNREGULATED INDIVIDUALS The Health Professions Council recommends that the Minister of Health and Minister Responsible for Seniors review all legislation governing community, long term care and home care programs and facilities to ensure they contain the appropriate safeguards so that the delegation of reserved acts to unregulated individuals is carried out in a safe and effective manner. (See the discussion "Delegation Protocol – Delegation to Unregulated Individuals" commencing on page 64.)
I. RISK OF HARM CLAUSE The Health Professions Council recommends that a provision similar to the following risk of harm clause enacted in Ontario be adopted by the Minister of Health and Minister Responsible for Seniors: No person, other than a member treating or advising within the scope of his or her profession, shall treat or advise a person with respect to his or her health in circumstances in which it is reasonably foreseeable that serious physical harm may result from the treatment or advice or from an omission from them. (See the discussion "Risk of Harm Clause" commencing on page 64.)
J. EXEMPTIONS FROM THE RESERVED ACTS SYSTEM The Health Professions Council recommends that the Minister of Health and Minister Responsible for Seniors include provisions for exceptions to and exemptions from the new regulatory model. (See the discussion "Exemptions from the Reserved Acts System" commencing on page 65.)
K. RELEASE OF PRESCRIPTIONS The Health Professions Council recommends that prescriptions for patients be delivered to patients free of cost. (See the discussion "Release of Prescriptions" commencing on page 65.)
III. EXECUTIVE SUMMARY – PROFESSIONSIn this section, the Council lists the final recommendations regarding the four elements of the scope of practice review for each of the 15 health professions subject to the review. The complete discussion, including the preliminary report and post-hearing updates for each profession, is set out in Volume II of this report. The Council submits to the Minister of Health and Minister Responsible for Seniors the following final recommendations with respect to its mandate of the scope of practice review of the 15 health professions.
(See the discussion for this profession in Part I Volume 2.) Scope of practice The practice of chiropractic is concerned with those aspects of the restoration and maintenance of human health which relate to assessment of the spine or other joints of the human body and the associated soft tissue or nervous system, and the treatment of non-organic diseases or disorders directly related to the neuromusculoskeletal system through manipulation and adjustment by hand or devices. Reserved acts 1. Making a diagnosis identifying as the cause of signs or symptoms of the individual, a disease, disorder or condition of the spine or other joints of the human body and their effects on associated soft tissue or the nervous system. 2(c) Performing the physically invasive or physically manipulative act of movement of the joints of the spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust. 2(e)(vi) Performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s) beyond the anal verge for the purpose of performing reserved act 2(c). 4. Ordering or applying a hazardous form of energy: X-ray for diagnostic purposes; ordering the application of a hazardous form of energy: MRI and CT scan. Reserved titles
Other recommendations
(See the discussion for this profession in Part I Volume 2.) Scope of practice The practice of dental technology is the fabrication or alteration of a dental appliance or device in accordance with a prescription from a dentist, denturist or medical practitioner, and the repair of such appliance or device. Reserved act 6. Dispensing prescribed appliances or devices for dental conditions, provided such dispensing can be performed without intraoral procedures. Reserved titles
Other recommendations
(See the discussion for this profession in Part I Volume 2.) Scope of practice The practice of dentistry is the maintenance of health through the assessment, management, treatment and prevention of any disease, disorder or condition of the orofacial complex and associated structures. Reserved acts
4. Applying or ordering the application of a hazardous form of energy, including ultrasound, electricity, magnetic resonance imaging, laser and X-ray, or as prescribed by regulation. 5(a) Prescribing, compounding, dispensing or administering by any means a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act or as prescribed by regulation. For the purposes of this reserved act, the following definitions shall apply: "prescribing": the ordering of a drug. "compounding": mixing ingredients, at least one of which is a drug. "dispensing": preparing or filling a prescription for drugs. 6. Prescribing appliances or devices for dental conditions; dispensing and fitting such appliances or devices for dental conditions. For the purposes of this reserved act, the following definitions shall apply: "prescribing": ordering the fabrication or alteration of appliances or devices for dental conditions. "dispensing": filling a prescription by fabricating or altering a dental appliance or device. Reserved titles
Other recommendations
(See the discussion for this profession in Part I Volume 2.) Scope of practice The practice of emergency medical assistance is the performance of prehospital emergency procedures necessary for the preservation of life and health for which training and medical direction or supervision are provided. Reserved titles
(See the discussion for this profession in Volume II, Tab 5.) Scope of practice The practice of massage therapy is the assessment of the soft tissues and joints of the body and the treatment and prevention of dysfunction, injury, pain and physical disorders of the soft tissues and joints by manual and physical methods to develop, maintain, rehabilitate or augment physical function to relieve pain and promote health. Reserved titles
(See the discussion for this profession in Volume II, Tab 6.)
Scope of practice The practice of naturopathy is the prevention and treatment of disease, disorder or condition of an individual through the use of education and natural therapies or therapeutics to support and stimulate inherent self-healing processes. Reserved acts 1. Making a diagnosis using naturopathic methods. 2. Performing the following physically invasive or physically manipulative acts: (a) procedures below the dermis but only for the following purposes:
(c) moving the joints of the thoracic or lumbar spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust; (d) administering a substance, other than a drug, by injection or inhalation; (e) putting an instrument, hand or finger(s) ii. beyond the point in the nasal passages where they normally narrow, iv.beyond the opening of the urethra, v. beyond the labia majora, or v1 beyond the anal verge. Reserved titles
Other recommendations
(See the discussion for this profession in Volume II, Tab 7.) Scope of practice The practice of nursing by licensed practical nurses is the provision of health care for the promotion, maintenance and restoration of health; and the prevention, treatment and palliation of illness and injury, including assessment of health status and implementation of interventions. Reserved acts 2(e) For the purpose of assessing an individual or assisting an individual with activities of daily living, performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s)
i. into the external ear canal, including applying pressurized air or water, for the purpose of cleaning patients’ external ear canal, taking their tympanic temperature and using an otoscope to examine cerumen build up; Reserved acts to be performed only if the act is ordered by a health professional who is authorized by legislation to perform the act 2. Performing the following physically invasive or physically manipulative acts:
(d) administering a substance, other than a drug, by subcutaneous injection, inhalation, irrigation or instillation; (e) putting an instrument, hand or finger(s)
i. into the external ear canal, but excluding cerumen management; iv. beyond the opening of the urethra; v. beyond the labia majora, but excluding the insertion of intrauterine devices; vi. beyond the anal verge; or vii. into an artificial opening into the body. 5(a) Administering orally or by subcutaneous injection a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. Reserved titles
(See the discussion for this profession in Volume II, Tab 8.) Scope of practice The practice of nursing by registered nurses is the provision of health care for the promotion, maintenance and restoration of health; the prevention, treatment and palliation of illness and injury, primarily by assessment of health status, planning and implementation of interventions; and co-ordination of health services. Reserved acts
1. Performing a nursing diagnosis by making a clinical judgment of the patient’s mental and physical condition that can be ameliorated or resolved by appropriate interventions of the nurse or nursing team to achieve outcomes for which the nurse is accountable. 2(a)(i) For the purpose of wound care, performing the following physically invasive or physically manipulative act of procedures on tissue below the dermis or below the surface of the mucous membrane:
2(a)(ii) For the purpose of establishing peripheral intravenous access and maintaining patency using a solution of normal saline (0.9 per cent), performing the physically invasive or physically manipulative act of venipuncture. 2(e) For the purpose of assessing an individual or assisting an individual with activities of daily living, performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s)
5(a) Administering or compounding a drug listed in Schedule II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. For the purposes of this reserved act, "compounding" means mixing ingredients, at least one of which is a drug listed in Schedule II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. Reserved acts to be performed only if the act is ordered by a health professional who is authorized by legislation to perform the act 2(a) For purposes other than wound care, performing the physically invasive or physically manipulative act of procedures on tissue below the dermis, below the surface of a mucous membrane, and in or below the surface of the cornea. 2(d) Performing the physically invasive act of administering a substance, other than a drug, by injection or inhalation, except as provided in reserved act 2(a)(ii). 2(e) For the purpose of treatment, performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s)
4. Applying a hazardous form of energy, including diagnostic ultrasound and X-ray. 5(a) Administering or compounding by any means a drug listed in Schedule I of the Pharmacists, Pharmacy Operations and Drug Scheduling Act.
For the purposes of this reserved act, "compounding" means mixing ingredients, at least one of which is a drug listed in Schedule I of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. 5(b) Designing, compounding or dispensing therapeutic diets where nutrition is administered through enteral or parenteral means. For the purposes of this reserved act, the following definitions shall apply: "designing": the selection of appropriate ingredients for enteral or parenteral nutrition. "compounding": mixing ingredients for enteral or parenteral nutrition. "dispensing": filling a prescription for enteral or parenteral nutrition. 7. Allergy challenge testing or allergy desensitizing treatment involving injection, scratch tests or inhalation, and allergy challenge testing by any means with respect to a patient who has had a previous anaphylactic reaction. Reserved titles
Other recommendations
(See the discussion for this profession in Volume II, Tab 9.) Scope of practice The practice of nursing by registered psychiatric nurses is the provision of health care for the promotion, maintenance, restoration and palliation, primarily of mental and emotional health and associated physical conditions by assessment of mental and physical health, planning and implementation of interventions and co-ordination of health services. Reserved acts 1. Performing a nursing diagnosis by making a clinical judgment of the patient’s mental and physical condition that can be ameliorated or resolved by appropriate interventions of the nurse or nursing team to achieve outcomes for which the nurse is accountable. 2(a)(i) For the purpose of wound care, performing the following physically invasive or physically manipulative act of procedures on tissue below the dermis or below the surface of the mucous membrane:
2(a)(ii) For the purpose of establishing peripheral intravenous access and maintaining patency using a solution of normal saline (0.9 per cent), performing the physically invasive or physically manipulative act of venipuncture. 2(e) For the purpose of assessing an individual or assisting an individual with activities of daily living, performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s)
5(a) Administering or compounding a drug listed in Schedule II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. For the purposes of this reserved act, "compounding" means mixing ingredients, at least one of which is a drug listed in Schedule II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. Reserved acts to be performed only if the act is ordered by a health professional who is authorized by legislation to perform the act 2(a) For purposes other than wound care, performing the physically invasive or physically manipulative act of procedures on tissue below the dermis, below the surface of a mucous membrane and in or below the surface of the cornea. 2(d) Performing the physically invasive act of administering a substance, other than a drug, by injection or inhalation, except as provided in reserved act 2(a)(ii). 2(e) For the purpose of treatment, performing the physically invasive or physically manipulative act of putting an instrument, hand or finger(s)
4. Applying a hazardous form of energy, including diagnostic ultrasound and X-ray. 5(a) Administering or compounding by any means a drug listed in Schedule I of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. For the purposes of this reserved act, "compounding" means mixing ingredients, at least one of which is a drug listed in Schedule I of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. 5(b) Designing, compounding or dispensing therapeutic diets where nutrition is administered through enteral or parenteral means. For the purposes of this reserved act, the following definitions shall apply: "designing": the selection of appropriate ingredients for enteral or parenteral nutrition. "compounding": mixing ingredients for enteral or parenteral nutrition. "dispensing": filling a prescription for enteral or parenteral nutrition. Reserved titles
(See the discussion for this profession in Volume II, Tab 10.) Scope of practice The practice of optometry is the assessment of the eye and vision system through the use of diagnostic drugs and instruments and devices, such as test lenses, test cards and trial lenses; and the treatment and prevention of disorders of refraction, sensory and ocular motor disorders, and diseases and disorders of the eye and structures directly related to the vision system through the prescription and dispensing of ophthalmic devices and therapeutic pharmaceutical agents prescribed by regulation. Reserved acts 1. Making a diagnosis of a disorder of refraction, a sensory and ocular motor disorder, disease or dysfunction of the eye and structures directly related to the vision system as the cause of signs or symptoms of the individual. 2(a) Performing the physically invasive or physically manipulative act of procedures on tissue in or below the surface of the cornea for the purpose of removing superficial foreign bodies from the eye. 5(a) Prescribing, dispensing or administering a drug prescribed by regulation. For the purposes of this reserved act, the following definition shall apply: "prescribing": the ordering of a drug. "dispensing": preparing or filling a prescription for drugs. The Health Professions Council recommends that the regulation through which optometrists are granted the use of therapeutic pharmaceutical agents must contain at a minimum the following elements:
6. Prescribing appliances or devices for vision conditions and fitting contact lenses. Reserved titles
Other recommendations
(See the discussion for this profession in Volume II, Tab 11.) Scope of practice The practice of pharmacy is the compounding, dispensing and sale of drugs; monitoring drug therapy and advising on therapeutic values, contents and hazards of drugs and devices; and identification, assessment and recommendations to prevent or resolve drug related problems. Reserved act 5(a) Compounding or dispensing a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act or as prescribed by regulation. For the purposes of this reserved act, the following definitions shall apply: "compounding": mixing ingredients, at least one of which is a drug. "dispensing": preparing or filling a prescription for drugs. Reserved titles
(See the discussion for this profession in Volume II, Tab 12.) Scope of practice The practice of physical therapy is the assessment and treatment of neuromusculoskeletal and cardiorespiratory systems of the body by physical or mechanical means for the purpose of maintenance or restoration of function that has been impaired by injury or disease, for pain management and for the promotion of mobility and health. Reserved acts 1. Making a physical therapy diagnosis by determining the cause of subjective symptoms and objective signs relating to movement dysfunction and functional limitations. 2. Performing the following physically invasive or physically manipulative acts:
(a) inserting needles below the dermis for the purpose of pain management and normalization of physiological functioning of the neuromusculoskeletal system; 4. Applying a hazardous form of energy: laser, electricity, therapeutic ultrasound, or as prescribed by regulation. 5(a)(i) Administering on prescription, by inhalation or instillation, a mucolytic agent, bronchodilator or analgesic solution listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. 5(a)(ii) Administering on prescription, by iontophoresis or phonophoresis, a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act. Reserved titles
(See the discussion for this profession in Volume II, Tab 13.) Scope of practice The practice of medicine is the assessment of the physical or mental condition of an individual or group of individuals at any stage of the biological life cycle; the prevention and treatment of physical and mental disease, disorder and condition; and the promotion of good health. Reserved acts
Reserved titles
Other recommendations
(See the discussion for this profession in Volume II, Tab 14.) Scope of practice The practice of podiatry is the prevention, treatment and palliation of disease, disorder or dysfunction of the foot, and includes the bones, muscles, tendons, ligaments or other soft tissue of the foot and lower leg which impact on or affect the foot or foot function. Reserved acts 1. Making a diagnosis identifying a disease, disorder or condition of the foot or lower leg as the cause of signs or symptoms of the individual. 2. Performing the following physically invasive or physically manipulative acts:
(a) procedures on tissue below the dermis of the foot and lower leg, including bony tissue and muscle, tendon, ligament or other soft tissue; 4. Ordering the application of a hazardous form of energy: X-ray, diagnostic ultrasound, MRI, CT scanning; applying a hazardous form of energy: laser. 5(a) Prescribing, compounding, dispensing or administering by any means a drug listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act or as prescribed by regulation. For the purposes of this reserved act, the following definitions shall apply: "prescribing": the ordering of a drug. "compounding": mixing ingredients, at least one of which is a drug.
"dispensing": preparing or filling a prescription for drugs.
7. Allergy challenge testing involving injection, scratch tests or inhalation, and allergy challenge testing by any means with respect to a patient who has had a previous anaphylactic reaction. Reserved titles
Other recommendations
(See the discussion for this profession in Volume II, Tab 15.) Scope of practice The practice of psychology is the treatment and prevention of mental and psychological disorders, dysfunctions and conditions; and the assessment, treatment and enhancement of behavioural, emotional and interpersonal functioning by the application and use of psychometric testing, psychological assessment, psychotherapy and the treatment and management of clinical and non-clinical conditions. Reserved act 1. Making a diagnosis, identifying a mental or psychological disorder, dysfunction or condition as the cause of signs or symptoms of the individual. Reserved titles
Other recommendation Use of the title "Psychologist" by persons who are not members of the College of Psychologists of B.C. is misleading to the public, and the Health Professions Council recommends that there be no exemptions from the title protection provisions of the recommendation on reserved titles.
IV. THE SCOPE OF PRACTICE REVIEW PROCESS
A. INTRODUCTION The Health Professions Council is a six-person advisory body appointed by the Government of British Columbia under the Health Professions Act (HPA), to make recommendations to the Minister of Health and Minister Responsible for Seniors about the regulation of health professions. The current members are:
None of these individuals is a health professional. The Council conducts its business in panels of three. This report is the result of the Council's review of the scope of practice of 15 recognized health professions pursuant to the Terms of Reference from the Minister of Health and Minister Responsible for Seniors. The primary purpose of the review was to make recommendations regarding redesign of the regulatory system for health professions in British Columbia. Under the traditional exclusive model, the various health professions were granted an exclusive right to practice within a legislatively defined scope of practice. No one, other than a member in good standing of that profession, can perform acts within the profession's scope of practice unless they are granted an exemption. The Terms of Reference contemplate a new system aimed at reducing exclusivity and increasing choices for the public. The new system is based on broad, non-exclusive scopes of practice and narrowly defined reserved acts. The Terms of Reference, which are included as Appendix A to this report, indicate that there are four main elements to the scope of practice review:
A regulatory framework of overlapping scopes of practice and narrowly defined reserved acts creates a system which offers greater choice and accessibility to health care services and at lower costs. It also imputes a greater responsibility to individuals to inform themselves about the choices available and the implications of those choices, and reduces the paternalism of government and the professions themselves.
2. The Process for the Scope of Practice Review Initially, the Council met with representatives of all of the professions subject to the review. This meeting gave the professions an understanding of the Council’s review process. The meeting also enabled the Council to seek the professions’ views regarding their current scope of practice and discuss how it should be revised to reflect the Criteria and Guidelines (Schedule A) of the Terms of Reference. After the initial meetings, the Council invited the regulatory bodies and professional associations of the health professions under review to submit written briefs outlining their positions on the four elements of the scope of practice review as they relate to their individual professions. The Council then sent out written consultation letters to all the regulatory bodies and professional associations, as well as professional associations of unregulated health professions, national associations of health professions in Canada and the United States, organizations representing employers and employees,consumer organizations, educational institutions, and departments of health in other provinces. The consultation letters asked the professions under review and the other respondents to comment on the position of the health professions as outlined in their written briefs. Between January 1998 and April 2000, the Council issued the preliminary reports on the scope of practice review of the 15 self-regulated health professions. The preliminary reports aimed to present the initial findings by the Council in response to the consultation process. The preliminary reports also sought to give an overview of possible issues to be raised at the public hearings which was the next step in the review process. Between June 1999 and June 2000, the Council conducted the public hearings for each health profession under review, except for emergency medical assistants for which a hearing was not required. The public hearings were designed to provide a general discussion amongst interested parties and the Council on the scopes of practice of the health professions under review. Afterwards, the Council carefully considered the issues raised at the public hearings. This entailed a re-examination of all stages of the scope of practice review process – from the initial written briefs by the health professions to the post-public hearing submissions.
B. HEALTH PROFESSIONS POLICY The early impetus for the Council’s scope of practice review was the Report of the British Columbia Royal Commission on Health Care and Costs (Seaton Commission). The Seaton Commission stated that the existing legislation governing the health professions creates persistent jurisdictional disputes and a distinct lack of co-operation among the health professions, despite the fact that all health professional colleges have the same mandate - to protect the public from preventable harm. The Seaton Commission found that the primary reason for the jurisdictional disputes was the present regulatory system's reliance on exclusive scopes of practice. Under this exclusive scope of practice system, the various health professions have been granted an exclusive right to practice within a legislatively defined scope of practice. No one, other than a member in good standing of that profession, can perform acts within the profession's scope of practice unless they are granted an exemption. The Commission concluded:
...exclusive scopes of practice should be narrowed to focus on preventing harm, as has been initiated recently in Ontario. We believe that more appropriate, cost-effective and timely health care could be provided to more patients if B. C. were to follow the Ontario initiative. The Ontario system of "controlled acts" was implemented through the Regulated Health Professions Act, SO 1991, Ch. 18, and contains the same key elements - scope of practice statements, reserved acts and reserved titles - described in the Council’s Terms of Reference. Alberta has adopted a similar regulatory model, and Quebec has undertaken a similar process. The Seaton Commission’s recommendation echoes comments made in an earlier report, Public Regulation of the Professions in Health Security for British Columbians, Special Report: Consumer Participation, Regulation of the Professions, and Decentralization, 1974, (Foulkes Report). In Chapter 3 of Volume 3, Professor J.T. McLeod dealt with public regulation of professions. Professor McLeod stated that professional interests are often in conflict with the interests of society, and cites as a growing public concern the conflict between professional regulatory bodies and the public:
[A] serious area of conflict between professional interest and the public interest appears to exist in the matter of relations between various disciplines and professions in the matter of legislative definitions of scope of practice. This is an area in which the law is at fault, but for various reasons scope of practice legislation is often unduly narrow and restrictive, preventing the addition or substitution of various mixes of skills for the services of the professional practitioner. Thus, the trend in regulatory policy for the health professions has been towards reducing exclusivity in order to enhance interdisciplinary practice, improve accessibility for population groups to health care services and increase consumer choice, while at the same time maintaining the fundamental objective of protecting the public. Government has the responsibility to ensure that those services which are accessible are safe and that the regulatory framework for the practice of health professions protects the public from incompetent, impaired or unethical practitioners. At the same time, the regulatory framework should not entrench a paternalistic function for professions or reserve exclusive areas of practice simply to enhance professional status and control. These policy trends are clearly reflected in the Terms of Reference for the scope of practice review which provide the basis for a new regulatory framework for health professions in British Columbia. The new system of overlapping scopes of practice and narrow reserved acts removes barriers to interdisciplinary practice and offers greater choice and accessibility to the public. The public interest is served by professional legislation which promotes quality in the delivery of health care services within safe parameters. Indeed, the Council's primary policy objective in conducting its review is achieving the optimum balance between safe practice and consumer choice.
C. DISCUSSION OF ISSUES The main issues raised by this review are the following four elements: scope of practice, reserved acts, supervised acts and reserved titles. 1. Scope of Practice The scope of practice statement describes what the profession does, the methods it uses, and the purpose for which it does it. Unlike the present legislative scheme, the statement itself does not grant an exclusive scope of practice. Nonetheless, the statement is important because: it defines the area of practice for which the governing body must establish registration requirements and standards of practice; it defines the parameters of the profession for members of the profession, employers, courts and educators; and it informs the public about the services practitioners are qualified to perform. The Council believes that it is not necessary or useful to itemize every facet of a profession's scope of practice. Rather, a scope of practice definition should be sufficiently descriptive so that other health professions and members of the public alike can understand what the particular health professional does. Reserved acts are an important element of the new scope of practice model reflected in the Terms of Reference. The rationale underlying the granting of reserved acts is to protect the public by limiting provision of those particularly dangerous acts to members of specific professions who are qualified to perform them.
It is important to understand the significance of an act being reserved in the provision of health care services. Once an act is reserved in the provision of health care services, it may only be performed by members of a regulated health profession who are authorized to perform that act under their professional legislation. In contrast, if an act is not reserved, it may be performed by regulated or unregulated practitioners.
a) The Shared Scope of Practice Model Working Paper Early in the review process, the Council decided to clarify the concept of reserved acts. To that end, the Council undertook a consultation process in order to formulate a specific list of reserved acts to guide the Council and all participants in the process. The Council’s primary concern in developing the list was whether a particular task or service presented such a significant risk of harm that it ought to be reserved to (a) particular profession(s). The Council established some basic principles to guide it in its assessment of what is a significant risk of harm. The Council was assisted, in part, by the 1994 report of the Manitoba Law Reform Commission, Regulating Professions and Occupations. That report indicated that regulation should not be imposed unless the threat of harm to the public is serious. The report stated that three factors should be evaluated in considering the seriousness of a threatened harm:
The Council recognized that it was not always easy to determine the point at which a risk of harm associated with an act becomes serious enough to justify reserving it, but these three factors serve as guides, not requirements, and were useful in the Council’s deliberations. The Council reviewed the initial scope of practice submissions, the responses to the submissions, various published materials, the regulatory model currently in place in Ontario, and the model being developed in Alberta. The list was developed from the consultation process and was based largely on the Ontario list of 13 "controlled acts." In July 1998, the Council issued the Shared Scope of Practice Model Working Paper (Working Paper) which contained the list of reserved acts. The Working Paper indicated that the list was a working list and changes may be made to the list depending on the information arising during the scope review process, or the Council's ongoing review of applications for designation. Some changes were made, and the final version of the list is set on page 4. The list is phrased more in terms of general descriptions, and professions can expect that, for the most part, particular professions will be granted more specific activities that fall within the general category or description. For example, it may be the case that one profession will be granted the reserved act of prescribing drugs while others may only be granted the reserved act of prescribing particular drugs. Also, some activities may fall within more than one reserved act. For example, administration of an intramuscular injection will fall within both reserved act 2(a): "performing a procedure below the dermis" and reserved act 5: "administering a drug." Once the Working Paper was issued to participants in the process, the Council proceeded with its review of each profession, and decided which act(s) were to be granted to each profession(s). The Council’s conclusions on this issue are set out in the Executive Summary - Professions section of this report. An important issue during the process was the criteria by which reserved acts were granted to individual professions. The Council’s primary consideration was whether a profession was trained and educated to perform a reserved act. An important consideration was whether a profession had already been performing a reserved act pursuant to its scope of practice. The Council also reviewed curricula of educational institutions and literature regarding clinical training programs. The Council recognized in several instances that basic training programs do not always encompass the full range of services provided by practitioners. Rather, the ability to perform reserved acts is developed through post-basic training and education programs. For example, in its review of physical therapy the Council considered the College of Physical Therapists of B.C.’s (CTPBC) request to perform acupuncture, which is not part of the general training of all physical therapists. CPTBC requires satisfactory completion of the three levels of courses offered by the Acupuncture Foundation of Canada Institute (AFCI) or the University of Alberta Programme on Medical Acupuncture. The CPTBC requires the completion of AFCI examinations or the certificate program in Medical Acupuncture of the University of Alberta. In light of this information, the Council was prepared to recommend that physical therapists be entitled to insert needles below the dermis for specific purposes set out in the recommendations on physical therapy. The foregoing discussion also underscores the important fact that not all members of a profession are necessarily competent to perform all of the reserved acts assigned to that profession. The Council’s task is to ensure that the profession generally, and not each individual member of that profession, is trained and educated to perform the reserved act in a safe and effective manner. Thus, an important part of the reserved acts system is that each profession to whom reserved acts are assigned must define the competencies required for the performance by its members of the reserved acts. This principle is reflected in section 16(2)(d) of the HPA which provides that one of the objects of a regulatory body is to establish, monitor and enforce standards of practice. Similarly, section 16(2)(c) states that another objective of a regulatory body is to establish, monitor and enforce standards of education and qualifications for registration of registrants. The importance of the existing functions of a regulatory body was underscored in the Council’s review of medical practitioners. Several respondents questioned the request of the College of Physicians and Surgeons of British Columbia (CPSBC) for a broad scope of practice including all of the reserved acts on the Council’s list. The CPSBC acknowledged that not all physicians necessarily practice all services which fall within the general scope of practice but that:
[T]his general definition does not suggest that all physicians can perform all practices. Only physicians who have demonstrated competence in a particular area or speciality can practice in that speciality. In other words, while physicians are qualified and licensed generally as physicians and surgeons, the actual practice of medicine is limited by the practical and ethical restraints which require that the practice clearly be within the physician's competence. The Council accepted the CPSBC’s submissions and found in the case of medical practitioners that the practical and ethical constraints justified the granting of all the reserved acts. The Council noted that the constraints included the following:
The Council felt that these constraints provided an assurance that medical practitioners practice within their level of competency.
b) Investigation of Reserved Acts As it proceeded through the review, the Council decided that it needed assistance to clarify two of the reserved acts. The relevant reserved acts were:
Reserved act 4: Applying or ordering the application of a hazardous form of energy including diagnostic ultrasound, electricity, magnetic resonance imaging, lithotripsy, laser and X-ray; and The first issue arose with respect to hazardous energy because in its initial list, set out above, the reserved act of ordering or applying hazardous energy was not defined exhaustively. The second issue arose with respect to hazardous substances because the Council received information that the reserved act as defined may not encompass all hazardous substances. In its Working Paper, the Council indicated that this act is not intended to encompass all forms of energy used by health professionals but only those that present a significant risk of harm. The Council also indicated that it would not be setting out a comprehensive list of hazardous energy at the outset but would leave the list non-exhaustive, and develop the list as it proceeded through the process. The Council did, however, give a preliminary indication of the types of hazardous energy that fell within the list, including diagnostic ultrasound, magnetic resonance imaging and x-ray. In the course of its scope review process the Council received information that indicates that there are certain substances used by some health professions, which are not listed in Schedule I or II of the Pharmacists, Pharmacy Operations and Drug Scheduling Act, but are nonetheless hazardous. For example, in its review of naturopathy, the Council received information that this reserved act, as currently worded, may not capture all potentially harmful substances. It appears that several of these potentially harmful substances are used in a variety of natural therapies and there is some overlap among the different traditions of natural medicine in their use of these hazardous substances. The Council believes that the precise identification of these is beyond its current resources and expertise. The Council requested the following:
Instead of convening a task force, the Minister of Health and Minister Responsible for Seniors authorized the Council to retain an expert consultant. The consultant has provided the Council with a report as to the types of energy and substances that should be reserved. The consultant provided the Council with lists of hazardous energy and hazardous substances. However, the assessment of this scientific data merits a more intensive analysis beyond the expertise of the Council. Accordingly, the reserved acts for both hazardous forms of energy and substances are not exhaustive but are subject to the enactment of regulations. The Council emphasizes that the lists are not complete, and therefore, for both hazardous forms of energy and substances, the phrase "or as prescribed by regulation" has been included in the Council’s Reserved Acts List.
c) Reserved Acts on Order Generally, when a reserved act is assigned to a specific profession, members of the profession have the authority both to make the decision that the act is required and to carry out the act. Thus the general concept of reserved acts is that once granted, the profession initiates and performs the act independently. During its review, however, the Council recognized that although a particular profession may be authorized to perform a particular reserved act, its performance may be dependent on being ordered by a member of another profession. A simple example is a pharmacist who may dispense medications, but usually only when a prescription is received from a medical practitioner. This is the concept of an order which recognizes the important distinction between competency to perform a reserved act and competency to initiate a reserved act. The term "order" was considered at length in the Council’s review of registered nursing. There, the Council recommended that registered nurses be granted the right to perform several reserved acts on the order of another health professional who is authorized to perform the reserved act independently. There was widespread criticism of the term "order" which indicated that such a requirement would seriously impair the ability of registered nurses to assist patients in a timely and effective manner. However, the Council did not intend the term to be interpreted as requiring a patient-specific instruction in every case. Rather, the term was meant to encompass the many means by which registered nurses currently perform many services. The Council was presented with several different definitions of the term "order." In commenting on the issue of "orders," the British Columbia Nurses’ Union (BCNU) made a valuable submission regarding terminology:
[T]he BCNU would caution the HPC not to rely on terms or definitions that different parties use in different context. The Council agrees with this submission and will clarify what was meant by the use of the term "order." Virtually all of the submissions dealing with this issue referred to such terms as "clinical practice guidelines", "clinical practice standards", "agency protocols" and "pre-printed orders." For example, the Simon Fraser Health Region, in speaking about various reserved acts, stated, "RNs develop and are guided by clinical practice guidelines and agency protocols for the safe enactment of these competencies." The submission also indicated that these processes are generally created through a collaborative process involving administrators and health care professionals. Simon Fraser Health Region included several examples of such guidelines and protocols with its submission. As a general comment, it stated that regulatory structures must be "flexible" and create the ability to "adapt to the increasing chaos of change." The Council supports the need for flexibility, and indeed its intention with regard to order-initiated reserved acts was intended to ensure first, public safety, and second, that health professionals and administrators would develop the processes themselves to meet the needs of the public. In other words, the Council’s impression was that the present system of guidelines and protocols works well and should be facilitated by its recommendations. The Ontario Standards of Practice for Nurses in the Extended Class contains a useful discussion of the term "medical directive" which serves to clarify further the Council’s intention: What is a "Medical Directive"? First, it is important to understand what the terms "medical directive" and "medical protocol" mean, and how they relate to the terms "order" and "standing order."
The Ontario Standards of Practice for Nurses in the Extended Class also states that the term "standing order" is not supported by either the College of Nurses of Ontario or the College of Physicians and Surgeons of Ontario:
In the past, a "standing order" was implemented for every client, regardless of the circumstances, with no judgment expected by the person implementing the order regarding its appropriateness. It is now recognized that knowledge, skill and judgment are critical, and that no order for treatment, regardless of how routine it may seem, should be automatically implemented. Thus, in Ontario the term order refers to both patient-specific and general orders, but not standing orders. Similarly, the Council intended that the term "order" encompass both. The Ontario Standards of Practice provide further details about orders.
When is a Medical Order Required? The Council’s intention was that an order could apply generally or to a specific patient. The professions involved in the process should develop orders of a general nature which would authorize nurses to proceed to perform the reserved acts assigned to them for certain classification of patients in situations which met the criteria and parameters set forth in the general orders. Specific orders would continue to be used as they are now in those situations where, for example, medical practitioners order specific reserved acts to be performed on specific patients. A number of submissions acknowledge that this does not represent a marked departure from the current practice and that such protocols or orders are in fact generally in place. The Council expects the professions themselves, together with others involved in the process such as hospital administrators, to work together to determine the best way to implement the initiation of reserved acts where the interest of the patients require the acts to be done by registered nurses who have the competence to perform them.
3. Supervised Acts The Criteria and Guidelines which are attached to the Terms of Reference state that although reserved acts may only be performed by certain professions, it may be appropriate for other persons to perform them, or aspects of them, under the supervision of members of those professions. The Criteria and Guidelines also indicate that where the Council is satisfied that a reserved act may be performed under supervision, it may recommend training and qualification requirements, limitations regarding where the act may be performed and the degree of supervision which should be exercised. The Council believes that some clarification of terms would be useful as the Terms of Reference do not define "supervision." In reviewing the responses to the scope of practice submissions, most professions have used the terms "delegation" and "supervision" interchangeably. However, technically, there appears to be a distinction between the terms. In his book A Complete Guide to the Regulated Health Professions Act (Canada Law Book, 1995), Richard Steinecke discusses the meaning of these terms. "Delegation" is where the delegating professional makes a determination that an individual is competent to perform a task and that individual then carries out the task without the delegating professional being present. "Supervision," on the other hand, implies a more intense control over the act than does "delegation" and will usually require the supervisor's physical presence. In the Council's view, although this Term of Reference refers to "supervised" acts, it is intended to encompass any situation where someone other than the person to whom the reserved act has been granted performs that act. In other words, this Term of Reference refers to both delegation and supervision. It implies that the Council will, for each reserved act granted to each profession, determine the circumstances in which the act may be performed by someone other than a member of that profession. Arguments were presented that legislation is a blunt instrument. Other submissions stated that the issue of delegation and supervision is a question of individual competence and the circumstances of each case, and that supervision of certain acts can be addressed only after a careful review of all the circumstances surrounding a particular act and by imposing, where necessary, clear guidelines, restrictions or conditions on such supervision. The College of Physicians and Surgeons of British Columbia (CPSBC) submits that compiling a list of acts which may be delegated or performed under supervision would not adequately address the complexities of medical situations which present to physicians, nor would it protect the public. CPSBC notes that there will be situations where, because of the individuals involved, the site or location, or the specific nature of the presenting problem, it may not be appropriate to delegate an act which might otherwise be capable of delegation. The Council accepts much of these submissions and believes that it would be better to take a general approach to the issue of supervision. The general thrust of the approach is that the decision as to whether an act can be performed under supervision should be left up to the health professions, and that a set of principles embodying the duties of the delegating professional and his or her regulatory college be established and enacted into legislation when the shared scope of practice model takes effect. The principles are derived largely from the Canadian Medical Association's Guidelines for Delegation of a medical act.
There are ethical and legal issues involved in assigning reserved acts which will have to be addressed by all parties. The Council wishes to emphasize that its proposal is not intended to apply on a case-by-case basis. The requirement for approval of the governing body is meant to apply generally and not to individual cases, and would be satisfied by, for example, a general protocol in respect of delegation of reserved acts. The Council believes this general approach to supervised acts more accurately reflects the reality that procedures to be delegated vary from profession to profession and may include subsets and variations of reserved acts and, further, may be performed under a myriad of circumstances and conditions. Finally, the Council emphasizes that the issue of supervised or delegated acts arises only with respect to reserved acts. Thus, the general provision regarding supervision will not apply in respect of acts which are not reserved. Reserved titles are titles reserved exclusively to a health profession. Reserved titles afford a means for consumers to identify the different types of health care providers, to distinguish the qualified from the unqualified, and to differentiate those practitioners who are regulated from those who are not. Titles must adequately serve the public in describing the practitioner and the services being provided and must distinguish the practitioner from others performing services outside the jurisdiction of the college. The Seaton Commission explained that while it may not be in the public interest to maintain exclusive scopes of practice, it may be appropriate to grant an exclusive (reserved) title to a health profession so the public will know that the professional with whom they are dealing is regulated by a college and is therefore qualified and subject to disciplinary processes for incompetent, impaired or unethical practice. a. The Society Act In the course of its review, the Council determined that currently any body that applies for registration under the Society Act, RSBC 1996, c. 433, including several health profession associations, can reserve titles under s.9(1) of the Society Act. The Council believes that the title protection system under the Society Act could be confusing or misleading to members of the public who may conclude, on the basis of the exclusive use of title conferred under the Society Act, that a member of a registered society or association is subject to regulation which does not, in fact, exist. Unlike the Council's review of an application for designation under the HPA, the Registrar under the Society Act does not conduct a detailed public interest analysis of the society, its membership or the services it provides with a view to regulation of the members of the applicant society. In addition, there is no general restriction on a health care worker using a title which includes the words "registered," "licensed" or "certified" even though he or she has not been granted a title under either the Society Act or the HPA. During the scope of practice review, a number of professions suggested the inclusion of the term "registered" in their title, but the practice of the Council has been to avoid use of the term "registered" and to reserve the descriptive term alone, such as "dietitian," for exclusive use of members of the college. The use of the term "registered" is unnecessary; however, there are exceptions, which have been discussed in specific instances, for example, "registered nurse." Generally, the title protection regime under the Society Act can be misleading to the public. In the Council's view, such unregulated use of these terms is not in the public interest as it may imply government sanction. In its 1991 Report: Closer to Home, the Royal Commission on Health Care and Costs recommended that:
7. a. the Society Act be amended so that the Health Professions Council must approve an occupational title or abbreviation before the Registrar grants protection of it;
b. all health profession titles previously granted protection under the Society Act that have not been approved by the Health Professions Council be revoked two years after the passing of the revised Health Professions Act; and
c. the Health Professions Act be amended to prohibit the use of words like "registered," "licensed" or "certified" by any health care worker unless that use has been approved by the Health Professions Council. The Council adopts and supports these conclusions and recommends their implementation.
b) Christian Science Nursing Although the title "Christian Science Nurse" appears in the current Nurses (Registered) Act, the Council received no comments or submissions on this title from Christian s Science nursing groups, nor did the three nursing groups reviewed by the Council request this title. Therefore, the Council did not recommend that it be reserved. In the course of its investigations, research and consultations, certain issues not explicitly included in the Terms of Reference were considered by the Council, including the following: a) Review of the Council’s Reserved Acts List The Council received many submissions requesting that a system be established to deal with revisions to the Reserved Acts List. Through such a system, the Reserved Acts List could be modified to include new technologies and treatment modalities. Further, the system could address requests for an expanded scope of practice when, by reason of advanced training, professions develop competencies and qualifications to perform reserved acts which were not previously assigned to them. It is important that the regulatory system be flexible enough to recognize changes in technology and treatment methods, and to provide for the expansion of a profession’s scope of practice, if necessary.
b) Access to Laboratory and Other Diagnostic Facilities The Terms of Reference indicate that barriers to practice should be eliminated wherever it is possible to do so without increasing the risk of harm to the public. So long as a person is practising within the assigned scope of practice they ought to have access to whatever additional services, as may be reasonably necessary or helpful, are available, and legislative barriers as well as barriers erected by other professions should be prohibited. A recurring issue in the scope of practice review was access to diagnostic facilities such as laboratories and imaging and scanning facilities. In the Council’s review it concluded that several health professionals, such as chiropractors and naturopathic physicians, ought to have access to certain diagnostic tests. However, the Council was advised that the College of Physicians and Surgeons of British Columbia (CPSBC) controls access to such facilities through the Medical Practitioners Act and Rules (the MPA). CPSBC has determined that anyone ordering a test is practising medicine, thereby excluding many health professionals from access to laboratories. The barrier created by the MPA effectively prevents chiropractors and naturopathic physicians from practising within their scope.
c) Review of Reserved Acts Granted Prior to the Scope of Practice Review The Council’s Reserved Acts List was developed from 1998 onwards in conjunction with the scope of practice review. A number of health professions were designated as health professions through regulation, and assigned reserved acts prior to the development of the Reserved Acts List.
d) Delegation Protocol – Delegation to Unregulated Individuals During its review of the nursing professions, the Council heard many submissions about the practice of delegation of reserved acts to unregulated individuals. The Health Employers Association of British Columbia (HEABC) indicated that in many workplaces, such as residential and long term care facilities, health care workers perform tasks and services normally performed by members of regulated health professions. One example is dispensing of medications. The HEABC was concerned that the new regulatory system would prevent the practice of delegating tasks to unregulated individuals whom they regarded as highly trained and educated but unregulated. HEABC submitted that, with resource shortages, this process must continue for these facilities to meet the growing demand for these services. Currently, section 14 of the HPA provides that it is not a violation of the HPA to practice a profession, discipline or other occupation in accordance with another act. This would appear to allow the practice of delegation to unregulated health care workers as long as it is done through the process provided by the relevant legislation. Nonetheless, after reviewing that legislation, the Council is concerned that the legislation referred to above does not contain the necessary safeguards, such as supervision and training, which ought to be in place.
e) Other Elements of the Reserved Acts System The Terms of Reference set out the main elements of a reserved acts model. As described in the Criteria and Guidelines, the model is based on the controlled acts model of regulation in Ontario. There are other elements of a reserved acts system which are essential to the proper functioning of the new regulatory model. These include: (ii) Risk of Harm Clause Inasmuch as the reserved acts system permits unregulated provision of health services other than reserved acts, it is essential that a general risk of harm clause be enacted to ensure accountability for the performance of health services by unregulated providers. This was considered essential by many of the parties responding. The Ontario model was frequently cited as an approved precedent. In Ontario, the harm clause prohibits any unregulated person from treating or advising a person with respect to his or her health in circumstances where it is reasonably foreseeable that serious physical harm may result from the treatment or advice. As Linda Bohnen states in her book, Regulated Health Professions Act, A Critical Guide, the "essence of the harm clause is that the practitioner should not have ventured on the treatment at all."
(ii) Exemptions from the Reserved Acts System In a reserved act system, only persons specifically authorized by legislation may perform reserved acts. All others are prohibited from doing so. Similar regulatory models recognize the need for exceptions to the general prohibition. Under the HPA, for example, section 14(b) provides an exception for "providing or giving first aid or temporary assistance to another person in case of emergency .…" Similarly, the Ontario exceptions include providing emergency assistance, students acting under the supervision of a health professional, treating a person by prayer or spiritual means, treating a member of one’s own household and assisting a person with "routine activities of living." The Ontario system also exempts certain services which might otherwise constitute reserved acts, such as ear piercing and ritual circumcision of boys.
f) Release of Prescriptions The Council has considered the issue of issuing prescriptions to patients for dispensing by another health professional. Examples are prescriptions for eyeglasses and contact lenses and prescriptions for dental appliances. To the extent restrictions on issuing or releasing such prescriptions represent a barrier to interdisciplinary practice, the Council recommends that they be prohibited.
D. A FINAL WORD Despite the countless hours that have been devoted to the production of this report, both by the members and staff of the Council and the dedicated members of the various health professions, not only in British Columbia but also in other parts of Canada and the United States, it is but the first step in what promises to be an exciting development of the regulatory system. Ontario is already seen throughout the continent as the innovator of a new and effective system that can serve as a model for others. The Council has liberally borrowed from Ontario, and during its review the comparable body in that province, the Health Professions Regulatory Advisory Council, has frequently called upon the Council’s experience in this field. We see this interaction as a much needed development, particularly with implications arising from requirements for portability and uniformity in the regulatory process. The Council trusts that those who now take up the task will be able to build upon the framework the Council has established. Of one thing the Council can assure them: the professions themselves are by and large governed by dedicated and objective members who take seriously their primary function of ensuring their professions are governed in the public interest. The Council has attempted to balance the objectives of this review process: to enhance the choices available to the public in determining its health care needs while ensuring that the choices are within safe parameters. It is in addressing the different points of view as to how these competing interests can best be satisfied that the challenge arises. The foundation is here, the structure now awaits fulfillment.
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