HEALTH PROFESSIONS COUNCIL
RECOMMENDATION ON THE
DESIGNATION OF PROSTHETICS AND ORTHOTICS



Armine Kazanjian, Chair
Dianne Tingey, Member
Frank Neads, Member

Application by the Prosthetics and Orthotics
Association of British Columbia

February 3, 1997

FOREWORD

This report is in response to an application by the Prosthetics and Orthotics Association of British Columbia for designation under the Health Professions Act (R.S.B.C. 1979, c. 162.7). Under this Act, the Health Professions Council is a nine person advisory body appointed by the Government of British Columbia to make recommendations to the Minister of Health and Minister Responsible for Seniors about the regulation of health professions. This report is the result of an investigation of the profession of prosthetics and orthotics by a three member panel of the Health Professions Council.

CONTENTS

EXECUTIVE SUMMARY

I. APPLICATION AND PROCESS OF INVESTIGATION

II. STATEMENT OF ISSUES

III. RECOMMENDATIONS

IV. RATIONALE FOR RECOMMENDATIONS

A.DESIGNATION AS A HEALTH PROFESSION

1. Definition

2. Public Interest Criteria

a. Risk of Harm

b. Discretionary Criteria

B. POSSIBLE ALTERNATIVE WAYS OF REGULATING PROSTHETICS AND ORTHOTICS

APPENDIX A: List of Parties Consulted

APPENDIX B: Summary of Submissions Received

EXECUTIVE SUMMARY

The Prosthetics and Orthotics Association of British Columbia submitted an application to the Health Professions Council for designation as a health profession under the Health Professions Act (the Act).

During its investigation of the application, the Council determined that the applicant group fell within the definition of a health profession in section 1 of the Act. However, after carefully considering the public interest criteria set out in section 5 of the Health Professions Regulation under the Act (the Regulation) the Council concluded that designation of the profession under the Act would not be in the public interest.

The primary reason for the Council's decision is that a self-regulatory college established under the Act for the practice of prosthetics and orthotics would be incapable of carrying out the duties imposed by the Act. The Act requires that a professional college establish various boards and committees to govern the profession, all of which entail a financial and administrative burden. The Council does not believe that the applicant has the necessary resources to properly carry out the functions required of a college under the Act.

Accordingly, the Council recommends that prosthetics and orthotics not be designated as a health profession under the Act.

However the Council believes that there is some risk of harm associated with the practice of the profession, and that some form of regulation may be appropriate. Therefore, the Council briefly examined alternative forms of regulation including the possibility of a centralized approach to regulating some of the professions with small numbers of practitioners. The Council recommends that prosthetics and orthotics be evaluated for inclusion in any alternative regulatory model which may be developed in the future.



I. APPLICATION AND PROCESS OF INVESTIGATION

The Health Professions Council received an application from the Prosthetics and Orthotics Association of British Columbia for designation under the Act.

The Association has represented prosthetists and orthotists since 1978, and has been incorporated as a society under the Society Act since 1981. According to the latest information received from the applicant, approximately 42 persons practice this profession in British Columbia, and the Association estimates that it represents 28 of them.

The practice of prosthetics and orthotics is not currently regulated in British Columbia. Indeed it appears that there is very little government regulation of the practice anywhere in Canada, and in provinces where regulation exists, the type of governance varies widely. In Ontario, the Health Professions Legislative Review declined to designate the practice under the Regulated Health Professions Act as it felt there were too few (116) practitioners. In contrast, the Government of Alberta recently recommended that prosthetics and orthotics be designated under Alberta's Health Professions Act. In Quebec, the government recommended that the Corporation professionnelle des technologues professionels assume the regulation of prosthetists and orthotists.

There is however a national certifying body, the Canadian Board for Certification of Prosthetists and Orthotists, which is responsible for entrance qualifications and standards of practice including a code of ethics.

In its application the Association gave the following reasons for seeking designation:

  • To ensure recognition of educational requirements and standards of practice.

  • To address concerns in preventing non-qualified personnel from using tax-payer dollars without accountability or evaluation of their standards.

  • To protect the public's expectation that they are being treated by an appropriately qualified practitioner.

The Council was satisfied that the applicant met the definition of a "health profession association" in the Act and decided to conduct an investigation pursuant to s.7(3)(c) of the Act. Notice of the investigation was placed in the Gazette.

Associations, related professions and other organizations having knowledge about the practice of prosthetics and orthotics were asked for their opinions about whether designation would be appropriate and also about what would be an appropriate scope of practice for the profession. Other jurisdictions were also contacted for information regarding the regulation of prosthetics and orthotics.

A list of the parties who were consulted is included as Appendix A and a summary of the positions taken by parties who responded is included as Appendix B.

The Council carefully considered the information provided and the submissions received, and determined that it had sufficient information to make a decision regarding the application without a public hearing to clarify the information received.



II. STATEMENT OF ISSUES

During the investigation, the main issues addressed by the Council were:

  1. whether the profession of prosthetics and orthotics falls within the definition of a health profession;

  2. whether the practice of the profession of prosthetics and orthotics may involve a risk of physical, mental or emotional harm to the health, safety or well-being of the public; and

  3. whether the applicant group, once designated, would be capable of carrying out the duties imposed upon a college under the Act.



III. RECOMMENDATIONS

The Health Professions Council recommends to the Minister of Health and Minister Responsible for Seniors that:

  1. the profession of prosthetics and orthotics not be designated under the Act because the applicant group does not possess the necessary financial and administrative resources to regulate the profession in the manner required by the Act.

  2. the profession of prosthetics and orthotics be evaluated for inclusion in any alternative regulatory model which may be developed in the future.



IV. RATIONALE FOR THE RECOMMENDATIONS

A. DESIGNATION AS A HEALTH PROFESSION

Recommendation

Prosthetics and orthotics not be designated as a health profession under the Act.

In order to recommend the designation of prosthetics and orthotics under the Act, the Council must determine that: (1) prosthetics and orthotics falls within the definition of health profession as set out in Section 1 of the Act; and (2) designation is in the public interest pursuant to Section 5 of the Regulation under the Act.



1. Definition

Section 1 of the Act states, in part:

"health profession" means a profession in which a person exercises skill or judgment or provides a service related to

(a) the preservation or improvement of the health of individuals, or

(b) the treatment or care of individuals who are injured, sick, disabled or infirm.

A review of the application indicates that an orthotist provides care to patients with disabling conditions of the limbs and spine by fitting devices known as orthoses while a prosthetist provides care to patients with partial or total absence of a limb by fitting devices known as prostheses. The applicant describes their expertise as orthopaedic bracing and artificial limb bracing, and states that their services have a profound effect on individuals' well being.

In the Council's view, prosthetics and orthotics falls within the definition of "health profession" set out above.



2. Public Interest Criteria

Section 10(1) of the Act sets out the Council's mandate regarding applications for designation:

Where the council receives an application under section 7(1) or a direction under section 8, the council shall determine whether it would be in the public interest to designate a health profession under this Act, having regard to the information obtained in any investigation conducted by the council and in accordance with the prescribed criteria, if any.

The "prescribed criteria" are set out in section 5 of the Health Professions Regulation:

5(1) For the purposes of section 10(1) of the Act, the Council must consider the extent to which the practice of a health profession may involve a risk of physical, mental or emotional harm to the health, safety or well being of the public, having regard to

(a) the services performed by practitioners of the health profession,

(b) the technology, including instruments and materials, used by practitioners,

(c) the invasiveness of the procedure or mode of treatment used by practitioners, and

(d) the degree to which the health profession is

(i) practised under the supervision of another person who is qualified to practise as a member of a different health profession, or

(ii) practised in a currently regulated environment.

(2) The council may also consider the following criteria:

(a) the extent to which the health profession has demonstrated that there is a public interest in ensuring the availability of regulated services provided by the health profession;

(b) the extent to which the services of the health profession provide a recognized and demonstrated benefit to the health, safety or well being of the public;

(c) the extent to which there exists a body of knowledge that forms the basis of the standards of practice of the health profession;

(d) whether members of the profession are awarded a certificate or degree from a recognized post-secondary educational institution;

(e) whether it is important that continuing competence of the practitioner be monitored;

(f) the extent to which there exists within the health profession recognized leadership which has expressed a commitment to regulate the profession in the public interest;

(g) the likelihood that a college established under the Act would be capable of carrying out the duties imposed by the Act, having regard to factors which in the view of the Council may affect the viable operation of the college;

(h) whether designation of the health profession is likely to limit the availability of services contrary to the public interest.

Thus, the criteria fall into two categories: the mandatory determination of risk of harm under section 5(1) and the discretionary criteria listed in section 5(2). The Council proposes to deal with each in turn.



a. Risk of Harm

The risk of harm involved in the practice of a health profession is the most important factor in considering whether to regulate its practitioners. In view of the possible negative effects of regulation under the Act, including the potential for reduced competition and consumer choice and increased cost, the Council believes that a profession should only be designated where the risk of harm is significant, having regard to the factors set out in section 5(1) of the Regulation under the Act.

s.5(1)(a) the services performed by practitioners of the health profession

Prosthetists and orthotists work either in clinics or independently upon referrals from medical doctors or other health professionals. They are involved in analyzing and formulating orthotic or prosthetic treatment plans and executing prescriptions for prosthetic and orthotic appliances, including designing, installing and adjusting the appliances.

As far as the general risk to patients, the applicant states that devices designed to support, correct or replace body parts must be snug, intimate and correct in their fit and alignment. Inappropriate assessment, poor fit, poor choice of materials, and poor follow-up may result in pressure sores with resulting infection or lack of correction or support of the affected body part.

Many of the submissions received also described the potential for harm from the services performed. For example, the Canadian Association of Prosthetists and Orthotists stated:

Devices need to take into consideration sound fitting principles which address the needs of the patient in function and life style. Inappropriate fitting leads to damaged residual limbs, ulceration, aggravation of chronic conditions, or more simply, a degeneration of the patient's condition.

The program head of prosthetics and orthotics at BCIT stated as follows:

In the use of a prosthesis or orthosis, considerable forces are applied to the body, often to areas unused to accepting such forces. Those in need of such appliances are often already experiencing problems with impaired circulation ... or lack of sensation ... Improperly designed or ill-fitting orthoses or prostheses can produce injury; incorrectly aligned devices can force more proximal joints into malalignment.

The BCIT representative also noted the potential for emotional harm:

Mental or emotional harm may be occasioned as well. Those seeking Prosthetics or Orthotics service are often in a difficult period of their lives. New amputees, for example, may still be grieving the loss of a limb. Parents of a child born with a missing body segment or with a neuromuscular disorder are vulnerable to insensitive or improper caregivers.

s.5(1)(b) the technology, including instruments and materials, used by practitioners

In performing their services prosthetists and orthotists use a variety of measuring devices such as rulers, tapes and calipers, and various devices for designing and constructing appliances including powered and non-powered hand tools, casting brims, grinding machinery and computer-assisted design and manufacture hardware and software.

s.5(1)(c) the invasiveness of the procedure or mode of treatment used by practitioners

While it would appear that most of the procedures performed by prosthetists and orthotists are non-invasive, at least some of the procedures are potentially invasive. For example, the applicant states that knives and other cutting instruments are occasionally used in close proximity to the patient's skin and some thermoplastic materials are moulded, while hot, directly to the patient.

s.5(1)(d) the degree to which the health profession is

(i) practised under the supervision of another person who is qualified to practise as a member of a different health profession,

(ii) practised in a currently regulated environment.

In the Council's view, the potential for harm is greater where services are performed in unsupervised and unregulated environments.

At present, prosthetics and orthotics is not regulated by government. However, there is currently a rather comprehensive form of regulation in place within the profession which is administered through the Canadian Board for Certification of Prosthetists and Orthotists (C.B.C.P.O.). This organization was created in 1966 for the purpose of recognizing proficiency in the field of prosthetics and orthotics.

The Board grants certification to applicants who show the necessary educational experience and pass the qualifying examination. In addition, the Board accredits prosthetic and orthotic facilities through inspection and evaluation. Certified members of the Board subscribe to the Board's Code of Ethics which outlines members' responsibilities to physicians, patients and the profession as well as listing various practices which are deemed to constitute unethical practice. People who seek the services of certified members of C.B.C.P.O. are thus assured that certain basic qualification standards have been met. In addition, in the area of prosthetics, the B.C. Pharmacare program will not provide coverage for services provided by practitioners who are not certified.

On the issue of supervision, the applicant states that once a professional is certified by the Board they are autonomous health professionals with sole responsibility for the appropriateness of fit and function of the appliance. The Council notes that prosthetists and orthotists are not completely independent practitioners, however, as they frequently work as part of a team or upon referral from physicians.

In a team, the prosthetist or orthotist practises along with a physician, physiotherapist, occupational therapist and sometimes, a social worker. Each professional contributes towards the needs of the patient with the prosthetist or orthotist having responsibility for design, delivery, patient care and follow up of the prosthesis or orthosis. Although many prostheses are delivered through such a team practice, this is not the case with orthotics where much of the practice is done upon direct referral from a physician.

Most referrals are made by way of prescription, usually through the patient's general physician. The physician is kept abreast of any actions taken and follow up is done in consultation with the referring physician to ensure that the appliance continues to be used correctly and safely. However, the applicant indicates that the degree of physician involvement varies widely, and sometimes there is very little follow up by the physician. This was confirmed by the BCIT representative.

The Council also notes that various forms of orthotic devices are widely available to the public through medical supply stores, sport stores and drug stores. In most such cases, there is very little, if any, physician involvement although it would appear that such devices present little risk of harm.



SECTION 5(1) RISK OF HARM CONCLUSIONS:

The Council believes that there is a potential harm to the public arising from the services provided in the practice of prosthetics and orthotics. In the Council's view, inappropriate assessment, poor fit, poor choice of materials and poor follow up creates the potential for risk of harm. The Council also accepts the fact that recipients of services in this area are frequently in a vulnerable state, both emotionally and physically, and that this contributes to the risk of harm.

The Council believes it important, however, to distinguish between prosthetics and orthotics in terms of the risk of harm. Generally speaking, prosthetics presents a greater risk of harm than orthotics. Although the provision of orthotics can be dangerous, the Council believes that there are many assistive devices that fall within the definition of orthotics but which present little risk of harm. Such devices are frequently available at any drug or department store.

While admittedly difficult to distinguish the safe from the potentially dangerous, in the Council's view, there is very little risk of harm from non-custom made devices, and any regulatory scheme for prosthetics and orthotics should not apply to such products. The Council notes that the applicant has relied on the distinction between custom made and non-custom made devices in its description of proposed reserved acts by restricting its request for exclusivity to "custom made rigid or articulating devices".

The Council is also of the view that the present delivery system for prostheses and orthoses contains certain checks which reduce the risks associated with the practice of the profession. Specifically, the Council believes that the interaction between prosthetists and orthotists and other health professionals, particularly when services are provided in a team environment, provides a significant safeguard against potential problems.

It appears, however, that there is considerable independent practice, some of which is carried on with very little involvement from physicians or other health professionals, particularly in the field of custom made orthotics. In the Council's view, these circumstances present some risk of harm.

In summary, after carefully considering the submissions and the factors set out in sections 5(1)(a) - (d), the Council believes that the practice of prosthetics and orthotics presents a sufficient risk of harm such that some form of regulation is appropriate.



b. Discretionary Criteria

The Council also applied the discretionary criteria in sections 5(2)(a) to (h) of the Regulation under the Act to the practice of Prosthetics and Orthotics.

s.5(2)(a) the extent to which the health profession has demonstrated that there is a public interest in ensuring the availability of regulated services provided by the health profession

This factor requires that the Council consider the extent of public interest in regulating the profession.

Although several of the submissions received support designation of the profession, there is little evidence of public demand for regulation of the practice of prosthetics and orthotics.

s.5(2)(b) the extent to which the services of the health profession provide a recognized and demonstrated benefit to the health, safety or well being of the public

The Council is satisfied that the profession of prosthetics and orthotics clearly satisfies the second criterion in that prosthetists and orthotists provide important treatment and care to patients with disabling conditions of the limbs and spines.

s.5(2)(c) the extent to which there exists a body of knowledge that forms the basis of the standards of practice of the health professions. 5(2)(d) whether members of the profession are awarded a certificate or degree from a recognized post-secondary educational institution

The applicant notes that members are certified by the Canadian Board for Certification of Prosthetists and Orthotists and the requirements include completion of a two year full-time educational program (of which there are three in Canada), a two year minimum supervised internship and successful completion of the national certification exam. Thus, the Council is satisfied that the profession meets criteria 5(2)(c) and (d) in that there exists a body of knowledge that forms the basis of the standards of practice and members of the profession are awarded a certificate or degree from a recognized post-secondary institution.

s.5(2)(e) whether it is important that continuing competence of the practitioner be monitored

The Council believes that like all health professions it is essential that prosthetists and orthotists keep updated on advances in their profession, and the Council notes that C.B.C.P.O. has mandatory continuing education requirements for certified members. The Association has also successfully undertaken numerous educational events.

s.5(2)(f) the extent to which there exists within the health profession recognized leadership which has expressed a commitment to regulate the profession in the public interest

The applicant appeared to the Council to have demonstrated committed leadership of their organization in representing the interests of the profession since 1978. In addition, the Council was impressed with the overall quality of the Association's presentation and its useful contribution to the Council's investigative process.

s.5(2)(g) the likelihood that a college established under the Act would be capable of carrying out the duties imposed by the Act, having regard to factors which in the view of the council may affect the viable operation of the college

The Council had great difficulty with this criterion. According to section 15.1(2) of the Act a college established under the Act has the following objects:

(a) to superintend the practice of the profession;

(b) to govern registrants according to the Act, the regulations and the bylaws of the college;

(c) to establish, monitor and enforce standards of education and qualifications for registration of registrants;

(d) to establish, monitor and enforce standards of practice to enhance the quality of practice and reduce incompetent, impaired or unethical practice amongst registrants;

(e) to establish and maintain a continuing competency program to promote high practice standards amongst registrants;

(f) to establish, for a college designated under section 12(2)(h), a patient relations program to seek to prevent professional misconduct of a sexual nature;

(g) to establish, monitor and enforce standards of professional ethics amongst registrants;

(h) to require registrants to provide to an individual, access to the individual's health care records in appropriate circumstances;

(i) to inform individuals of their rights under this Act, the regulations and the bylaws of the College and the Freedom of Information and Protection of Privacy Act;

(j) to administer the affairs of the College and perform other duties through the exercise of the powers conferred by the Act, the regulations or the bylaws.

A college established under the Act is also required to establish registration, inquiry and discipline committees.

Clearly, carrying out these duties and functions is a taxing responsibility. All of the committees and procedures required for designated health professions entail a financial cost and an administrative burden in terms of demands on its membership for participation on the various committees and boards.

In addition, section 15.1(1) of the Act states that the college must exercise its powers and responsibilities in the public interest. In other words, there should be a clear separation between membership promotion functions and licensing and discipline functions. Clearly, such a separation places additional personnel demands on the professional membership.

The applicant included a financial projection for the first year of the proposed college which shows projected fee revenues of $58,000 and expenses of $44,000. The fee estimate is based on a $1,000 fee for certified members and a $500 fee for technical individuals. The projected fee revenues are also based on the assumption that the proposed college would recruit all 42 certified members and 30 technical staff. In this regard, the applicant notes:

It is possible that many of our members will resist the high registration fees set by the college, as the perceived benefits of belonging to a college will not outweigh the costs. (Given that the Canadian Board for Certification of Prosthetists and Orthotists already sets the educational, professional and ethical standards for our profession.)

From the outset of the Council's activities the declared policy of government has been to recognize designation under the Act as a means of implementing self-governance at little or no cost to the government and only when the resources of the profession in both numbers and funding makes self governance viable.

The Council believes that it is unlikely that a college established under the Act for the practice of prosthetics and orthotics would be capable of carrying out the duties imposed by the Act. In the Council's view, the applicant has neither the financial nor the human resources necessary to carry out the duties and objects of a self-regulatory college.

s.5(2)(h) whether designation of the health profession is likely to limit the availability of services contrary to the public interest

In its application, the applicant proposes that several services be reserved exclusively to members of the proposed college, with some exceptions for services which are also provided by occupational therapists and physical therapists. Several submissions received expressed concern about the reserved acts proposed by the applicant, notably those of the Registered Nurses Association, the Pedorthic Association of Canada and the BC Association of Podiatrists. In addition, the B.C. Medical Association indicates many professional groups, including physicians, give advice on the application and use of appliances and therefore recommends against restricting services in this area of practice. The Council agrees with these submissions, and believes that the proposed reserved acts are rather broadly stated and have the potential to limit availability of services. Thus, to the extent that certain acts were to be reserved to orthotists and prosthetists, designation has the potential to limit services contrary to the public interest.



SECTION 5(2) DISCRETIONARY CRITERIA CONCLUSION:

In summary, after carefully considering the information gathered during the investigation and the public interest criteria in s. 5 of the Regulation, the Council has determined that the profession of prosthetics and orthotics should not be designated as a health profession under the Act. In reaching this conclusion, the Council was particularly influenced by the limited financial and human resources of the applicant which the Council believes make a self regulatory college impractical and unviable. In addition, the Council believes that the current regulatory environment and delivery system for the profession reduces appreciably the risk of harm in the practice of the profession, thus alleviating any immediate need for regulatory intervention.

The Council wishes to emphasize that its conclusion should not in any way be construed as a slight to the dedication and professionalism of prosthetists and orthotists. On the contrary, the Council was very impressed with the quality of the applicant's presentation. The Council's major focus is on whether the profession should be designated under the Act, and after considering the public interest criteria, the Council believes that a self regulatory college is not an appropriate way to regulate prosthetics and orthotics.

B. POSSIBLE ALTERNATIVE WAYS OF REGULATING PROSTHETICS AND ORTHOTICS

Recommendation

The profession of prosthetics and orthotics be evaluated for inclusion in any alternative regulatory model which may be developed in the future.

In considering the risk of harm associated with the practice of prosthetics and orthotics the Council determined that the practice of prosthetics and orthotics presents a sufficient risk of harm such that some form of regulation is necessary. However the Council also determined that the current regulatory environment and delivery system for the profession reduces appreciably the risk of harm in the practice of the profession thus alleviating any immediate need for regulatory intervention.

It has become increasingly clear to the Council that designation under the Act may not be the appropriate instrument for regulation of a health profession even when the risk of harm is such that some form of regulation may be required to protect the public. Prosthetics and orthotics is just such a case. The Council has concluded that there is a risk of harm in the practice of the profession but because of the small number of practitioners in the profession a self regulating college is unworkable.

The Council has received applications from several groups which on first review do not appear to have the administrative and financial resources necessary to sustain a profession. The Council has discussed, in a very preliminary manner, the possibility of alternative regulatory models which involve a more centralized approach to regulation. The advantage of such an approach is that many functions, such as complaints and discipline, can be centralized and applied by a single body across several professions thus avoiding the duplication required by the college model of regulation.

We do not feel that a detailed analysis of these alternatives is warranted in response to the present application. Nonetheless, the Council believes it useful to outline, in avery general manner, some of the alternatives which have come to its attention in the present investigation.

The Quebec Approach to Prosthetics and Orthotics

The Quebec Professional Code establishes a system for regulating professions which includes self regulatory colleges. Unlike B.C. however, the legislation applies to all professions, not just health professions. In 1993, the Office des professions du Quebec considered an application by the Association of Prosthetics and Orthotics for self regulatory status. The Office determined that prosthetics and orthotics not be self regulating in light of the practice setting of prosthetics and orthotics, the small likelihood of irremediable harm and the potential to be regulated under the Professional Code as part of another college. The Office recommended that the profession of prosthetics and orthotics be governed under the existing College of professional technologists. Since that College did not encompass any health professions, the Office recommended that certain steps be taken to integrate prosthetics and orthotics within that College. The steps included changes in the technologists' regulation pertaining to educational qualifications, and the development of control tools such as a code of ethics, file maintenance rules and inspection rules. In summary, in Quebec thegovernment decided to integrate the regulation of the profession into an existing regulatory structure rather than establish a new regulatory college.

The Washington Approach to Health Professions Regulation

Washington has a centralized approach to regulating health professions. Under the Washington system, there are three forms of professional "credentialling":

(i) Registration:

This is the least restrictive form of regulation and requires only that the practitioner of a health profession be identified to the department (i.e., registered), and does not require a qualifying examination. No person may practice or represent himself or herself as a practitioner of a health profession by the use of any title description of services without being registered to practice by the department, unless otherwise exempted. The state maintains a roster of practitioners in a profession and the location, nature and operation of the health activity practice. A registrant is subject to the Uniform Disciplinary Act, the state law that provides for the disciplining of practitioners for unprofessional conduct. The main sanction is that if registration is denied or cancelled the person is prohibited from carrying on the practice for remuneration.

(ii) Certification:

Certification is a voluntary process by which the state grants recognition to an individual who has qualified by examination and met established educational prerequisites. A non-certified person may perform the same tasks, but may not use "certified" in the title.

Again, certified practitioners are subject to the state's Uniform Disciplinary Act.

(iii) Licensure:

Licensure is a method of regulation by which the state grants permission to persons who meet predetermined qualifications to engage in a health profession which would otherwise be unlawful in the absence of the permission. Licensure protects the scope of practice and the title. That is, only a licensed practitioner may perform services within the scope of practice of the profession. Licensed health professionals are also subject to the Uniform Disciplinary Act.

Generally, Washington's practice is to employ the least restrictive level of regulation consistent with the public interest which includes a balance between consumer choice and protection of the public. An obvious advantage of the Washington model is that it provides for the centralization of several core regulatory functions such as registration and discipline. Note, however, that the practice of prosthetics and orthotics is not currently included in the Washington state health regulation system.

CONCLUDING REMARKS

As noted above, the Council does not feel that specific recommendations regarding alternative regulatory models are warranted in the present application, in light of the absence of a pressing need for regulation. We anticipate that the issue of alternative regulatory models will be examined in more detail in the course of considering some of the pending applications, and recommend that the present applicant group be evaluated for inclusion in any alternative regulatory model which may be developed.



APPENDIX A
List of Parties Consulted

British Columbia College of Chiropractors

British Columbia Registered Dental Technicians Association

Denturist Association of British Columbia

College of Dental Surgeons of British Columbia

Certified Dental Assistants Society of British Columbia

British Columbia Chiropractic Association

Commercial Dental Laboratory Association of British Columbia

Pacific Denturist Association

B.C. Federation of Dental Societies

College of Dental Hygienists of British Columbia

British Columbia Dental Hygienists' Association

Board of Hearing Aid Dealers and Consultants

Hearing Instrument Specialists Society of British Columbia

Massage Therapists Association

Midwives Association of British Columbia

Emergency Medical Assistants Licensing Board

British Columbia Association of Speech, Language Pathologists and Audiologists

College of Massage Therapists of British Columbia

College of Midwives of British Columbia

Association of Naturopathic Physicians of British Columbia

British Columbia Naturopaths Association

Licenced Practical Nurses Association of British Columbia

Registered Psychiatric Nurses' Association of British Columbia

College of Opticians of British Columbia

British Columbia Association of Optometrists

British Columbia Council of Licensed Practical Nurses

Registered Nurses' Association of British Columbia

The Dispensing Opticians Association of British Columbia

Board of Examiners in Optometry

College of Pharmacists of British Columbia

B.C. Pharmacy Association

British Columbia Medical Association

Physiotherapy Association of B.C.

College of Psychologists of British Columbia

College of Denturists

College of Physicians and Surgeons of British Columbia

College of Physical Therapists of B.C.

British Columbia Association of Podiatrists

British Columbia Psychological Association

College of Dental Technicians

Alberta Health

Saskatchewan Health

Ontario Ministry of Health

Canadian Institute of Health Information

New Brunswick Department of Health and Community Services

Professions and Occupations Bureau, Alberta Health

Manitoba Health

Ontario Health Professions Regulatory Advisory Council

Office Des Professions Du Quebec

Nova Scotia Department of Health and Fitness

P.E.I. Department of Health and Social Services

Yukon Territory Department of Health and Human Resources

Hospital Employees' Union

B.C. Ministry of Skills, Training and Labour

British Columbia Health Association

Newfoundland Department of Health

Northwest Territories Deputy Minister of Health

Health Sciences Association of British Columbia

Canadian Association of Prosthetists & Orthotists

Insurance Corporation of British Columbia

Workers' Compensation Board

Sport B.C.

B.C. Rehabilitation Society

B.C. Coalition of People with Disabilities

BC Institute of Technology, Department of Prosthetics and Orthotics

Workforce Planning and Legislation, Alberta Health

Allan McGavin Sports Medicine Centre

Canadian Diabetes Association

War Amputations of Canada, Vancouver Branch

Canadian Association of Prosthetists and Orthotists

Canadian Board for Certification of Prosthetists and Orthotists

Sunny Hill Hospital for Children

Queen Alexandra Centre for Children's Health



APPENDIX B
Summary of Submissions Received

1. PROFESSIONAL ASSOCIATIONS / SOCIETIES

A) The Society of Occupational Therapists

The Society was generally supportive of the application. However, it expressed concern with the use of the term "prescription" and felt that it should be replaced by a less medical term such as "intervention plan". The Society also expressed concern about whether the applicant would be able to govern the profession effectively given that it has only approximately 45 members.

B) Pedorthic Association of Canada

The Association generally supported the application but expressed concern about the use of the term "prescription" under the proposed scope of practice. The Association indicated that it would prefer to see a division between prescribers and the providers of prosthetics and orthotics. In addition, pedorthists indicated that they also assess, design, manufacture and fit custom made foot orthoses and therefore requested an exemption from any reserved acts.

C) The Canadian Association of Prosthetists and Orthotists

The Association was supportive of the application, and made submissions regarding all of the public interest criteria. However, the Association expressed concern about whether designation would decrease interprovincial mobility.

D) The British Columbia Medical Association

The Association was supportive of the application and felt that regulation would decrease the risk of harm from incompetent, unethical or impaired practice. The Association was generally supportive of the scope of practice statement; however, it expressed concern about the recommendation that orthotists and prosthetists be given the authority to prescribe devices in the absence of physician involvement. The Association also expressed concern about the fact that the prescribing professional would also be the manufacturer and supplier of the therapeutic device. In the Association's view this presented the potential for a conflict of interest. The Association also noted that several professional groups, including physicians, orthopaedic surgeons, neurosurgeons, sports medicine physicians, physiotherapists, and occupational therapists give advice on the fitting and application of articulating devices which cross a joint, and that the general public can be well served by the members of these professional groups. Therefore, the Association recommended that not all services in this area of practice be restricted to certified orthotists.

E) British Columbia Association of Podiatrists

The Association directed its comments to the area of foot orthotics. Although generally supportive of the application, the Association felt that the applicant's scope statement was too broad with respect to the provision of foot orthotics and that the proposed reserved acts would affect the practice of podiatry. The Association felt that podiatrists should be exempted from any restrictions in the area of foot orthotics.

F) Licensed Practical Nurses Association of B.C.

The Association expressed general support for the application.

2. REGULATORY BODIES

A) British Columbia Naturopathic Association

The Association indicated that it is not opposed to the application. However, it expressed concern that only Occupational Therapists and Physical Therapists are exempted from the proposed reserved acts. The Association indicated that orthotics has been a focus of naturopathic medicine and requested an exception from any reserved act in this area.

B) Registered Nurses Association of British Columbia

The Registered Nurses Association expressed concern about the proposed reserved acts. The Association indicated that registered nurses currently provide services that fall within the proposed reserved acts, and requested that it be granted a general exemption for registered nurses from the reserved acts of other professions.

C) College of Physical Therapists of B.C.

The College made submissions regarding the public interest criteria, and in particular the risk of harm in the practice of the profession. The College stated that there is a potential for risk of harm in the profession arising from pressure areas from faulty or ill fitting devices. The College noted that this problem is heightened by the fact that many patients receiving such treatment have sensory or cardiovascular impairment. The College did not object to the proposed titles, scope of practice or reserved acts.

D) BC College of Chiropractors

The College stated that it would not be in the public interest to designate prosthetics and orthotics under the Act. The College felt that there was an insufficient risk of harm in the practice of the profession in that the services performed in the profession that do present a risk of harm are performed under the supervision of a physician or another regulated health professional. The College also submits that there are an insufficient number of prosthetists and orthotists to effectively maintain and establish a college under the terms of the Act.

3. OTHER ORGANIZATIONS / INDIVIDUALS

A) Queen Alexandra Centre for Children's Health

The Centre was generally supportive of the application and made submissions regarding the public interest criteria. It thought that designation would act as a safeguard to the public and the private purse by ensuring that professionals certified under the college are ethically guided and disciplined if inappropriate or unnecessary devices are dispensed.

B) Insurance Corporation of British Columbia

The Corporation discussed several advantages to designation, including regulation of incompetent and unethical practitioners and ensuring continuing competency. The Corporation also suggested that some limitations be imposed to reduce the potential conflict between prescription and merchandising.

C) BC Coalition of People with Disabilities

The Coalition was generally supportive of the application. However, it expressed some concern that formulating prescriptions not be part of the scope of practice and that this service should be left to the referring doctor.

D) Sports Medicine Council of B.C.

The Council expressed serious reservation about the proposed reserved acts. In particular, the Council expressed concern about an exclusive scope of practice for foot orthoses which it indicated are currently being provided by certified pedorthists as well as orthotists.

E) Workers' Compensation Board of British Columbia

The Workers' Compensation Board made submissions regarding the public interest criteria, and in particular expressed concern about whether a college established under the act would be able to govern the profession effectively given the number of members of the applicant body. The Board also expressed some concern about the proposed scope of practice and in particular the definition of orthotics. It felt that the term may have been defined too broadly with the risk that services of other practitioners may be restricted.

4. EDUCATIONAL PROGRAMS / UNIVERSITIES

A) British Columbia Institute of Technology, Department of Prosthetics and Orthotics

The Institute was generally supportive of the application and made submissions regarding the public interest criteria. The Institute noted that in addition to the physical harm discussed by the applicant, mental or emotional harm may be occasioned in the provision of prosthetic or orthotic services. The Institute also suggested that podiatrists should be included in the exceptions to the reserved acts for orthotics.

B) Alan McGavin Sports Medicine Centre, The University of British Columbia

The Centre expressed concern that pedorthists were not included in the application and noted that these practitioners also provide services in this area and that the current application had the potential to restrict the availability of those services.

5. OTHER PROVINCES

A) Alberta Health

The submission from the Alberta Ministry noted that the Health Disciplines Board of Alberta had recently recommended that prosthetists and orthotists be regulated under the Health Disciplines Act.

B) Office de profession du Qu‚bec

In Quebec, a decision was made not to grant prosthetists and orthotists independent self regulatory status. However, it was suggested that the issue of whether they could become part of the professional technologists college be explored.

C) New Brunswick Health and Community Services

The Ministry noted that prosthetists and orthotists are not a regulated profession in New Brunswick.

D) Ontario Ministry of Health

The Ministry stated that although it determined that there was a substantial risk of harm, the small number of practitioners (approximately 116) made self regulation unviable. The Ministry also noted that the risk of harm is somewhat reduced because in the Ontario scheme there is little independent practice. The Ministry also made submissions regarding the public interest criteria.