Does Ontario have too many under-regulated health workers?
In recent years, various health care professions have called for better regulation – including paramedics, personal support workers, physician assistants and others. Inadequate regulation has led to confusion that can put the public at risk, representatives of the professions say.
In Ontario, as in many other provinces, some health professions, including doctors and nurses, are highly regulated, with their own governing Colleges incorporated under the Regulated Health Professions Act (RHPA). Others, including personal support workers, are hardly regulated at all. Then there are groups like physician assistants and paramedics, who are regulated but, they argue, poorly and inconsistently.
The issue of how these non-RHPA professions are regulated is very much on the government’s radar, according to Ontario’s Deputy Minister of Health Bob Bell. “When I look at the future of the Ontario health system, how we train, accredit and supervise professions like personal support workers…is really important,” he says.
Bell didn’t disclose how any of the non-RHPA professions will be regulated in the future. But he did suggest that the government is reluctant to create more self-regulating Colleges. “The Ministry is responsible for ensuring that Colleges protect the public interest. With 26 Colleges, it’s difficult to know that that’s occurring,” he says.
How non-RHPA professions are currently regulated
Some of the non-RHPA health professionals are regulated to an extent. For many paramedics in Ontario, the Emergency Health Services Branch of the Ministry of Health sets the rules around how paramedics transport people and provide basic care like managing wounds, while base hospitals delegate more advanced care activities like administering medications and inserting breathing tubes. Likewise, physician assistants do tasks that are delegated to them by physicians, and thus they’re supervised and held accountable by their physician employers.
Other non-RHPA occupations have less oversight. Personal support workers, who provide services including assisting with bathing, helping patients adhere to their medications and other tasks in the home, don’t have any provincial body to monitor their training or to ensure they’re practising appropriately, explains Miranda Ferrier, president of the Ontario Personal Support Worker Association (OPSWA).
What’s wrong with the current state of regulation? For paramedics, the regulation they have is inconsistent and limiting, says Rob Theriault, professor of paramedic programs at Georgian College. He explains that it’s up to medical directors of base hospitals to delegate tasks to paramedics, and these doctors tend to err on the side of under-delegation, knowing that if something goes wrong, they’ll be held accountable. “If there’s a patient who is not completely conscious and is at risk of losing their airway [stopping breathing], in some regions, paramedics can sedate the patient enough to get the tube in the trachea, but in other regions, they can’t,” Theriault says. “Some medical directors don’t know what we’re skilled at and they don’t want to risk their own licence.” Meanwhile, for hundreds of private paramedics (those who work in industry or non-emergency medical transportation, for example), there’s no regulatory oversight, says Theriault.
For the cases of physician assistants, meanwhile, “some health professions refuse to accept orders from PAs,” says Patrick Nelson, executive director of the Canadian Association of Physician Assistants, because they don’t understand their role. In addition, “there is no governing body to investigate complaints against PAs.”
The vacuum of regulation also means that there are no provincial registries to report if a member of a non-RHPA-regulated profession has been fired for misconduct, for example. “A personal support worker could be fired because of an accusation of abuse or neglect and they can literally get up and walk down the street and get hired by another agency and they wouldn’t know anything about it,” says Ferrier.
The OPSWA conducts a national criminal record and credential check for the 16,000 PSWs registered with them, but registration is voluntary. There are over 80,000 PSWs in the province who haven’t registered with OPSWA, Ferrier explains. “We would like to see one curriculum for all PSWs,” she says. “There should be expectations upon them for retraining and we should have the ability to blacklist ones that get charged with abuse.”
Much like PSWs, pedorthists (who are trained to modify footware and employ assistive devices to help people with conditions that affect the feet or lower limbs) have formed a voluntary organization, the College of Pedorthists of Canada, that will certify pedorthists by confirming their qualifications, and investigate complaints from the public. In reality, however, anyone can call themselves a pedorthist, says Johnathan Strauss, chief executive director of the Pedorthic Association of Canada. The lack of regulation has led to poorly trained or unethical providers who charge insurance companies and patients for devices that didn’t help, he says.
Why some professions are self-regulated and some aren’t
For professions who are self-regulating under the RHPA, members of a profession decide on the skills fellow members must possess, the standards they must adhere to, and the disciplinary processes. The rules and regulations set by self-regulating professions are approved by the government.
So why are some health providers regulated by the RHPA while others aren’t? When the RHPA was created in 1991, “there were fewer professions than there are today,” explains Francesca Grosso, a former policy director at the Ontario Ministry of Health and current principal at Grosso McCarthy. But in the last 25 years, “a whole number of new providers have come into play,” she says.
While some professions are new, others have evolved. Paramedics, for example, have gone from being seen as somewhat outside of health care – performing basic first aid and transportation roles – to, in some cases, being the main care providers for patients with serious, chronic conditions.
Some providers have been incorporated into the RHPA in recent years, however. Chinese medicine practitioners were granted self regulating status in 2013 and naturopaths in 2015 – but not without controversy.
Theoretically, self-regulation makes most sense when a profession is performing tasks that only their peers can adequately understand and evaluate (the work of a surgeon is best critiqued by another surgeon, for example) and when the risk of harm to the public justifies the costs of a full regulatory College, explains William Lahey, a professor of law at Dalhousie University.
But why certain providers have more recently been given self-regulatory powers also has to do with “political factors,” explains Tracey Adams, chair of the Department of Sociology at the University of Western Ontario, who researches how different health providers are regulated in various provinces. These factors can include how long and how effectively a profession has lobbied for self regulation and “who is in power when regulation is asked for,” she says.
How should non-RHPA providers be regulated going forward?
Some, like Lahey, think that most of the professions currently calling for RHPA regulation don’t warrant self regulation. Lahey argues that rather than focus on the RHPA, the government can improve public protection by putting more resources into government regulation of health professions. “The problem is that not just in Ontario but broadly, in Canada, we’ve defined regulation in health care as self regulation and other countries don’t do that.”
Adams says that the current government in Ontario seems to be taking cues from other countries, like the UK and Australia, which have moved away from self-regulation toward more government oversight. While Bell doesn’t say this outright, he does say he’s “reluctant to extend self regulation.” He says, “I fear that the primary purpose of colleges today is perhaps not to protect the public interest but rather to establish the turf of the group providing care.” (He added, however, that many Colleges were “doing great work” recently in improving transparency.)
Part of the problem with the existing Colleges is that the RHPA legislation is “cumbersome,” says Grosso, with complaint and supervision processes clearly defined. That has limited Colleges from acting nimbly to ensure public accountability. For his part, Bell says, “the Regulated Health Professions Act, which was groundbreaking at time it was introduced, is now old. It probably needs to be reviewed and updated.”
In light of the problems with the RHPA, Grosso is calling for legislation that “would focus on what is essential for public protection but would allow for flexibility in matters such as how processes work, inclusion of other professions, protection of other titles and details of the make-up of the oversight body.” And if the professions aren’t sufficiently regulating members, “government can force the professions to do their regulatory job without the barriers that exist under current RHPA legislation.”
New legislation should also allow smaller professions that can’t afford to maintain an RHPA-defined College to have title protection, says Grosso. And the voluntary oversight the professions currently do recognized legally, she adds. “When it comes to public protection, size should not matter,” says Grosso.
Strauss and Ferrier, who lead associations for pedorthists and PSWs, would appreciate the kind of flexible self-regulation Grosso describes. Still, the representatives of the professions we spoke to be said they would ideally like to be regulated in the same way as RHPA providers.
Physician assistants in Ontario could be regulated by the College of Physicians and Surgeons, which is how physician assistants are regulated in Manitoba and New Brunswick and how the government of Alberta has indicated they’ll be regulated there, explains Nelson.
Theriault adds that being regulated in the same way as doctors and nurses would allow paramedics to perform to the full extent of their training. Only paramedics can understand the skills and processes involved in “caring for someone under a car while lying on your belly in sub-zero temperatures” or “dealing with a combative patient in an air ambulance,” so it makes sense that paramedics establish standards of how paramedics should practice, Theriault argues.
Alberta’s government has overseen the development of a College of Paramedics, which is expected to be an official, self-regulating body this spring. While forming a College is costly, Becky Donelon, deputy registrar of the College, thinks it will be cheaper than the current costs of hospital-based supervision for paramedics. She says that by being regulated under Alberta’s Health Professions Act, “we enable practice in whole different ways that save delivery a lot of money,” she says, including providing more community care. (In the current situation, a doctor has to delegate tasks to community paramedics, which can pose a barrier in setting up community paramedicine programs, Theriault explains.)
It’s not clear how the Ontario government will regulate non-RHPA providers. But in an era of increasing interdisciplinary care, the system of one group of providers being highly regulated with their own Colleges and others not regulated or inappropriately regulated is looking increasingly unsustainable to many. “It falls short of good public protection,” says Grosso.