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.
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I found your article extremely insightful but worrisome particular given the escalating healthcare costs within the next 10-15 years.
I would be interested in attending one of your next round table events in the GTA.
Thank you.
I am an RN and I despise working with PSWs in areas of the hospital where it is not safe to have them.
I have yet to meet one that is not outright disrespectful to the RN’S, takes 3 hour breaks, is more concerned about gossiping or theit own insecurities, nevermind their abuse towards patients or leaving patients lying in filth.
And these are really really sick patients. Weren’t PSW s created for HOME CARE and LONG TERM CARE???
If you want to bring your family member to a hospital – find out who your “nurse” is. Because it’s likely someone with zero medical training and not even close to bring a nurse.
Welcome to Trying to Survive in certain Ontario Hospitals 2017. Good luck
PSW’s should ONLY work in long-term care and home care.
No wonder hospitals get sued!!!
Lol and they want to save $$.
Best way – get rid of the ones that aren’t needed and bring down the value
Care aides only disrespect registered staff and I see them standing around, they pretend they are nurses. I always ask and go to another place
No way…maybe if my family member was at home for sure but not in the hospital
Unregulated PSW’s or Care Aides should NEVER be employed by an acute care hospital.
They have a role but ONLY in long term care, home care, retirement homes and etc.
It’s horrific to think they work in a hospital with IV lines, tracheostomies, ventilators, blood transfusions
The public needs to know if they or their family member are entering an acute care hospital that has UCP’s on units with very ill patients.
Even worse is if they call themselves an RPN or an RN, wear similar clothing and yet have never gone to school.
I agree.
they were created for long term care and home care.
I will only go to hospitals that are staffed by RN- RPN.
Look it up…..you can find the ones that only employ nurses. These are usually the beat hospitals.
The problem with allowing a full-fledged self-regulated profession to include a “para-profession” under its regulatory umbrella is that it’s in danger of becoming a containment policy to limit expansion. A primary example is the inclusion of independent paralegals in Ontario under the umbrella of the Law Society of Upper Canada (LSUC). There is clearly a public need for the expansion of the “limited legal service” mandate of the paralegals. However, despite a five year review in 2012 calling for an expansion and a series of access to justice reports the LSUC stubbornly refuses to let independent paralegals invade the turf of lawyers’ income services.
Something most people do not realize is that the RHPA regulatory colleges are NOT government agencies, NOT accountable to the public, and NOT even subject to FOI legislation. They are corporations… but they are EXEMPT from the Corporations Act. They run wild, driving up prices for practitioners and their clients by making Members jump through ridiculous hoops to the point of mental, emotional and financial exhaustion and frustration, and are highly influenced by an INTERNATIONAL, NWO organization (“CLEAR”, Council on Licensure, Enforcement and Regulation) that trains members to subvert democracy within their own jurisdictions.
The recently-resigned Registrar of CRPO, career bureaucrat and CLEAR member Joyce Rowlands, is a perfect example of how this works. To call this “self-regulation” is ridiculous.
We are being regulated to death, literally. The regulation we currently have is not remotely working for public safety, as was intended – by regulating ONLY the acts that are truly inherently risky and leaving every else alone. Instead it props up self-serving career-regulators, Big Pharma and the Medical Mafia, who have always been on a mission to eliminate all competition to their epically disastrous approach to healthcare.
The more regulation by the government, the more costly and the more danger the public is put in, because once the public is disempowered and unable to make their own decision based on outcomes, the marketplace becomes filled with those who would not otherwise make it in an open marketplace.
The rules and regulations ARE NOT made at these Colleges by practitioners and peers, but by those with little to no training whatever in the professions they are regulating. In Ontario, the regulated professions are ‘directed and influenced’ by the front non-profit corporation FHCRO that has insinuated itself into our healthcare system, claiming to help the colleges regulate. However, the colleges are streamed to the interntional training business called CLEAR…getting us all ready for international regulatory agendas under the TPP/TISA.
All regulation under the RHPA is in the bio-medical model. It is a disaster and now, since the expanded regulation in Ontario, Ontario is reated as the worst healthcare provision in Canada. Top-notch front-line practitioners who the public paid for out-of-pocket are now gone…unable to pay the extortion fees charged as membership and fully disgusted with having to take ‘training and upgrading’ that they do not need and at extreme costs in time and money…just to satisfy self-licking ice-cream cones.
The ONLY system that is working in the public interest is the unregulated system…proven by at least 2 Fraser Institute studies in 2006-2007 to be completely safe, saving the imploding regulated system $7-10 billion annually, that amount to double every 10 years.
There is not a single healthcare regulatory College in Ontario that can claim to be of any benefit to the public. In fact, the College of Physicians and Surgeons is part of the medical system that is now the leading cause of death and disability in North America. Psychology (and by extension psychotherapy), the recent Texas Fifth Circuit Court of Appeal has stated is ‘unscientific’ and Psychology laws unconstitutional…yet in Ontario, they are undermining the entire holistic industry and taking over all mental health care under the RHPA, forcing all practitioners to join the new College of Registered Psychotherapists, complete with Standards of Practice demanding mental illness diagnoses and pharmacology training. Imagine that, now in Ontario, you will have to see a Registered Psychotherapist to get grief counselling, a mental illness diagnosis and drugs…whereas holistic spiritual care practitioners use to be able to help people humanely.
Mr. Theriault talks about private paramedics when he in fact there is no such thing. To be in a position of responsibility with a Provincial College and continuing with this rhetoric is rather nefarious. To be a Paramedic in the province of Ontario according to the Ambulance Act you must be employed by an ambulance service. Stop using the term differently. You state you want title protection of the term Paramedic yet you use it very loosely yourself and it is disrespectful. Additionally doctors know very well what we are skilled at and as a provincial body decide what we can and cannot do. It is a little pompous to think one knows better than a physician who has many more years of education and a group of physicians that set our standards. Yes we get that he and the OPA want a regulatory body. Accept the fact that HPRAC recognized that in the province of Ontario we are already well regulated. HPRAC said it, doctors have said it, most paramedics are saying it. Paramedics are one of the most trusted professions in this country and putting misleading information out there known to be untrue for the sole purpose to fear monger is inappropriate. We are a trusted profession for a reason.
To hold MAC up as a shining beacon is ludicis. Recent decisions from a single strong willed physician has cut PCP’s ability to deliver pain relief in half. Protocols need to be based in science, with evidence based research. (More than a single study) Also recent PCP and ACP advisors (who have no voting rights in our own profession) have told me they are largely ignored in MAC discussions.
That’s entirely incorrect. The Ambulance Act simply defines “paramedic” for the purposes of the Act. Similarly, O. Reg. 257-00 defines “primary care paramedic’, “advanced care paramedic” and “critical care paramedic” for the purpose of the Regulation. The key phrases, respectively, are “In this Act” and “In this Regulation”. In no way does this correspond to the title protection provided under the RHPA, e.g., for doctors in s. 33(1) (“Except as allowed in the regulations under this Act, no person shall use the title “doctor”…”) and for nurses in the Nursing Act s. 11(1) (“No person other than a member shall use the title “nurse”, “nurse practitioner”, “registered nurse”, or “registered practical nurse”…”).
That discrepancy was pointed out in the OPA’s application to HPRAC, pp. 17-18.
Physician Assitant’s really should be regulated in Ontario as they are in other provinces and currently with lack of regulation in Ontario there are people being hired into the PA role that have not completed Physician Assistant training or Certification. This current practice can certainly put the public at risk.
Why build an entire self-licking ice-cream cone bureacracy at million of dollars to break the backs of innocent practitioners when a simple requirement for certification or other proof of training would do? These colleges are driving people clear out of their professions…the public does not gain…it loses big time. Ontario, just since it’s rabid ‘regulation’ of everything that moves, is now providing the WORST healthcare in Canada.
CERTIFICATION and proof of training is more than enough. Prior to this expansion of regulation for any reason (especially to provide lots of jobs for those who do nothing to help front-line provision of health care) we had a good, affordable system. When studies show that the unregulated professionals are safe and effective and the public is happy to pay-out-of-pocket for their services, it is time to get the government out of our lives before we are buried alive in useless Master’s degrees.
This article is highly misleading in respect to Paramedics. As opposed to most RHP’s who have only 1 level of oversight , Paramedics have 3 seperate and distinct and independent levels of oversight.
More than sufficient oversight.
Just another bunch trying to create a position for themselves…always misleading, biased and pro bio-medical. The more every profession is regulated in the image of the bio-medical system, the more everyone loses…Ontario now has the worst healthcare system in Canada.
Get the Wynne government out of our lives or we won’t have one.
Rob Theriault continues use the term “private paramedics” as a justification for a regulatory college for paramedics. One only has to turn to the Ambulance Act and its regulations for the definition of a paramedic. A paramedic in ontario must meet the standards which include employment in a recognized ambulance service provider and be certified by a base hospital physician. This definition is further affirmed in HPRACs December 2013 report on Paramedic regulation. HPRAC (Health Professions Regulatory Advisory Council) in this report also recommended that paramedics do not require a regulatory college given their present state of governance, as they do not form a risk of harm to the public.
Despite Theriaults comment that the current system could pose a barrier in setting up community paramedicine programs, the Minister of Health today committed to continued funding and working towards a long term plan.
I understand that the Ministry committed in continued funding to the community paramedic program, but it’s the base hospital that permits Paramedic to perform medical acts. Therefore handcuffing Paramedics in gaining more skills or performing the ones they already know if they decide not to grant them the right to do so. These restraint prevent the Paramedics from reaching their full potential as community servant and at the same time care given to the public is not optimal. Paramedics are not deemed dangerous to the public but also the public as no information on disciplinary actions taken against paramedics. Those disciplinary actions are also inconsistent.
And why does the public need access to disciplinary actions? If someone is in a private practice and the public has the option to choose a practitioner they may require that information but when you call 911 you don’t get to pick who arrives at your door.
Public practioners, even though they’re might only be one of a certain discipline in your county are subject to those procedures by their colleges. It’s about transparency and making sure the highest quality health care is given to the public.
Colleges by their own statements ensure ‘minimum standards’ not the highest standards. The free marketplace ensures the highest standards…if you don’t provide the best service in a fee marketplace, you are out of business very quickly.
This regulation of everything is a protection racket and it ensures that everything is forced into a bio-medical box, for total regulation by medical supremacists who have not earned their positions at the head of our healthcare system. In fact, if the CPSO and FHCRO were banned, the police would be handling sexual abuse by doctors properly, the Health Care Consent Act would be properly enforced and we would have the best, not the worst healthcare treatments.
You points are valid for every profession brought under RHPA regulation since 2006…its a protection racket. Driving practitioners out of their professions, driving costs up for the public and ensuring a worsening situation in Ontario healthcare, although most people don’t think it can get much worse.
Never is there the required study done to prove that interference with a profession is remotely required. Instead, it’s all done as a matter of ‘opinion’ of those who never do front-line work. They find one or two stories and massage them to death until they get another bureaucracy built and a cushy job to boot.
Nailed it
Ontario’s then Health Minister also ignored HPRAC’s advise regarding an RHPA controlled act of “psychotherapy”, which HPRAC stated years ago would be completely unfeasible but the MOH went ahead with it anyways. Now we have “psychotherapy” legislation that was buried in an Omnibus bill, sneakily designed to eliminate the entire safe, valued holistic healthcare industry.
The self regulation process hasn’t worked as well as it should. Whether those hearing the case intend to tread lightly on those “they” regulate is based on the fear: “There, but by the grace of God go I…I’m not sure.
However, there have been far too many complaints lodged, particularly against physicians, who’ve clearly violated the public’s trust, yet they remain in practice despite a CPSO hearing. Case in point: a recent CBC Fifth Estate program revealed how a London Psychiatrist had betrayed the trust of several female patients over an extended period of time yet never lost his license.
While the concept of self regulation might have some merit the process is in need of an overhaul. The fox guarding the henhouse hasn’t worked, at least not with the CPSO.
perfect assessment. The more regulation, the more unsafe we are because the foxes are morally and ethically bankrupt and worse, they have one thought in mind…creating more work for themselves on the backs of the poor practitioners who have to pay their salaries.
Us PSWS need to keep up involvement on these topics….. Especially to support those that work in retirement homes where the care and demand vary. And there are less staff to report to unlike nursing homes and hospitals…..