It is stated in the document that there has been considerable prior consultation with health professions about these proposals. The NZCCP does not seem to have been included in those consultations and we would value participating in future consultations about this important topic.
We support the Government’s wish to improve access to quality healthcare for all people in Aotearoa, New Zealand. However, the overwhelming view of both the Executive and members of the NZCCP was that the proposals outlined in this document would do little to support this goal and risk achieving the opposite result. Our major concerns are outlined below.
The NZCCP believes strongly in the importance of patient-centred care and improving equitable access for the population of Aotearoa New Zealand to healthcare services including psychological services.
However, we do not believe that the regulatory framework for health professionals is a major cause of limitations of access to health professionals. We see that under-supply of health professionals in health services is a far larger issue. In the specific case of clinical psychologists, conditions in the public sector including understaffing, organisational dysfunction, practices that are incompatible with effective practice, and remuneration have led many psychologists to leave the health service for private practice or other social service sectors. Retention is a major issue in clinical psychology and in many other health disciplines. Changing the regulatory control structure will not improve this. Training more health professionals, such as psychologists, and ensuring that conditions are such that they choose to stay working in the system, are key to improving access.
Both the Executive and a vast majority of the member respondents expressed surprise at the position expounded in the document regarding cultural safety being “a factor beyond clinical safety.”
The NZCCP does not agree with this perspective. In psychological practice, understanding the person in their cultural and other contexts is vital to safe and effective practice, and is an important set of competencies for practitioners to obtain and maintain. Cultural safety is an important part of clinical safety. One of our members said:
“The separation of cultural safety from clinical safety .. is at best ill-informed and at worst overtly racist”
Developing cultural competencies is an important aspect of the effective delivery of health care, and not just in psychology. The poorer outcomes experienced by Māori and Pasifika people in our health services underlines why it is important. While it may be somewhat less obvious in other health professions, cultural competency remains an important determinant of health outcomes in many health activities. We believe that professional regulators ensuring that training programmes in Aotearoa New Zealand have the resources to teach cultural safety (through the accreditation process) and ensuring that professionals arriving from overseas develop the skills to work in a culturally safe way, is reasonable both to honour our commitments to Te Tiriti o Waitangi and to achieve the desired equity of access to, and benefit from, health services for all people in Aotearoa New Zealand. Failure to do so will ultimately be costly by increasing ineffective use of health resources.
Scenario D on page 8 (a practitioner needing to complete a course about cultural issues) trivialises this important issue. It is notable that in this scenario the practitioner is not being prevented from practising in Aotearoa New Zealand, they are merely being asked to undertake a course to prepare them to work effectively here, the same as they may be asked to upskill in the medications available locally or the laws relevant to their practice.
The NZCCP is supportive of ensuring that regulatory bodies are able to work efficiently and effectively, and we believe there will be economies that could be made through utilising consistent administrative systems, IT systems, and other processes that are appropriate for many of the administrative functions that regulators undertake.
Ensuring that the administrative overhead of the regulatory system is minimised so that health professionals can focus on their patients is important. However, it but must be done without compromising the quality and safety of care and increasing risk to the public.
We believe that combining of different regulatory bodies would have to be done with considerable care, and may not be generally desirable. A regulator requires an in-depth understanding of the profession they are regulating. In the case of psychologists, there is a need for oversight by a regulator that understands the work that psychologists do.
If regulators are to be combined, the key issue will be to ensure that the combined regulator and its Executive have sufficient understanding and representation of all disciplines within its purview to ensure that it can respond adequately to the regulatory issues.
The NZCCP is supportive of strong public consultation in helping to achieve patient-centred regulation. Public consultation, along with consultation with the profession, could help to ensure that the professions operate in ways that are responsive to the needs of the public. This may include frequent dialogue between the regulator and the public, and having representatives of the public sitting on the regulator, as already happens. However, many of the issues that the regulator must grapple with require the specialist understanding that one is most likely to have by being a practitioner in that field. Many of the issues dealt with by the regulator and its Sub-Committees requires the in-depth knowledge of a practitioner, and if the proportion of practitioners on the regulator became too small there would be insufficient practitioners to carry out these roles. For this reason, we believe that a solid majority of the members of the regulator should be practitioners from that field. This could be accompanied by ensuring that the regulator’s processes are set up so that the opinions of the non-practitioner Regulator members are given careful consideration.
The NZCCP is not supportive of Government having direct influence over the Regulator. This is because
1. The Minister or Ministry may have limited understanding of the practice of the profession
2. The Minister or Ministry may have less information on which to base a decision than was available to the regulator, and
3. The interests of the Government may prioritise different factors than provision of optimal health service and protection of the public.
Regulators need independence to continue to hold responsibility for public safety. If regulatory bodies were under pressure to align their decisions with the priorities and direction of the health system, then their ability to perform their primary role of protection of the public would be severely compromised. The Government overriding the decisions of the regulator puts both the regulator and practitioners at risk of being put in untenable positions which may create risk for the public.
We can see advantage in providing a level of review for decisions made by Regulators that does not require recourse to the Courts, but we are not supportive of Ministerial Reviews being used as a method of reviewing such decisions, because the Minister often will have only limited understanding of the situation and context in which it was made, and may also be responding to factors other than the safety of the public in their judgements in these reviews. The concept of an Occupations Tribunal may be of value, or, similarly, a Health Professional Regulatory Ombudsman, may be able to provide a level of review of regulator’s activities. A third alternative is to establish more robust review processes within the regulators themselves, perhaps using suitably qualified external advisors.
We do understand that the function of the Regulators significantly impacts on broader systemic issues such as the development and staffing of the health system, and so is of relevance to the government. However, we believe that processes other than direct governmental control of the regulator will better ensure that regulators are mindful of these broader issues while undertaking their primary function of protection of the public.
The NZCCP recognises that the needs of the population change over time, and health professions also change over time.
Ensuring that health professionals from overseas are appropriately and safely able to work here has the potential to improve the access to health services for people in Aotearoa New Zealand. However, the role of the regulators in this is only one part. Around the world, there are many variations in training to become a registered psychologist. We are aware of overseas-licensed psychologists coming to Aotearoa New Zealand and appropriately not being registered as they do not have the competencies to practice safely. There is need for a training programme that could assist these people to upskill to the standard required in Aotearoa New Zealand. This would allow us to utilise this valuable resource and also protect the safety of the public.
While there is a wide variation of opinions amongst our members regarding the advisability of establishing new workforces with more circumscribed training and scope of practice, the current initiative of Associate in Psychology, provides an example of how a regulator can support workforce development. This position utilises people with academic credentials in psychology, but without the full professional training, and trains them to work within a limited scope of practice with people with mild-moderate mental health and associated difficulties. The NZ Psychologists Board is currently undertaking work to develop the scope of practice and competencies requirements, and is also working with Te Whatu Ora Health New Zealand and the training providers to ensure that this new workforce is able to practice safely and effectively. To enable this work to produce a safe and effective outcome, a high level of understanding from the regulatory authority into the particulars of the specific profession is needed.
The alternative regulation approaches discussed on Page 9 may be appropriate for some workforces, but are not appropriate for more high-skill and high-risk occupations including medicine, nursing, and psychology. For example, credentialling by employing organisations for medics and psychologists would not be appropriate as they would not necessarily have the skills to run a robust process, and/or workforce needs may encourage them to credential an insufficiently trained person. If any of these approaches were to be applied to the psychological workforce, and if the result was to lead to Aotearoa New Zealand having a less robust training and regulatory environment than is currently the case, this could lead to training here becoming less attractive for local and international students, and our qualifications being less well accepted internationally, including creating difficulties with the Trans-Tasman Mutual Recognition (TTMR) arrangements between Aotearoa New Zealand and Australia.
There are a variety of different regulated and unregulated groups of health workers who deliver psychological therapies. We are supportive of alternative approaches to regulation being used with these groups if it assists to encourage ethical, safe, and effective practice.
Thank you again for the opportunity to respond to this document. While the bulk of our comments are of the nature of concerns, we appreciate the need to improve the access of people in Aotearoa New Zealand to health care, including from psychologists. Should you wish to discuss this submission further, you are most welcome to contact us.
Sent on behalf of the Executive board of NZCCP
via office@nzccp.co.nz
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