1. CIHR/HEALTH CANADA CHAIR IN HEALTH HUMAN RESOURCE POLICY Conceptualizing Different Approaches to Health Professional Regulation: Comparing Ontario & Brazil Dr. Ivy Lynn Bourgeault Institute of Population Health ivy.bourgeault@uottawa.ca

2. Overview A conceptual model of health professional regulation Case Study #1 Ontario, Canada –Reference to poster by colleague K. Hirschkorn Case Study #2 Brazil What is the role of health professional regulation?

3. A Heuristic Conceptual Model of Health Professional Regulation State Regulation Professional Self- Regulation Content Context

4. What is the role of regulation? Case Study #1 Ontario, Canada 1983 - Health Professions Review in Ontario criteria for inclusion in legislative package: –Is it a health profession? –Can it do harm? –Does the profession have a body of knowledge that can form the basis of standards of practice? –Will it favour public over professional self-interest? –Is it likely to comply with regulation? –Is there a sufficient number of members to bear the costs of self-regulation

5. Regulation in Canada The traditional approach has separate statutes for each health profession that grant certain, often exclusive practice scopes prohibiting anyone other than a member of the profession from providing specific services. Trend in health profession regulation in Canada is toward a common legislative framework for health professions regulated in each province or territory, often referred to as ‘umbrella legislation.’ Involves enactment of an overarching statute that provides a uniform regulatory framework for all professions governed by the legislation, and profession- specific laws or regulations are then developed in accordance with the umbrella act.

6. Example: The Regulated Health Professions Act (RHPA) in Ontario Proclaimed December 31, 1993 Applies to 23 self-regulating professions Establishes a common framework emphasizing public interest principles: protection from harm accessibility accountability equity quality of care equality

7. Form of Regulation: Self-regulation Scope of Practice vs. Controlled Acts (14) –profession vs. public interest –flexibility of health care division of labour (advantages & disadvantages) Provisions for the “Delegation of Acts”

8. Controlled Acts The concept of “controlled acts” is set out in RHPA. This means that no one is permitted to perform a controlled act unless they have been authorized by their profession specific Act to do or the controlled act has been delegated to them by someone authorized to perform it. http://www.hprac.org/en/reports/resources/hprac- regulationsbycontrolledactandprofessionMarch1609_fina l.pdfhttp://www.hprac.org/en/reports/resources/hprac- regulationsbycontrolledactandprofessionMarch1609_fina l.pdf

9. Examples of Controlled Acts Communicating to the individual or his or her personal representative a diagnosis. Performing a procedure on tissues below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surface of the teeth. Moving the joints of the spine beyond the individual's usual physiological range of motion. Setting or casting a fracture of a bone. Administering a substance by injection or inhalation. Applying or ordering the application of a form of energy. Prescribing, dispensing, selling or compounding a drug

10. Colleges: The governing bodies of the professions are required to act in the public interest by developing & maintaining standards: –qualification –practice –knowledge &skill –professional ethics –continuing competency

11. Colleges (cont.) The Colleges are required to have greater public representation on their councils –no less than 40 & no more than 50% Meetings and hearings must be open Colleges are also required to develop a common framework for complaints and discipline matters.

12. Health Professions Regulatory Advisory Committee: HPRAC was created under the RHPA to continue to provide advice to the Minister of Health regarding the regulation of health professions in the public interest. The Advisory Council consists of appointed members (not members of a health profession) It is headed by a Chair & supported by a secretariat providing policy analysis, administrative services and consultation coordination

13. HPRAC Mandate: HPRAC's duties under the RHPA are to advise the Minister of Health on: –which professions should be newly regulated or no longer regulated –amendments to the RHPA and related Acts –regulations proposed under the Act and related Acts –any matter referred by the Minister of Health relating to the regulation of health professions

14. A Heuristic Conceptual Model of Health Professional Regulation State Regulation Professional Self- Regulation Content Context

15. Brazil Case Study Impetus for the move from self to state regulation –Controversy over Mais Medicos program –Recruiting Cuban physicians to underserviced areas Issues that this raises for the State –Capacity? context vs. content

16. What is the role of health professional regulation? Protection of the public –Does this include access as well as quality? –Who best to do this? State or Professions or both State regulation does not necessarily = Public interest –Neither does self regulation –Different dimension?

17. Other considerations Scopes of Practice > Controlled Acts Regulate professions separately -> collaboratively Discontinuities between architecture and practice

18. Integrated HHR: Interprofessional Collaboration Umbrella legislation with non-exclusive scopes of practice provides a possible foundation for interprofessional collaboration (IPC). –It is argued that the regulatory frameworks, and the practice cultures they influence, are “one of the determinants of the shift to a culture of interprofessional regulation.” –Changes to statutory instruments alone will not transform the traditional hierarchies and silos of health care practice –Older statutes may structure health care environments in ways that work against this modern approach. Regulatory barriers’ are often mentioned as inhibitors to IPC but with little explanation of the precise role they play and with not much attempt to differentiate their impact from that of more amorphous factors, such as professional identities or hierarchies.

19. Latest Ontario Developments Bill 179, Regulated Health Professions Statute Law Amendment Act, 2009 amended the RHPA, certain health profession Acts and other Acts to expand the scope of practice for numerous health professions and introduced a legislative obligation on health regulatory colleges to collaborate interprofessionally where they share controlled acts and to incorporate interprofessional collaboration into their quality assurance programs.

20. For more information, copies of reports & update on progress please go to: www.ivylynnbourgeault.ca Thank you