Policy and Political Action

Policy & Political Action

Regulation of Chiropody and Podiatry in Ontario (HPRAC)

Dear Health Professions Regulatory Advisory Council, The Registered Nurses' Association of Ontario (RNAO) is the professional body representing registered nurses (RNs), nurse practitioners (NPs) and nursing students working in all practice settings in the province of Ontario. We are pleased to respond to HPRAC’s consultation request on the regulation of chiropody and podiatry in Ontario. This submission was informed through consultation with RNAO members, with two of RNAO's expert interest groups (the Diabetes Nursing Interest Group and the Community Health Nurses' Initiatives Group), and with the Canadian Association of Foot Care Nurses. This is RNAO’s second submission to HPRAC on the topic of foot care – the first responded to HPRAC’s call for analysis of foot care in Ontario. RNs and NPs in Ontario deliver expert foot care across a broad range of health-care settings. A foot care nurse carries out foot risk assessments, develops individualized care plans, and provides treatment, health teaching and referrals to other interdisciplinary team members as needed. Nurses play an essential role in providing foot care, as they often work with those who are most vulnerable. RNs in home care are integral in helping their clients maintain foot health in order to prevent falls and promote safety , mobility, and independence among older adults . Nurses in this setting address skin issues, nail problems, foot wounds and ulcers that occur in both healthy older adults and those with chronic illnesses.ii Nurses also provide street outreach services for homeless populations who may have difficulty accessing foot care services due to lack of proper identification, precarious and often transient living circumstances. RNAO's submission corresponds to the objectives in the proposal put forward to HPRAC by the College of Chiropodists of Ontario: Correct gaps and anomalies in the current scope of practice to allow chiropodists and podiatrists to provide a safe, continuum of care in the best interest of patients and for health system efficiency. RNAO supports chiropodists and podiatrists in practising to their full scope and removing barriers for them to do so, as a means to improve universal access and increase efficiencies in the health-care system. Given the advanced biomechanical assessments they conduct and types of interventions they provide, RNAO agrees that chiropodists and podiatrists should be able to communicate diagnoses, perform procedures below the dermis, administer injections, order forms of energy, and order laboratory tests. According to the Ministry of Health and Long-Term Care, the average provincial wait time for forefoot surgery (the time within which 90 per cent of patients have their procedures completed) is 240 days. Clearly, foot care and limb salvage are in serious need of improvement in Ontario, especially when chronic health conditions like diabetes are involved. However, universal access and increased efficiency must occur within the context of a publicly-funded, not-for-profit service delivery model. Services must be allocated based on need, and not ability to pay, in order to protect the province’s most vulnerable populations. According to a study on lower extremity amputations, lower socioeconomic status and insufficient access to health care increase amputation rates. However, services provided by podiatrists are only covered up to $135 per year by OHIP– a number that hasn't changed since 1989. The rest of the cost is paid through private insurance coverage or out of pocket by clients. This is concerning because recent media reports have revealed that one in three Ontario workers does not have medical or dental benefits through their employer. Of even greater concern is that low income workers and women are disproportionately affected. RNAO supports greater integration of podiatrists in the health-care system provided that there is a commitment to expand publicly-funded podiatric services and not rely on third party insurance or private payment models which leave many Ontarians without adequate care. Public investment in foot care will save money by preventing costly complications. For example, foot ulcers and amputations result in enormous societal costs, including lost wages, job loss, prolonged hospitalization, lengthy rehabilitation and an increased need for home care and social services. A cost-utility evaluation of best practice implementation of leg and foot ulcer care in Ontario estimates that lower extremity ulcer care costs $511 million per year. An interdisciplinary strategy that includes education, prevention, and close monitoring can decrease rates of amputation by 49-85 per cent. Focusing on health promotion and disease prevention – as nurses do by educating clients and increasing access to foot care and foot wear – will also improve efficiency. In the UK, a multidisciplinary diabetic foot care team consisting of a diabetes nurse specialist and two podiatrists was established in 1995 by a university hospital. The team ran a four-hour clinic once per week and decreased major and minor amputation rates by more than 50 per cent over 5 years. Furthermore, the initiative cost only 14 per cent of the funds the hospital saved from averted amputations. Beyond fiscal savings, a study analyzing a preventative foot care program found that nursing assessments and patient education were associated with a decrease in neuropathy experienced by diabetic patients with end stage renal disease. For these reasons, RNAO believes health system funds would be more effectively spent in preventing foot complications rather than treating them. Expand the scope of practice to reflect a North American podiatry model whose efficacy has been amply demonstrated elsewhere and in order to enhance patient choice and access to more advanced footcare. While the College of Chiropodist’s submission provided studies to support a cost-benefit line of reasoning in favour of podiatric services being more fiscally efficient, it did not provide the same level of scientific evidence to show that expanding the scope of practice in podiatry would effectively improve patient outcomes. Since the College is not requesting hospital privileges, evidence is required to indicate that podiatric services can be performed safely in an office setting or surgical centre. A rapid review conducted by the Health Professions Regulatory Council on chiropody and podiatry found “limited information was found on patient safety and risk of harm associated with foot care. Two studies identified potential for inappropriate care arising from risk misclassification and anaesthetic toxicity. ” While other Canadian provinces, states in the U.S. and regions of Mexico have expanded the scope of practice of podiatrists, RNAO is unable to support an expanded scope in Ontario without compelling evidence demonstrating safety and positive client outcomes. Address regulatory inefficiencies and anomalies by adopting a unitary profession with a single title and scope and revoking the “podiatric cap”. The transition from chiropody to podiatry is complex, particularly in the management of grandfathered chiropodists, and is of concern to RNAO. There are significant educational differences between chiropodists and podiatrists. While the College has grouped 603 members into six cohorts to assess their competency, there will have to be individual assessments and follow-up with practitioners to prove they are able to effectively perform their expanded acts. Registration restrictions will also need to be managed on an individual basis and these restrictions will have to be clearly communicated to the public. Lastly, requisite bridging programs will also have to be accessible to current Ontario chiropodists. It is unclear how these programs will be provided given that there is currently no accredited education program for podiatrists in Ontario. RNAO supports the adoption of a unitary profession, provided that HPRAC is satisfied that the appropriate regulatory instruments/processes would be in place by the regulator to effectively transition chiropodists into the podiatry profession, with emphasis on transparency and patient safety. RNAO also supports revocation of the podiatric cap to allow the profession to expand and evolve. However, only under two conditions: that the government commits to publicly-funding podiatric services, and that an accredited Ontario podiatry program be developed. RNAO greatly appreciates this opportunity engage in the important discussion surrounding the regulation of chiropodists and podiatrists in Ontario. We hope you will consider our recommendations and are open to future consultation on this matter. Warm regards, Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT. Chief Executive Officer Registered Nurses' Association of Ontario
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