“Top of scope”: no rights without responsibilities

Frankly, I don’t think any of us have the right to extend our scope of practice without accepting the responsibility of submitting to appropriate oversight to keep the public safe

I HAVE been thinking a lot lately about the push to enable health care workers to work “top of scope”. Scope of practice is traditionally defined by professional standards, codes of ethics and codes of professional conduct, and includes skills that an individual practitioner is “educated, authorised, competent and confident to perform”.

However, “top of scope” has often implied extending practice beyond the traditional limits of a particular role.

There seems to be an assumption that this is a good thing for health care workers, will be cheaper for the health service, and any opposition to it is merely a “turf war” argument designed to protect existing siloes. However, hidden in the arguments justifying increasing scope of practice are a number of key questions we need to answer as a professional community.

• Who gets to decide my current scope of practice? Do I get to extend my scope because it increases my job satisfaction, sense of agency and, let’s face it, professional standing and income, or do I need to demonstrate competencies to some sort of governance body to justify the change in my scope?
• Does the context matter? Is it okay to extend my scope in rural and remote practice but not okay to do the same in urban settings where there are fewer workforce shortages? Scope should be decided on level of skill, but the ability to apply those skills may well be context-based, so who gets to decide when and where I practise my skills?
• Is it cheaper for the community when people are working “top of scope”? Although individual health workers may differ in their hourly rates, does this mean that the patient costs drop when we use health care workers with lower annual incomes to deliver services? Who takes over the responsibilities of the “bottom of scope” tasks? What is the cost associated with that shift? Do we measure it? Does it increase the burden of care on patients and their families?
• How do we measure the outcomes of change in practice? How do we ensure evaluation of changes in practice is objective, because conflicts of interest should be avoided in evaluating outcomes. Evaluation of a new intervention should always be benchmarked against existing care and should include a consideration of impacts outside the trial (eg, cost to patients excluded from the trial).
• Is consumer satisfaction sufficient to justify the shift to using fewer highly trained health workers to provide clinical services? If there is an argument to suggest other health workers can achieve the same outcomes, is there a need to alter the curriculum, standards and accreditation of higher trained health workers so there are less expectations and faster, more efficient training?

I thought it may be helpful to reflect on my own “top of scope” journey to consider some of these questions and reflect on the impact of “top of scope” decisions.

When I started in rural practice as the only female doctor within a 3-hour range, I knew there would be a community need for me to upskill in obstetrics, gynaecology and women’s health. Before I could deliver babies, I was required to complete an accredited course, with a curriculum designed by a combined committee of the Royal Australian College of General Practitioners (RACGP) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).

I was examined by obstetricians and GPs, and interestingly, one of my oral questions was designed to ensure I didn’t practice “over my scope”. I was very clear that I had no intention of delivering triplets in a one-bed labour ward 3 hours from tertiary care.

I was credentialled by the RANZCOG and required to continue my continued professional development to maintain my accreditation. My small rural hospital checked to ensure I kept up to date, and my indemnity insurer also checked that I was credentialled. There were consequences, however. In upskilling and working “top of scope” in one area of practice (women’s health) I was acutely aware that I was at risk of deskilling in other, equally important areas of practice (trauma care and chronic disease management). Deepening skills vertically in one area ran the risk of reducing my capacity to manage breadth. I still remember a conversation with my GP supervisor at the time, when I asked him how long it took until you could sleep through the night when a woman was in labour without worrying what might happen. “Five to ten years”, he said, and I think he was right. I still remember his favourite saying “there is nothing more lonely than a primipara who is not progressing in a small rural hospital”. Working at the edge of our scope can be frightening, and I will always be grateful for the supervision I had while consolidating my competence.

My patients, however, knew none of this. Perhaps they read my transcript on my wall, but really, I think, they trusted the hospital to ensure the doctors who worked there were skilled enough to perform the medical tasks they managed.

In contrast, we have the cosmetic surgery industry. Undoubtedly, there are skilled and competent GPs and dermatologists performing important work in this space, particularly when removing skin cancers. However, their dedication, skill, training and professionalism has not been enough to protect the public from rogue operators.

The reality is that although we would like to see all our patients as well informed, capable consumers, many are still vulnerable for a variety of reasons, and may not have the literacy, health literacy or critical thinking skills to detect the difference between highly skilled and less skilled health practitioners. If I reflect on times I have had difficult and serious health decisions to make for myself or my family, I recognise that I have relied on medical guidance, because my capacity to make decisions has been reduced by illness, stress and fear. I suspect many of us are the same. Consumers should not have to evaluate the competence and skills of a health professional to perform a clinical task. They may not have the resources to do so at the same time.

In primary care, we have fewer layers of governance than “St Elsewhere’s” in the inner city. Primary care practitioners can work in solo practice, which may mean their practice can deviate significantly from the norm without being obvious to peers, oversight bodies, or patients. This is particularly problematic in communities where patients are vulnerable: the elderly, people from culturally and linguistically diverse backgrounds, rural and remote communities, and communities that live with socio-economic disadvantage. Working at the edge of our competence increases risks to patients. When risk is increased, there needs to be greater oversight, particularly when health care workers practise in isolation.

Extending our scope of practice: the North Queensland Pharmacy Trials

When professions decide to extend their scope of practice to a new level, how can the community manage this so that patients are protected? What training, assessment, supervision and evaluation are necessary to ensure the most vulnerable members of our community are safe? There will always be keen, enthusiastic learners who will take great pride in mastering new skills, but they are not the problem. As always, the problem lies with the outliers who extend their services without necessarily extending their skills sufficiently to provide safe care to the public.

The North Queensland Pharmacy Trial is a case in point. The national accreditation standards for pharmacy programs do not include the diagnostic skills training required to underpin the urinary tract infection (UTI) trial. When the Pharmacy Guild decided to extend the scope of practice of pharmacists, they designed and delivered online education on the diagnosis and management of UTIs. Unlike rural obstetric training for GPs, the education package for the UTI trial was designed, accredited and evaluated by pharmacists alone, with minimal regulatory oversight from independent agencies. In fact, several organisations including the National Aboriginal Community Controlled Health Organisation (NACCHO) withdrew from the steering committee due to concerns about safety, leaving oversight of the trial to pharmacists. The academics leading the evaluation were also pharmacists.

The trial relies on following protocols for the detection and management of UTIs. By following a protocol, on average, a less skilled practitioner may provide the best antibiotic for the bladder, but we all know the best treatment for a body part is not always the best treatment for a patient.

There are indications that this lack of governance put the public at risk. For instance, the protocol asked whether women were at risk of sexually transmitted infections. Only 6 women of the 6000 women in the trial were classified “at risk” by the pharmacists involved, which seems extraordinarily low, and may account for the cases of chlamydia that were misdiagnosed as UTIs. The evaluation concludes that patients and pharmacists were happy with the trial and would do it again “because of the benefit it would provide for patients”. Concerns about the outcomes of the trial have been dismissed as a “turf war” by doctors.

The trial has been extended indefinitely, with the Queensland government announcing it had been “incredibly successful” despite concerns about outcomes, particularly in Aboriginal communities. There are also plans to extend the scope of pharmacist practice further in the proposed chronic disease management trials.

Supporting primary care practitioners to work “top of scope”

There is always a risk when extending beyond the traditional scope of practice that a profession will not recognise the skills they may need to acquire in order to be safe with the full range of patients they may see. This is why GPs extending their skills in procedural disciplines, such as obstetrics, anaesthetics and surgery, worked with the non-GP specialist colleges to develop curriculum, assessment and standards, to ensure patients received appropriately skilled care. Patients deserve to know that practitioners have skills and resources to manage unexpected complexity.

One of the hardest skills in primary care is always dealing with “unconscious incompetence”, recognising when we do not know what we think we know. Unfortunately, complex patients do not announce themselves in the waiting room so we can redirect them elsewhere. Protocols are usually developed to treat the average patient with the average problem. Following a protocol will, on average, lead to a good outcome. However, the outcome for the outlier may be devastating. Diagnosis is harder than it looks, and making a premature diagnosis without the skills to detect the outliers is dangerous.

If we are to safely enable primary care practitioners to extend their scope we should at least:

• ensure we measure outcomes, not just satisfaction. Good professional practice may not make patients happy (eg, restricting unnecessary antibiotic use in bronchitis to reduce antibiotic resistance);
• involve the primary care practitioner bodies with the greatest expertise to participate in the planning, oversight and evaluation of the trials (eg, involving psychologists, consumers and carers in the teaching of focused psychological strategies to GPs);
• measure the cost, and ensure there is a benefit to the community (eg, seeing a nurse at the nurse-led clinics in the Australian Capital Territory costs four times as much as seeing a GP, and increases accident and emergency visits, so the cost to benefit ratio is low); and
• place the pilots in areas of high demand for services (eg, most of the pharmacy trials were done in large cities in normal business hours so the benefit to the system was low).

If our professions are serious about extending scope of practice, we should consider developing curricula collaboratively. Perhaps in codesigning, we could have serious, balanced conversations about what skills are necessary to protect the public, how those skills could be credentialled, and how health services could receive appropriate oversight. The main issue is ensuring the discipline with the greatest experience (eg, dieticians in nutritional medicine) influences the curriculum, training, assessment and credentialling. Otherwise, we may be training practitioners who are unconsciously incompetent.

Frankly, I don’t think any of us have the right to extend our scope of practice without accepting the responsibility of submitting to appropriate oversight to keep the public safe.

We are operating in a resource-poor environment where we need to use each dollar optimally to improve the performance of the health system as a whole. To do this, we need to use every health care worker in a way that provides the best outcome for the lowest cost. We should be able to work together to assist each other to reach out maximum potential, as individuals and as a system.

Even if it means I don’t get to practise at the “top of my scope” and replace the highly competent midwives at my local hospital.

Louise Stone is a GP with clinical, research, teaching and policy expertise in mental health. She is Associate Professor in the Social Foundations of Medicine group, Australian National University Medical School and works in youth health.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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