Joint Committee on Health debate -
Wednesday, 1 Jun 2022

Health and Social Care Professionals Act 2005 (Section 95(3)) (Variation of Title: Chiropodist) Regulations 2022

Chairman

There will be two sessions to this meeting. In this session, we are meeting officials from the Department of Health to discuss the order passed by the Dáil on 31 May and by the Seanad on 24 May on the proposal that both Houses approve the following regulations in draft: Health and Social Care Professionals Act 2005 (Section 95(3)) (Variation of Title: Chiropodist) Regulations 2022.

All witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if the witnesses' statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with all such directions.

From the Department of Health, I welcome Ms Alessandra Fantini, principal officer in the professional regulation unit, and Mr. Aidan Tumbleton, assistant principal officer. I call Ms Fantini to make her opening remarks.

Ms Alessandra Fantini

I thank the committee for the opportunity to address it on the draft regulations to be made by the Minister for Health to protect the title of "chiropodist" as a variant of "podiatrist".

The Houses of the Oireachtas are being asked to approve the following regulations in draft: Health and Social Care Professionals Act 2005 (Section 95(3)) (Variation of Title: Chiropodist) Regulations 2022. These regulations are being made pursuant to the Health and Social Care Professionals Act 2005. The Act provides for the protection of the public by promoting high standards of professional conduct, education, training and competence through statutory registration of the health and social care professionals designated under the Act. Regulation under the Act is primarily by way of registration of practitioners and the statutory protection of professional titles. The use of protected titles is restricted to practitioners granted registration under the Act. Registrants must comply with a code of professional conduct and ethics and are subject to fitness to practise rules similar to those applying to nurses, midwives and doctors. The structure of the system of statutory regulation comprises registration boards for the professions, a committee structure to deal with disciplinary matters, and the Health and Social Care Professionals Council with overall responsibility for the regulatory system. These bodies and the executive are collectively known as CORU. The Act prohibits a person whose name is not on the register from using the title of a designated profession and provides that CORU may initiate a criminal prosecution summarily to enforce the prohibition on a designated title's misuse.

When the podiatrists' register completes its two-year transitional period on 31 March 2023, the title of "podiatrist" will be protected. The Podiatrists Registration Board contacted the Department in 2019 requesting that the title of "chiropodist" also be protected as a variant of podiatrist. The registration board's view is that the public cannot be adequately protected without protection of this title. In its correspondence to the Department, the registration board set out a number of reasons for its view. It stated that many members of the public, particularly the older generation, still use the title "chiropodist", and it is concerned that some of those who will choose to use that title may not have the correct skills to treat patients. If the title "chiropodist" is not protected in the State, there will be practitioners who may take advantage of this and choose not to register with the regulator but continue to use the title.

The registration board highlighted that the HSE still uses the title chiropodist for some of its podiatric staff and grading system. Therefore, the terms continue to be used interchangeably even in the professional field. This only adds to the likelihood that the public could unwittingly use the services of an unqualified professional. The fact that a high percentage of these professionals are in private practice raises the risk to the public in this regard. In short, if the title of chiropodist remains unprotected then those practitioners who do not want to submit to the oversight of a regulator could legally continue to practise using the title and the public could unwittingly continue to use their services. The Health and Social Care Professionals Council would have no powers to initiate a prosecution against the practitioners.

The Department sought the view of one of the main professional bodies - the Society of Chiropodists and Podiatrists. The society welcomed the protection of the title chiropodist as a variant of podiatrist and agreed that the two titles are used interchangeably by the public. It highlighted that the term chiropodist is the original term but the English-speaking world has moved towards the term "podiatry" in the recent past. The view of the professional regulation unit is, therefore, that the variant title of "chiropodist" should be prescribed in order to protect the public and ensure that its use is restricted to qualified professionals registered with the Podiatrists Registration Board.

Section 95(3) of the Health and Social Care Professionals Act 2005 provides that the Minister for Health "After consulting the registration board of any designated profession ... and any organisations that he or she considers appropriate, the Minister may, by regulation, prescribe one or more than one title that is a variant of the title specified in that section for the profession".

Section 95(7) provides that:

A regulation may be made under subsection (3) only if—

(a) a draft of the proposed regulation has been laid before the Houses of the Oireachtas, and

(b) a resolution approving the draft has been passed by each House.

The Podiatrists Registration Board opened its register on 31 March 2021 and the transitional period for existing practitioners to register will end on 31 March 2023. Once the transitional period ends the title "podiatrist" will become a protected title. Subject to the approval of the Houses, it is proposed that these regulations will come into effect as soon as possible, which will allow the title "chiropodist" to be protected as soon as the transitional period ends.

I thank everyone for their attention and I am happy to take questions.

Chairman

I thank Ms Fantini and open up the debate to questions.

Deputy Bernard J. Durkan

I thank Ms Fantini for her presentation and the delegation is very welcome. How did use of the two titles and descriptions come about? Was it a result of European law, European generated law, the professionals or between the new and old professions here? I refer to the podiatrist as opposed to the chiropodist. Who asked to be moved up the line?

Mr. Aidan Tumbleton

To be perfectly honest, I am not 100% sure. Both titles have been interchangeable for a long time. The Irish professional group had settled on the title "podiatrist" around the time that the 2005 Act was passed as the title it was going to use in future. As Ms Fantini has said, there is still a bit of carryover and perhaps a generational thing where some people will still use the title "chiropodist". I think that the third-level course is now called podiatry but we think, for the protection of the public and to remove ambiguity, we need to cover both titles.

Deputy Bernard J. Durkan

There is an obvious need to remove any confusion that might arise. However, it would be helpful if the committee knew who requested, organised and progressed this initially so that we now have two professional descriptions? We note that the older professional, which is the chiropodist, may or may not have the same qualifications.

Mr. Aidan Tumbleton

They will be required to have the same qualifications to register with CORU. It is the same profession but we have two titles that are in common usage. I think that the title of "podiatrist" was decided on just at the time of Act, and that was the third-level course and that was what it was called but, historically, the two titles have been used interchangeably. They are used interchangeably in other European jurisdictions so the UK and EU states.

Deputy Bernard J. Durkan

Is it possible that some chiropodists may be told at a later stage that they no longer fit the description and, therefore, no longer have the necessary qualification and are no longer employable?

Mr. Aidan Tumbleton

CORU did a very active information campaign in the run up to the regulation of the profession and the title was designated as far back as 2005. Anybody practising in the profession knows that the two titles are used interchangeably.

Deputy Bernard J. Durkan

Is there a disadvantage to using either title?

Mr. Aidan Tumbleton

I do not foresee any, no.

Chairman

Clearly, as there is an anomaly whereby one is called a chiropodist and the other a podiatrist so the legislation fills the gap. Am I correct?

Mr. Aidan Tumbleton

They are the same profession. There is no difference and it is just two titles.

Deputy Colm Burke

The UK has left the European Union and Mr. Tumbleton mentioned that people in the UK call themselves "foot care practitioners". I presume that unless people are physically registered here they will not be entitled to practise here, which applies both to people who come from other European countries or the UK.

Mr. Aidan Tumbleton

CORU seeks to protect the titles of podiatrist and chiropodist. Anybody who wants to practise under those professional titles must be registered with CORU. If not, then CORU has an enforcement option to take a prosecution for the misuse of a protected title. CORU will also buttress that with an information campaign that tells people if they want to avail of these services to please check that the professional is on the CORU register.

Deputy Colm Burke

I know that a person from the UK does not have the same right to practise here as they are now non-EU. What about if someone comes here who is registered in Germany and has a qualification? Will he or she still be required to register here before setting up a practice? I ask because I know of instances where people have come here from abroad and set up a practice but I would seriously question whether they have the required qualifications. For instance, there are people providing scanning services but there does not appear to be a registration system regarding the provision of scanning services. I have no difficulty with suitably qualified people. Will qualified people who come here from other European counties be aware that they must register here? If so, what checks and balances are in place?

Mr. Aidan Tumbleton

If they come here from another European country then they will be assessed under the professional qualifications directive. CORU will look at their qualification and map it out against the Irish qualification. If there is a shortfall in training then CORU will offer a period of adaptation or, alternatively, the person can do a competence exam. If CORU finds that a qualification matches with the Irish qualification then CORU will recognise the EU degree, and allow the professional to register and practise in the State. Therefore, that professional will appear on the Irish register and the Irish public can check whether his or her qualifications are registered and thus be reassured that a person is a properly qualified practitioner.

Deputy Colm Burke

What if someone sets up in this country without going through all of that process on the basis that he or she argues that he or she is entitled under European law to practise in any one of the 27 member states? Who checks that these people are registered?

Mr. Aidan Tumbleton

If such people practise under the professional title then CORU can initiate a prosecution, as we discussed, for misuse of the professional title.

Deputy Colm Burke

CORU now has a whole range of professions that it supervises so has CORU the capacity in staffing terms to do all of the required checks?

Mr. Aidan Tumbleton

Yes, Deputy. CORU has an enforcement team that pursues exactly this issue. In 2020, the team had its first successful prosecutions. An unregistered occupational therapist and an unregistered speech and language therapist were prosecuted for the misuse of title.

Deputy Colm Burke

Yes.

Chairman

Would this have come from a complaint made by a customer?

Mr. Aidan Tumbleton

It would. It can be either a member of the public notifying CORU or alternatively CORU's enforcement wing can take a prosecution off its own bat.

Senator Martin Conway

I thank our guests for the presentation. What is being proposed makes sense. Is there a shortage in this profession? There are skills shortages in many areas and I am interested to know what the situation is here. Second, has anybody from Ukraine started practising here? What is the story with assessing Ukraine's qualifications compared to those in Ireland? I am interested to know if there are specific examples of any of our Ukrainian refugees practising.

Ms Alessandra Fantini

I will try to address the Senator's first question and I will hand over to my colleague for the second. In terms of the specific profession, I am not aware of any shortage but we know the agency has embarked on a big recruitment drive across all professions, including health and social care professionals. It is targeting health and social care professionals to implement the shift to community care that it is trying to effect with the reform of Sláintecare. The number of health and social care professionals in general has increased by 157 whole-time equivalents, WTEs, from the end of December to the end of April. The agency is addressing recruitment in a number of different ways. I apologise that I do not have a specific view on shortages. They have not come to our attention in this particular profession, but I can make inquiries of my colleagues.

Senator Martin Conway

One would assume that things are reasonably okay if it has not come to Ms Fantini's attention. I am sure if there was a crisis she would be aware of it. That is fine.

Chairman

The anecdotal evidence is that there is a shortage, depending on who one talks to.

Senator Martin Conway

Unless there is a complete breakdown I would imagine that if there was a problem, Ms Fantini would be aware of it. What about the Ukrainian element of the question?

Mr. Aidan Tumbleton

CORU has three applications from Ukrainian professionals in train at present. I understand it has received approximately 20 inquiries. The Medical Council of Ireland and the Dental Council of Ireland have both received approximately 100 inquiries from Ukrainian professionals but, as yet, have received no formal applications. English language ability and qualification recognition will be key to ensuring they are safe to practise. Departmental officials are actively engaging with the health professional regulators regarding practitioners arriving from Ukraine. The intention is to ensure that these practitioners will be assisted and facilitated in gaining access to the professional registers, where possible, mindful at all times of the importance of maintaining and promoting public safety.

Departmental officials are part of a co-ordination group established by the European Commission to examine the registration of Ukrainian health and social care professionals arriving in EU states as a result of the conflict. This group shares knowledge and best practice and is examining methods to streamline and expedite the recognition of Ukrainian professionals, including the use of electronic databases, the EU information centres for academic recognition and machine translation tools. On top of that, all Irish health regulators have been linking with the Ukrainian Embassy, providing designated points of contact for Ukrainian professionals and translating the information into the Ukrainian language.

Senator Martin Conway

It is to set up a one-stop-shop.

Mr. Aidan Tumbleton

Pretty much, and the HSE is working with that as well.

Senator Martin Conway

The Department probably needs to carry out an information campaign in that regard among the Ukrainian community because many of them do not have a clue where to go, what to do or how to approach it. The Department has to provide some information in Ukrainian and target it at the various groups. There are ways and means of doing that. I am sure the ambassador would be very helpful in that regard.

Chairman

On the timescale for registration and checking qualifications, how long does that take?

Ms Alessandra Fantini

In general?

Chairman

Yes. If somebody from abroad wants to register, is it a lengthy period, a couple of weeks or months?

Ms Alessandra Fantini

My understanding is that it varies on where people are coming from and how familiar CORU would be with their qualifications if they are from outside the EU or EEA member states. CORU has also put in place many measures to try to expedite and shorten the times. Normally, somebody would have to apply for recognition of his or her qualification and then the person can register once his or her qualification is recognised. One of the measures CORU has put in place is to implement a type of parallel track where it tries to ensure that applicants start on both to shorten the timeframes a little. There also has been an increase in its staffing in respect of recognition and registration in the last number of years. A backlog arose during the years of the pandemic, but the timing is between eight and 12 weeks. I do not have the exact figure but I can refer back to you with it, Chairman, because we have it. I will be happy to do that.

Chairman

The other matter is the importance of diabetics and so forth getting their feet checked. Again, the anecdotal evidence I have is that this is a challenge depending on where one lives. In rural areas there is probably a smaller chance of chiropodists being in those areas. Even in urban areas, however, and in Tallaght in my constituency, I have heard of people having difficulty trying to access services. The importance of it for diabetics, in particular, is that one can lose toes and it is important that people go to qualified people who know what they are doing. There is also an eye check for diabetics. It is important that people regularly check their feet, particularly if they have diabetes although there are probably other illnesses as well.

You mentioned that in the legislation it is a criminal offence for those who are not qualified to practise. Is there a fine as well, and what is it?

Mr. Aidan Tumbleton

It is a class A fine or six months in prison.

Chairman

Okay.

Deputy Bernard J. Durkan

Are there any hidden obstacles that we might not know about at this stage in respect of registration? The first obstacle that is likely to arise is registration. Presumably, qualification is the first issue and whether the professional qualification has been achieved. I saw in some other areas that this did not work as smoothly as was intended. I am not referring to CORU's area. From their knowledge, do the witnesses know if there are any issues that have come up already or are likely to come up or are anticipated?

Ms Alessandra Fantini

Is it specific to podiatrists?

Deputy Bernard J. Durkan

Chiropody.

Mr. Aidan Tumbleton

This registration board has moved quite quickly. This is a very well-established profession compared to some of the other professions that CORU is trying to regulate at present, which can be more challenging. This registration board will move from establishment to opening the register in just two years. I believe the education entry level has been set already and we do not foresee any challenges with it. It is a well-established, long-standing profession with an agreed entry level and scope of practice. We do not foresee anything.

Deputy Bernard J. Durkan

The witnesses have not been alerted to the existence of anything.

Mr. Aidan Tumbleton

No, certainly not.

Deputy Bernard J. Durkan

In other words, in a transitionary period such as this normally one would be alerted by one or other organisation as to the difficulties it might present. There will be no such instance.

Mr. Aidan Tumbleton

No, I do not think so. CORU has done very good work on this and it is moving very quickly.

Deputy Bernard J. Durkan

I thank the witnesses.

Chairman

Finally, you mentioned that there was one successful case in respect of a person who was not registered. Are cases such as that prioritised in the courts system, as I imagine it would be if it was a doctor? Is it similar? I am not speaking specifically to that case.

Mr. Aidan Tumbleton

It was two cases in 2020, Chairman. You might think that this is quite a low level of activity but I believe that what usually is sufficient is that CORU will alert the practitioner and if the practitioner is not aware of the regulations in Ireland, it is sufficient for the enforcement team to contact the practitioner and inform him or her that he or she must go through the process. In such a case, where it is simply a misunderstanding, it is often not in the public interest to pursue that case all the way to the High Court with all the expenses involved in that.

I understand that the particular circumstances in those cases warranted pursuing them all the way to the High Court. It is often sufficient just to engage with the practitioner and to tell them what the rules are in Ireland and that they need to get their qualifications recognised and to get on the register. However, it is my understanding that they are quite active.

Chairman

Again, I know nothing about the system. If the individual is to continue operating during two years of court proceedings, however, that could be quite lucrative. The other area that was pointed out was practitioners not using the title. I assume they could call themselves foot care practitioners or whatever. That is where the wriggle room is within the law, but I do not see that could be legislated for.

Mr. Aidan Tumbleton

The Chair has touched on a good point. People often ask why we do not regulate by scope of practice but the reality is that many CORU professions, and medical professions generally, have overlapping scopes of practice, which makes that simply not possible. In addition, the scope of practice in emerging professions will develop and change over time, often quite rapidly. We protect by title because it is what we can hang the regulation on. We then rely on public information campaigns and customer empowerment. We tell people that these professions are regulated and that they should check the register. That is what we rely on.

Ms Alessandra Fantini

CORU has embarked on a media campaign through radio advertisements in recent years to raise awareness among members of the public that they can check the registers. Practitioners who are registered may also use the CORU branding and name in their business correspondence or in any sort of advertisement.

Deputy John Lahart

I thank the witnesses. There was an issue a number of years ago with regard to physical therapists and physiotherapists. Is there any similarity between that issue and the matter we are discussing today?

Mr. Aidan Tumbleton

Again, we are protecting a variant title so it is quite similar in that "physical therapist" is a term that was often used interchangeably with "physiotherapist". That is what we are trying to accomplish here. Thinking back to Deputy Durkan's question, that was more problematic because there was a distinct group of practitioners who were practising as physical therapists and who had a slightly different scope from that of physiotherapists. That does not arise in this case. The same professionals are using the titles "chiropodist" and "podiatrist" interchangeably. It is the same legislation but, if we look at the nuances, we can see that it is a different issue. I would say that this is a lot less problematic or complex.

Chairman

Are there standards for the profession arising from the legislation or is that separate work for the organisation that organises chiropodists? If someone goes in for an appointment and it lasts ten minutes while another person goes in for an hour, they will still be charged the same amount. Again, I have no experience in this area but I am told that some practices operate like factories and just churn out patients. I assume there are standards within the profession. You also learn not to go back to that individual.

Mr. Aidan Tumbleton

I guess what the Chair is talking about is really a customer service complaint. What the registration board is going to do is to set the entry-level standard for education so any Irish customer going to see a chiropodist or podiatrist will know that person has been educated to the appropriate level to be a safe practitioner. They will also know that the practitioner has signed up to a professional code of conduct to which they are held accountable and that he or she is engaged in continuing professional development. People will also know that any practitioner who engages in professional misconduct or whose professional performance is poor will be subject to enforcement measures such as fitness-to-practise hearings. The Irish public will have that assurance once the register opens.

Chairman

That is all the questions we have. I really appreciate the witnesses coming in and giving us their time. We will now go into private session for a few minutes to wait for our next round of witnesses.