On March 7, 2017, the report prepared by the Health Professions Regulatory Advisory Council ("HPRAC") evaluating chiropody and podiatry in Ontario was released to the public. In June 2007, the Minister of Health and Long-Term Care (the "Minister") had made its initial request that HPRAC assess the profession and determine whether there should be any amendments to the existing legislation. The Minister directed that the project begin by January 2014. On August 31, 2015, HPRAC submitted its final report to the Minister.
Chiropodists and podiatrists are regulated under the Chiropody Act, 1991 (the "Act") and are members of the College of Chiropodists of Ontario (the "College"). Chiropodists are authorized to perform certain acts as are set out in Section 5(1) of the Act. Under Section 5(2) of the Act, Podiatrists, who are categorized as its own class of members, are authorized to diagnose foot diseases or disorders, and perform bone surgery on the foot, in addition to those acts that chiropodists are authorized to perform. The Act has prohibited the registration of any new podiatrists in Ontario since 1993.
HPRAC's review focused on: (1) the current model of foot care in Ontario; and (2) the regulation of chiropody and podiatry in Ontario. Following its review, HPRAC made the following observations and recommendations.
The Foot Care Model
Ability to Access Care
Most chiropodists and podiatrists in Ontario practise in private settings. In those clinics, only podiatrists are eligible to bill OHIP, with an annual amount of just $135 per patient available to be recovered. Therefore, many of those individuals who require foot care cannot afford to obtain it. Even those practitioners who practise in publicly funded clinics do not always accept new patients. Patients who are fortunate enough to be accepted often experience long wait times.
Preventative Foot Care
HPRAC stressed the importance of preventative foot care. Preventative foot care would increase quality of life and alleviate some of the pressure on the healthcare system by reducing the need for more costly foot procedures down the line that are covered by OHIP.
Accordingly, HPRAC recommended that the Minister consider: (i) enhancing access to foot care services and devices in Ontario by expanding or increasing the number of centres where such services are provided; and (ii) examining whether this increased access will alleviate costly foot surgeries.
Regulation of Chiropody and Podiatry
Expansion of the Scope of Practice
In the healthcare context, "scope of practice" is utilized to define the procedures, actions and processes that a group of practitioners is authorized to perform. Under the Act, the scope of practice for chiropodists and podiatrists is "…the assessment of the foot and the treatment and prevention of diseases, disorders or dysfunctions of the foot by therapeutic, orthotic or palliative means".[1]
HPRAC considered expanding the scope of practice to include new authorized acts, such as granting the authority to:
- chiropodists to diagnose diseases and disorders;
- chiropodists and podiatrists to order laboratory tests;
- chiropodists and podiatrists to order radiographs;
- chiropodists to perform bone surgery on the foot;
- chiropodists and podiatrists to perform bone surgery on the ankle;
- chiropodists and podiatrists to dispense and sell drugs (as the current authority is only to prescribe drugs); and
- chiropodists and podiatrists to administer injections in areas other than the foot.
HPRAC assessed the possibility of expanding the scope of practice by determining whether the profession has the ability to meet the necessary standards to implement these changes, as well as the need for such changes. HPRAC utilized the following factors in making its decisions:
- relevance to the profession;
- risk of harm;
- education and accreditation;
- leadership's ability to favour the public interest;
- profession's support and willingness to comply with regulation;
- economic impact; and
- public need.
Ultimately, HPRAC did not support increasing the scope of practice. HPRAC felt that there were not sufficient evidence-based reasons to justify doing so. HPRAC believes that the most significant needs for the public are accessibility of services and preventative foot care, and that expanding the scope of practice would instead create a foot care model that focuses on advanced foot and ankle surgery.
Titles of Chiropodists and Podiatrists
The report stated that the general public, and even healthcare providers, do not understand the distinction between the roles of chiropodists and podiatrists. As a result, HPRAC discovered that foot care is not obtained in the most expeditious manner, as patients are unclear as to where they should obtain these services. The terms "chiropodist" and "podiatrist" are often used interchangeably. Over the last two decades, all provinces but Ontario have adopted the titles "podiatry" and "podiatrists" to describe all practitioners within the profession.
HPRAC concluded that the use of two distinct titles within one profession is confusing. The use of a single title with different designations would encourage public understanding. Therefore, HPRAC recommended that practitioners registered as "chiropodists" transition to the title of "podiatrists", practitioners registered as "podiatrists" transition to the title of "podiatric surgeons", the College alter its name to "The College of Podiatrists of Ontario", and the title of the Act be amended accordingly.
Expansion of the List of Approved Medications
While HPRAC did not recommend that the Minister expand the list of approved medications prescribed by chiropodists and podiatrists, it did suggest that the Minister take this matter under consideration. HPRAC acknowledged that the current list might very well be outdated, as additional and more effective drugs not previously approved may now be available on the market.
New Podiatrists in Ontario
HPRAC considered whether the Minister should permit new podiatrists to be registered in Ontario. HPRAC determined that there is currently no evidence to suggest significant public need for the services offered solely by podiatrists. To the contrary, it felt that the public requires greater access to routine, affordable and basic foot care as is provided by chiropodists. As such, HPRAC recommended that the Minister maintain the prohibition of the registration of new podiatrists.
Additional Considerations
Throughout its review of the profession, HPRAC was continually reminded of the need to provide access for preventative and affordable foot care to the public. While beyond the scope of the project, HPRAC suggested that the Minister consider whether foot care services should be publicly funded and whether the foot care needs of the public require a greater role for chiropodists and podiatrists in foot surgeries.
[1] Chiropody Act, 1991, s. 4.
