Ontario's RxP initiative

On June 28, 2007, former Ontario Minister of Health and Long-Term Care (MOHLTC), The Hon. George Smitherman, requested that the Health Professions Regulatory Advisory Council (HPRAC) provide advice on a number of issues to support the government's commitment to ensure the health profession regulatory system keeps pace with the health care needs of Ontarians. One of the issues was the prescribing of drugs by non-physician health professionals.

In response, in January 2009, HPRAC released “Critical Links: Transforming and Supporting Patient Care,” a report which recommended a regulatory system that would enable Ontario's health professionals to contribute to patient care to the fullest extent of their training and abilities, to collaborate with each other to produce the best possible results for patients, and to respond to the rising expectations of health care consumers.

HPRAC described the challenges facing the health care system, including the changing demographic make-up of the province. It was noted that Ontario is growing, aging, and become more urbanized and more diverse, creating new and more complex needs. HPRAC argued that rapid changes in population needs, coupled with advances in technology and clinical practice, place enormous demands on professionals to keep pace; demands that must be met not only by working the maximum extent of their capabilities, but also by developing new competencies.

With respect to prescribing, HPRAC noted that Ontario's health care system faces challenges in the areas of access, efficiency, and sustainability. Allowing additional qualified health professionals to prescribe was considered integral to more efficient and effective patient-centred care.

The Ontario Psychological Association's RxP Initiative

In 2007, the Ontario Psychological Association (OPA) set up a task force to examine the issue of prescription privileges for psychologists, and explore the interest of the members in pursuing this expansion of practice. The development of the Task Force was announced through the Listserv with significant support from members. The OPA membership was also surveyed with regard to their support of expanding their scope of practice to include prescriptive authority. The survey indicated that 83 percent of members were extremely supportive of this initiative. The remaining 17 percent of members requested more education on the initiative. Given this level of support, the OPA Prescriptive Authority Committee was struck to move forward on submitting the request to the MOHLTC.

It is the position of OPA that extending the scope of practice of psychologists to include prescriptive authority would positively impact mental health care in Ontario. By substantially increasing health human resources in psychotropic prescribing and management, psychologists would fill gaps in professional services, improve access, and reduce wait times. Given that they are highly trained and qualified mental health professionals, psychologists with prescriptive authority would enhance the quality and efficiency of services and reduce risk of harm to patients.

With the ability of psychologists to integrate psychotherapeutic and psychopharmacologic modalities and standards of practice there would be improvement in patient outcomes, reduced system fragmentation, and better consistency of care. There would be benefits as well with respect to the economic burden of mental health care delivery through fewer hospitalizations and re-hospitalizations, and reduced visits to hospital emergency rooms and walk-in clinics.

The Process of Expansion of Scopes of Practice

Requesting changes to scopes of practice in Ontario first requires a letter of intent be sent to the MOHLTC, who would then charge HPRAC with providing direction to the minister regarding the request.

HPRAC has criteria that it relies on in the consideration of advice to the MOHLTC concerning a potential change in the scope of practice of a health profession in Ontario. Where there is a sponsoring organization or profession, the proponent is asked to complete a questionnaire to describe its response to the criteria. HPRAC then sets out to determine relevant public interest concerns and questions, and attempts to understand all perspectives on an issue including those of key health care practitioners, other affected health care professionals, clients and patients, advocates and regulators.

Each issue proceeds through a multi-stage process where information and responses are requested from and shared with stakeholders. HPRAC will conduct literature, jurisdictional and jurisprudence reviews, and engage in key informant interviews. Its analysis of the issues will lead to a determination of additional information required, and the appropriate process to be used.

OPA decided to assist HPRAC with their duties by meeting with stakeholders to determine support and with the College of Psychologists of Ontario to secure their agreement to regulate prescribing psychologists prior to developing our submission.

The OPA Submission

On Nov. 9, 2012, OPA forwarded a letter to Hon. Deborah Matthews, then the MOHLTC, requesting that the scope of practice of psychologists in Ontario be extended to include prescriptive authority. This was accompanied by a 165-page submission corresponding to HPRAC criteria, as well as supporting letters from the College of Psychologists of Ontario, and representatives of U.S. jurisdictions who are pursuing or have been granted prescriptive authority.

We outlined necessary changes to legislation to allow psychologists to prescribe substances that fall within the definition of “drug” as set out in the Drug and Pharmacies Regulation Act, R.S.O. 1990 related to appropriate Schedule I drugs. This would include adding the following to the Psychology Act, 1991 :

Treatment includes, for prescribing psychologists, the ability to prescribe psychotropic medications within the recognized scope of the profession, including the ordering and review of laboratory tests and other diagnostic tests in conjunction with the prescription, for the treatment of behavioural and mental conditions, the diagnosis of neuropsychological disorders and dysfunctions and psychologically based psychotic, neurotic and personality disorders and dysfunctions.

The response from the MOHLTC to our submission was overwhelmingly positive, but before Minister Matthews could refer it to HPRAC, Premier Dalton McGuinty prorogued the legislature, effectively bringing government to a standstill. Following his subsequent resignation, the Hon. Kathleen Wynne was appointed as the new Premier. Given that Ontario now had a non-elected Premier leading a minority government, no decisions were to be made that would require legislative change. Eventually, an election was held, and a new MOHLTC was appointed, Dr. Eric Hoskins. This was followed by a rather prolonged period to allow the new minister to get up to speed.

Current Status of the OPA RxP Initiative

With the appointment of a new minister, there were also staffing changes throughout the bureaucracy, and so we had to start again by meeting with new ministerial staffers, parliamentary assistants, assistant deputy ministers and the deputy minister. We met with the Deputy Minister Dr. Bob Bell, on March 8, 2015, and find ourselves once again in a holding pattern while the MOHLTC reviews the OPA submission.

During all of the delays, the OPA Prescriptive Authority Committee did not sit idle. We continued to meet with stakeholders and other healthcare associations to garner support. When we previously went through this process, we received incredible assistance from the Nurse Practitioners Association of Ontario, the Ontario Pharmacy Association, and the College of Family Physicians. The only exception was the Ontario Medical Association (OMA), whose psychiatry section was adamantly opposed to RxP. After ongoing discussions, however, the OMA is considering supporting our submission, as is the Royal College of Physicians and Surgeons. This is, of course, very exciting.

We have also asked the MOHLTC to grant the right to execute Form 1s for involuntary psychiatric admissions and hospital admission and discharge privileges to psychologists. We have been meeting with other healthcare associations who are seeking expansion of practice, or pursuing initiatives that require legislative or regulatory change, so that we can move forward together.

We recently held a reception at Queen's Park, our Legislature, where representatives of OPA met with elected officials from all three parties to discuss initiatives including RxP. We had a number of ministers and MPPs (members of Provincial Parliament) speak about the necessity of expanding our scope of practice. There does indeed seem to be good momentum on the government side.

OPA also started a public education campaign through our new website and social media platforms regarding the benefits to psychologist prescribing. We are meeting with patient and other advocacy groups who are already concerned with gaps in the mental health system in Ontario. These well-organized and media-savvy groups will help us to drum up public support for RxP.

We now have quite a number of Ontario psychologists enrolled in postdoctoral master's programs. The OPA Prescriptive Authority Committee is working with Dr. Bob McGrath of Fairleigh Dickinson University and the Ontario Pharmacy Association to develop a Canadian-content curriculum for FDU's postdoctoral master's in psychopharmacology.

We have also come to an agreement with the Nurse Practitioners Association of Ontario to establish prescribing nurse practitioners (who have been granted the same prescribing authority as physicians) as potential supervisors for the clinical supervised experience portion of RxP training. This will provide an alternative for our members should it prove difficult to find willing physicians.

In conclusion, we don't know what the future holds for the RxP initiative in Ontario, but the OPA submission has been well-received by the MOHLTC, and every other healthcare association that has pursued prescriptive authority has been granted it. The OPA Prescriptive Authority Committee remains optimistic that our request to expand our scope of practice will be successful.