The United States: Regulating strict scopes of practice
In the United States, the regulation of health professions primarily falls to the states. State-based laws and regulations define specific legal scopes of practice for health professionals including the health services that can be legally offered (e.g., controlled acts) and the circumstances under which these services may be provided (the context for professional practice). Regulation occurs under the auspices of a range of state agencies, including departments of health, education and state in which regulatory boards are housed. The configurations of state boards vary in scope of authority, level of autonomy, and control over administrative processes . A 2020 report on state regulatory structures provides a comprehensive overview of these configurations and included survey responses from 161 representatives in 45 states and the District of Columbia . In 26 of these jurisdictions, regulatory boards had full autonomy in decision-making; 16 states employed a mixed model where some regulatory bodies had autonomy while others used a central agency for decision making. Four states relied exclusively on a central agency for decision-making and boards functioned only in an advisory capacity.
Although states have the constitutional authority to govern regulatory processes, the federal government is able to influence state governance. Recent advisory opinions from the Federal Trade Commission and several court rulings, including one from the US Supreme Court, cite the inherent risk in self-regulation, i.e. the potential for professional self-protection  and monopolistic practice in violation of federal anti-trust laws . These advisories recommend active oversight of certain board decisions by external bodies  to avoid unnecessarily anti-competitive outcomes. Several states have proposed changes in the structure of professional regulatory boards or have created centralized review boards with the power to accept or reject board recommended regulatory changes [28, 29].
A critical challenge associated with the regulation of health professions is state-to-state variation in scope of practice, which is limited by the location of the professional rather than by their skills and competencies. Most health professionals in the U.S. are trained in nationally accredited educational programs using standard curriculum and most complete national competency exams. Despite these national standards, some states limit a health professional’s ability to practice to the full scope of their demonstrated professional competency. State based laws can restrict practice, which is especially relevant in times of crisis, and can also impede the provision of health services across state boundaries .
State licensing laws may also impede services when the consulting clinician is licensed in a state other than the one where the patient is located. To address this barrier, some states have opted to join interstate licensure compacts that allow a clinician who meets licensure requirements in one state to practice in other states in the compact. Although the models differ in detail, there is now a nurse licensure compact effective in 25 states  and an interstate medical licensure compact effective in 29 states and DC . Other professions are developing interstate compacts as well, including emergency medical personnel and physical therapy. These compacts have been especially useful during the COVID-19 outbreak in the US, allowing clinicians to cross state borders and practice where there was great demand for health workers. In addition, in response to the need to quickly build workforce surge capacity during the pandemic, some states issued emergency regulations allowing physicians, nurses and other health professionals licensed and in good standing in other states to practice in their state.
Efforts to recognize new professions or modify scope of practice for existing health professions usually require the enactment of or amendment to state law, a process which is typically slow and, at times, adversarial. States often solicit input on proposed changes from stakeholders, including professional associations and, to a more limited extent, consumer groups. Emerging professions with fewer resources to mount advocacy campaigns may be disadvantaged in this process by more powerful and well-funded professional constituencies in a state.
Scope of practice regulations also affect the distribution of health professionals. Currently, the practice locations of physicians are highly predictive of the practice locations of nurse practitioners (NPs) and physician assistants (PAs). Supervision requirements often result in the co-location of NPs and PAs with physicians, which limits their dispersion in underserved areas and results in reduced primary care capacity, especially in rural locations. A 2018 study that examined supply and distribution of NPs in the US found that the supply of NPs in geographic areas designated as health professions shortage areas was highest in states that recognized more autonomous scopes of practice for NPs . In response to the COVID pandemic, some states temporarily waived supervisory requirements for NPs and PAs, which enabled them to practice where needed.
Health care in the U.S. is changing and these changes have heightened discussion about the impacts of scopes of practice on access to needed services. Enacting regulations to support overlapping scopes of practice among health professionals is at the crux of many of the contentious debates occurring in states. Standardizing scopes of practice for health professions based on competencies would enable service delivery unencumbered by state boundaries. Proposing the establishment of new professions and expanding practice for existing professions must be based on the best available evidence and be within the parameters of training and competency for the profession .
Canada: Regulating flexible scopes of practice through tasks
Health professional regulation falls under provincial and territorial jurisdiction in Canada. As such, and despite national level accreditation and educational standards for many professions, there is substantial variation across the country in terms of regulatory models, which professions are regulated, and the activities that are regulated. As in the US case, this results in differential access to providers and services across the country.
What is common across Canada is the self-regulatory status of most health professions via the statutory delegation of authorities to the ministers of health to establish regulations, and to regulatory authorities (often called regulatory colleges) to govern their respective professions [35-37]. The introduction of new regulated health professions and scopes of practice changes therefore require either legislative or regulatory amendment. Professional regulatory authorities are responsible for establishing entry-to-practice credentials, maintaining a public register of health professionals, upholding standards of practice, and overseeing complaints and disciplinary proceedings. The regulators are expected to act in the public interest, which distinguishes them from professional associations that focus on professional interests [36-40].
The traditional model of health profession regulation across Canadian provinces is based on separate statutes and exclusive scopes of practice for each profession. There has been a trend to move away from this model towards umbrella frameworks characterized by overlapping scopes of practice [36, 37, 41-51]. This began with the Regulated Health Professions Act, 1991 (RHPA)  in Ontario and other provinces have since followed with similar umbrella legislation.
Umbrella frameworks apply uniform standards to the health professions that are governed by the legislation. The legislation sets out consistent provisions for governance, registration, complaints, discipline, appeals, public representation, regulation and by-law making powers. The umbrella act is accompanied by specific regulations or statutes for individual professions that confer title protection and include broad, non-exclusive scope of practice statements. These legislative statements are then used by the regulatory bodies to develop competencies, guidelines, and standards of practice. Legislative scope of practice statements and regulatory policies generally set the outer limits of the professions’ scope of practice.
In addition to title protection and non-exclusive scope of practice statements, the umbrella legislative frameworks enumerate a number of controlled or restricted acts. These controlled or restricted acts are an effort to balance promoting interdisciplinary care while still restricting higher risk activities to specific professional groups . The same controlled activities may be granted to more than one profession and may also be delegated. The dominant position physicians maintain in the health care system is reflected in how many controlled acts they are authorized to perform .
The introduction of overlapping scopes of practice through the non-exclusive scope of practice statements and controlled acts model is also intended to enhance flexibility in the provider(s) who deliver services, as well as encourage interprofessional practice [45-47]. Other statutory changes to encourage collaboration, team-based models of care, and new providers have accompanied or followed the introduction of these umbrella frameworks [43, 48-50]. Newfoundland and Labrador, for example, has established the Council of Health Professionals, an independent body that is responsible for coordinating the regulation of eight health professions. In Ontario, 2009’s Regulated Health Professions Statute Law Amendment Act  mandated the health regulators collaborate in the development of standards where controlled acts are overlapping.
Umbrella legislation with overlapping scopes of practice does not entirely prevent scopes of practice from being a barrier to collaborative, team-based care, as it effectively entrenches a narrower range of controlled activities . A 2018 report commissioned by the Ontario government identified the current system as ill-suited for the future since it prevents a health professional from embracing a broader scope of practice or engaging in a controlled act even if that professional can demonstrate an appropriate level of competence . These umbrella frameworks have nonetheless been considered a key instrument for introducing regulatory flexibility and loosening the restrictiveness of scopes [42, 48]. At the very least, “Umbrella legislation with more flexible scopes of practice provides a possible foundation for collaborative models of care” [18, p. 54].
Another Canadian province, Nova Scotia, has taken an alternative approach to facilitating regulatory collaboration and flexible scopes of practice. In 2012, Nova Scotia introduced the Regulated Health Professions Network Act  to establish a statutory Network of self-regulating health professions that enables voluntary regulatory collaboration. The Network legislation authorizes regulatory authorities to enter into agreements respecting the interpretation or modification of scopes of practice without the need for further legislative amendment, provided the provincial health minister determines the agreement is in the public interest . Reform is currently proposed in British Columbia that would see a reduction in the number of regulatory authorities from 20 to six ; this reform recognizes that regulating single professions in isolation does not allow regulatory colleges to respond nimbly to the complexities of modern team-based care.
Health professional scopes of practice in Canada have traditionally been enshrined in regulatory regimes on the basis of history and politics rather than best utilizing skills and knowledge best meet contemporary population health needs . That seems to be changing with the complement of regulatory reform recently undertaken and currently proposed in Canada to facilitate collaboration and provide more flexibility in order to support health workforce innovations. The COVID-19 pandemic has necessitated further emergency reforms to facilitate surge capacity; however, the continued reliance by most Canadian provinces on discrete regulatory authorities for individual professions and the lack of national coordination around scopes of practice form barriers to interjurisdictional mobility and efficient health workforce reform.
Australia: National consistency in outer boundaries of scope of practice
Australia has seen a major transformation to the legal framework and institutions governing the regulation of health practitioners. Historically, the health professions were regulated by statute in models that were primarily profession specific and were based on both restricting practices and titles. This had the impact of constraining or protecting scopes of practice through statute and being relatively unresponsive to the changing needs of the population and design of the health care system and workforce. The legislation and institutions regulating health practitioners were separated not only by profession but also replicated for each of eight jurisdictions in the federation. This was a highly fragmented and duplicative system for a country relatively large by land mass yet with a small and distributed population. Despite having mutual recognition mechanisms, this model presented mobility barriers, different professional standards, and regulatory costs to practicing across borders.
In 2010, Australia moved away from this state/territorial regulatory system to the National Registration and Accreditation Scheme. This scheme was established with the enactment of the National Law (beginning with the Health PractitionerRegulation National Law Act,  enacted in Queensland as the host jurisdiction, followed by uniform legislation in the other states and territories). The National Law covers 15 registered professions. One regulatory agency, Ahpra, manages this scheme while 15 National profession-specific Boards establish professional standards for registration and practise for their respective professions. The National Boards are responsible for registering professionals, imposing any necessary conditions on registration, developing standards and codes of conduct, and considering complaints about registrants.
Scope of practice regulation in Australia is now primarily accomplished through title protection under the National Law and minimal scope of practice restrictions by the National Boards. The National Boards develop registration standards about the scope of practice of registered health practitioners and also address roles and competencies in broad terms in documents such as practice standards and codes of professional conduct, where there is often a requirement that the health professional recognize and work within the limits of their competence and scope of practice. For example, the Nursing and Midwifery Board of Australia includes a requirement that nurses practice within their scope of practice. The regulator defines scope of practice as “that in which nurses are educated, competent to perform, and permitted by law” and adds that “actual scope of practice is influenced by the context in which the nurse practices, the health needs of people, the level of competence and confidence of the nurse and the policy requirements of the service provider” [60, p. 6]. As such, the National Boards do not provide detailed explanations of scope of practice or regulate through restricted acts but rather maintain the outer boundaries of practice through their registration and practice standards.
The National Boards are also authorized under the National Law to “endorse” the registration of certain professionals. An endorsement recognizes that a health professional has an extended scope of practice in a particular area of practice because they have additional qualifications that are approved by the National Board . Registered nurses may be endorsed as nurse practitioners, for example, and dentists may be endorsed for the approved area of practice of conscious sedation. Each National Board sets the requirements for endorsement for areas of practice within their profession. These endorsements thus provide an expanded scope built upon the foundation and inclusive of the professional’s original scope of practice on registration in the profession.
In addition to endorsements, specialties and specialist titles may also be developed by the National Boards. As of the time of writing, specialist registrations may be granted in dentistry, medicine, and podiatry. A ministerial council comprised of the health ministers of all eight state and territories and the Commonwealth approves the standards set by each National Board for entry to practice, for endorsement of registration for advanced practice, and for specialist registration .
While the factors leading to endorsement and specialist registration by a National Board are generally straightforward, the expression of these expanded scope of practice is often shaped by federal, state, and territory legislation around funding and prescription drugs that can form a barrier to practicing to full scope [63-65]. This has been found in particular in relation to nurse practitioner scope of practice where jurisdiction and clinical context continues to be a major influence on defining scope of practice [63, 64]. Further, employers or professional associations may develop their own lists of skill sets that define scope of practice within specific settings or may use credentialing to verify the ability of practitioners to provide specialized practice within specific organizational environments .
As such, there remain jurisdictional differences in scopes of practice for some Australian health professions due to state legislation, clinical context-specific guidelines, and employer or professional association-level credentialing. However, the uniform legislation and regulatory authorities operating nationally provide title protection and set the outer boundaries of practice through registration and practice standards. This national coordination has been used during the COVID-19 pandemic response to facilitate a short-term sub-register for fast tracking a return to the workforce for experienced and qualified professionals  and to provide national guidance on telehealth .
The United Kingdom: Differing regulatory approaches in a complex landscape
In the UK, there are ten separate statutory organisations, mostly called councils, that regulate health professionals. These ten regulatory authorities have a common set of core functions: setting standards for registrants, quality assuring courses of higher education, keeping the register, and managing allegations that registrants are unfit to practise. Despite the common set of activities, there are differences in legislation, standards, approach, and efficiency reflecting the way that the councils have evolved over many years. Some of the councils regulate single professions, while the Health and Care Professions Council (HCPC) regulates 15 different professions; some regulate hundreds of thousands of registrants while some only regulate a few thousand; some have been in existence for a long time while others were founded much more recently. Most are UK wide bodies except for the regulators of pharmacy and Social Work England which regulates social workers in England only.
The ten statutory regulators are overseen by the Professional Standards Authority for Health and Social Care (the Authority) that conducts and publishes regular performance reviews for each of the regulators. The Authority also reviews all final hearing decisions in fitness to practise cases and can take action where it believes the decision is not sufficient to protect the public. The Authority shares good practice in the sector, conducts research, and promotes new ideas such as right-touch regulation .
Determining scope of practice is complex and multi-faceted in the UK with many influences. As well as the professional regulators, there are many other organisations in the UK responsible for regulating different aspects of health systems and services. Professional regulators are just one of a somewhat crowded landscape governing practice, and individual scopes of practice are influenced by local or institutional factors. Since the core focus of professional regulators in the UK is ensuring fitness to practise, a crucial challenge is ensuring there are governance and oversight arrangements to mitigate the risk to the public when individual professionals practice outside their scope of competence.
Among the 10 professional regulators in the UK, there is no common approach to determining scope of practice, nor is there any agreed definition of scope of practice. One commonality is that regulators routinely state in their standards of practice that registrants are responsible for recognizing the limits of their knowledge, skill, and experience, and must not practice unless they are capable of doing so safely and effectively. Where they provide more detailed guidance on the limits of practice, they do so in different ways.
The HCPC, for example, defines scope of practice for registrants as “the limit of your knowledge, skills and experience. It is made up of the activities you carry out within your professional role, provided that you have the knowledge, skills and experience to do them lawfully, safely and effectively.” . In the standards of conduct, performance and ethics, the HCPC prescribes that registrants must refer a service user to another practitioner if the services needed are outside a practitioner’s scope . The HCPC publishes standards of proficiency guidance  for each of the 15 professions that it regulates, and notes that while these standards of proficiency may inform a registrant’s scope of practice, job descriptions, employer policies, legal restrictions, coverage by professional indemnity insurance, and guidance from professional bodies will also inform scope of practice. The HCPC thus prompts practitioners to determine their scope of practice based on their professional judgment.
The General Dental Council (GDC) takes a more formalized approach, publishing a document specifically addressing scope of practice for all of its registrant groups (dental nurses, orthodontic therapists, dental hygienists, dental therapists, dental technicians, clinical dental technicians, and dentists). Unlike the HCPC’s approach, which focuses on specific knowledge areas, the GDC sets out the tasks that each group can undertake. Establishing first, like the other regulators, that scope of practice describes the areas in which registrants have the knowledge, skills and experience to practise safely and effectively, for each group it then distinguishes between the skills and abilities all registrants in the group should have, additional skills which could be developed with further training, and additional skills that can be carried out if prescribed or directed from another registrant . The guidance also defines what certain groups do not do; dental hygienists, for example, “do not: restore teeth, carry out pulp treatments, adjust unrestored surfaces, extract teeth.” [73, p. 7]. For registrants working at the highest level of risk – dentists – the guidance is at a higher level of abstraction rather than a list of tasks are in and out of scope: dentists may “diagnose disease…prescribe and provide endodontic treatment on adult teeth…prescribe and provide fixed orthodontic treatment” [73, p. 11]. This may be changing, as the GDC is currently engaged in a scope of practice review to explore whether its guidance document is working as intended. The aim of this review is to “provide as much flexibility to dental professionals as possible, so they are using their own professional judgment about the provision of care” .
While it is clear that scope of practice will evolve over time, both at the individual and the profession level, it is not clear how the arrangements and influences by which scope of practice is currently determined at either level in the UK influence this evolution; for example, whether they present barriers to innovative approaches to the delivery of care, particularly in the wake of the COVID-19 pandemic. Nor is it clear how these different arrangements and influences relate to different levels of risk being managed by the different professions, and whether there are areas of unmanaged risk to patient safety.