The Decibel - How nurse practitioners could help Canada’s primary care crisis
Episode Date: May 15, 2024Canada is in the midst of a primary-care crisis. 6.5 million Canadians don’t have reliable access to a family doctor, and some jurisdictions are turning to nurse practitioners to fill the gap. Alber...ta recently announced a program that would make it possible for nurse practitioners to receive public funding to establish a practice, although it comes with its conditions and concerns from other organizations.The Globe’s national health reporter, Kelly Grant, walks us through the role nurse practitioners have in providing primary care, how they’re funded, and Alberta’s new plan to address the shortage of primary-care providers.Questions? Comments? Ideas? Email us at thedecibel@globeandmail.com
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Through the new program, Alberta's government will compensate these highly trained, highly valued medical professionals to practice patient care and provide the health care they are qualified to do.
That means that nurse practitioners will be able to open their own clinics, take on patients, and offer services that reflect the full extent of their training skills and experience.
Alberta Premier Danielle Smith recently announced a plan that would allow
nurse practitioners to open their own publicly funded practices. This plan could help address
the current shortage of primary care providers in Canada because an estimated 6.5 million people
don't have a family doctor. Today, there are fewer medical students choosing to specialize
in family medicine, according to the Canadian Medical Association.
And as of 2022, nearly one in six family doctors were 65 and older and nearing retirement.
Nurse practitioners can perform many of the same tasks as family doctors, from diagnosing illnesses to making referrals and writing prescriptions.
That's why there's a growing
push for them to do more primary care work across the country. The Globe's national health reporter,
Kelly Grant, has been reporting on those efforts. She's on the show to tell us how nurse practitioners
could help fill Canada's primary care gap. I'm Cheryl Sutherland, and this is The Decibel from The Globe and Mail.
Kelly, thanks so much for coming on the show. Thanks for having me.
So just to get started, what exactly is a nurse practitioner?
A nurse practitioner is a health professional who first trains as an RN, a registered nurse,
then practices as an RN for at least a couple of years,
sometimes longer, and then goes on to do an extra two years of postgraduate training to become a
nurse practitioner. At that point, they have the scope of practice to do a fair number of the same
tasks as family doctors do. They can diagnose illness, they can prescribe widely, they can order tests
and scans, and they can refer to specialists. So it sounds like they can do a lot of the same
things that doctors can do, but how are they different from a doctor and RNs like you mentioned?
So they have less schooling and a smaller scope of practice than doctors do. I think a thing to understand about
the designation of family doctor is that if you're a person who lives in a big city and is lucky
enough to be healthy, you'll probably come across your family doctor doing a lot of fairly basic
things in an office like monitoring your diabetes or, you know, diagnosing your kids when they've got a mystery rash or a sore throat
or an earache. But outside of big cities, especially because Canada is such a large rural
country, family doctors do have this wide scope of practice where they do things like deliver babies,
work in the ER, and every family doctor is trained to be able to do that.
It just depends on how they practice. So those types of things like delivering babies are outside
of the scope of practice for NPs. And a few of the things I mentioned earlier that makes NPs
different from RNs is some of those things like diagnosing and prescribing and ordering certain tests and
doing referrals to specialists. Now, there is a bit of a movement. Ontario was one of places that
has begun this to have RNs do some lower level prescribing that is beginning to happen, at least
in Ontario. So sometimes these distinctions start to get blurry as the health care system tries to figure out how best to use every available hand.
Gotcha.
How many nurse practitioners are there in Canada?
So when I spoke with the Nurse Practitioner Association of Canada, they said the numbers are now approaching nearly 10,000.
The profession is growing at about 10% per year. Now, the most recent national official stats that I can get from the Canadian
Institute for Health Information, which is usually our sort of go-to organization for getting national
healthcare stats, is that there were about 8,000 in 2022. And of those, just a little over 7,000
were involved in direct patient care. So we have about 10,000, you said. How does that compare to nurses and doctors?
So it's a much smaller profession right now than either of those other two. This is, again,
according to CHI-HI, which is the Canadian Institute for Health Information. In 2022,
for RNs, there were just a little over 255,000 RNs involved in direct patient care. And doctors of all kinds, the most recent figure from
CHI-HI, also from 2022, is that there are a little over 96,000 doctors in Canada.
Okay. And what kind of settings do nurse practitioners work in?
Mostly, they work in the acute care setting. And that's a bit of a reflection of the fact
that there haven't really been longstanding payment models in every province to have NPs work in primary care.
So you'll find them in hospitals doing jobs that are a bit more senior and a bit more
medically complex than what an RN does. That's the main place they work now. They do also work
in long-term care. And like I said, they do work in primary care, but the numbers are
more in acute care than elsewhere. Okay. And when we say acute care,
that's basically in hospital settings. That's kind of what it means.
That's correct. Okay. Let's talk a bit about nurse
practitioners in primary care settings. They're often part of what's called a primary care network
or a family health team. Can you just help me understand what that is exactly?
So those you just mentioned are a couple of models of interdisciplinary primary care. The primary care networks is the name of the model that Alberta uses. Family health team is one of
the models that Ontario uses. The idea is that rather than having doctors working in solo practice,
billing the government fee for service, which is where they
bill for each individual unit of care they provide. These teams, the idea is that you'll
have a mix of MDs, NPs, RNs, social workers, dieticians, pharmacists, ideally all working
to the top of their scope to provide care for patients. And what does this look like in a community?
Like how would it function?
Maybe the best example I can give is my own experience as a patient in Toronto where I
live.
I belong to a family health team.
And so I have a doctor who is my doctor.
And when I can see her, she's lovely.
I think she's great.
But if I need a same day or next day appointment and she is full or not available, then I am often directed to either other doctors in the practice or other kinds of professionals.
So I almost only see the NP now, to be honest with you, because I'm fortunate enough to be healthy and to have the kinds of health issues that NPs are well positioned to handle.
But if, for example, I had diabetes and I needed some help managing my diet,
then this practice would also have a dietician they could direct me to.
If I was taking a ton of different medications and I needed to figure out how to manage those
medications or perhaps see what I could get off of, then they have a pharmacist who they
would refer me to. So that's the idea is that you've got all of these professionals in one
building. And as a patient, you can be directed to the right professional to help you have your
needs met. Okay. So Kelly, how are NPs in primary care funded? That is an excellent question. And it depends on where you are in the country. So in primary care, doctors essentially run their own small businesses, and then they treat patients NPs to build a public health system exactly the way doctors build a public health system.
So as a general rule, public funding for NPs usually comes in the form of salaries.
But there are some other funding models in some specific provinces that encourage them to come into primary care.
So in Ontario, for example, within the family health teams that I mentioned,
there are some NPs in those practices who are publicly funded.
Ontario also has something called nurse practitioner-led clinics.
Ontario sort of was ahead of the curve on this and currently has 25 of those clinics,
plus another five that they've promised to fund sometime in the near future. And those are clinics where they can be interdisciplinary,
but the sort of top practitioners there are nurse practitioners, there aren't doctors,
you know, on site and involved in those practices. BC has a couple of nurse practitioner-led clinics as well.
They also have a contract model where NPs can join up with other practitioners and then they are paid a salary, but it's through this contract model that is different from an employee model.
And then the newest thing on the horizon for funding NPs in primary care is what Alberta has just rolled out last month.
So Kelly, we've talked about all these funding models, but I've also heard
about people paying out of pocket to see a nurse practitioner. What's going on there?
Nurse practitioners fit into a bit of a gray area when it comes to the Canada Health Act,
which is the federal legislation that in an umbrella fashion governs
how Medicare works in Canada. It was passed in 1984 when nurse practitioners, for all intents
and purposes, barely existed. And the Canada Health Act specifically applies to medically
necessary services that are delivered in hospitals or by physicians. It mentions physicians by name.
So fast forward now to 2024, and what we have is a world where NPs are more often providing primary
care. But if they work in a province that doesn't have a funding model for primary care NPs, then the only way they can provide primary care and make money
is to charge patients out of pocket. So one of the things that you may have heard about in the news
is cases where, say, NPs join up with physicians and then the office will have like a monthly or annual subscription fee
that you pay to access the NP or the NP just fully advertises here's what it costs to see an NP for
X, Y, and Z and here's the price for an appointment and there is some debate about whether or not they
are allowed to do this but it has been going on at a low level for quite some time because it's just not clearly spelled out that the Canada Health Act applies to them the same way that it does to physicians.
I actually just wanted to ask you kind of a basic question because I think we hear about nurse practitioners as being kind of a potential solution to our primary care crisis in Canada.
I guess, why is there such a focus
on nurse practitioners as part of the solution? I think because everyone recognizes that the line
of people who need a family doctor is just growing and growing and growing. And as a result,
we're looking for what are the other solutions. And if it takes less time to train NPs,
and we have this pool of more than 250,000 RNs right now that we could conceivably draw from,
I think people look at it as one piece of a solution
that could be scaled up somewhat quickly.
We'll be right back.
Okay, so across the country, we've got shortages of primary care providers for a number of reasons. You know, people are choosing not to go into family medicine at nearly the rate doctors are retiring.
The population keeps growing and the need is there because we also have an aging population.
So there are all kinds of different ways to address this.
And Alberta has introduced a new plan that involves nurse practitioners. Can you tell
me how that plan works? This Alberta plan involves inviting nurse practitioners more into primary
care by remunerating them at 80% of what a family doctor is compensated in the province. This is a program that will see them
open their own practices, likely in cooperation with other professionals, including MDs, and then
paid a certain salary every year as long as they work full time and as long as they enroll a
minimum of 900 patients. And the more patients they enroll,
the higher their yearly compensation will be. Wow. 900 patients would be for one practice?
For one practitioner. Practitioner. Okay. You mentioned that nurse practitioners will be able
to have kind of their own practice without doctors. Is this kind of how it would work?
In theory, yes. But in practice, I don't think that's what is going to happen.
Speaking with the Nurse Practitioner Association in Alberta, they think that because the amount
of money that nurses are compensated to run their own practice, it's a gross payment.
And so after that, they have to pay their overhead.
They have to pay their staff.
They have to pay rent.
They have to buy all their supplies.
So they think that probably it's not going to be financially feasible for a nurse practitioner
to join this program and set up an office all by themselves.
What they're already seeing in terms of expressions of interest from NPs and from existing clinics
is that these nurse practitioners will join up with other professionals, almost certainly
including MDs.
So you can imagine a scenario
where you've got, you know, an existing practice of four or five doctors, where one doctor has
been perhaps desperately trying to retire for a few years, but cannot find a family doctor who
wants to replace him or her. That's a scenario where an NP could apply to this program,
join up with that practice, use the available space, contribute to the overhead
and pick up some of those patients who are about to lose a doctor.
You mentioned 80%. Why that number?
To be honest with you, I don't 100% know. I do know that the Nurse Practitioner Association
in Alberta was pushing for full pay equity and feels that if their nurse practitioners are delivering the same services as a family doctor in primary care, that they deserve full pay equity.
But this is what they expected.
On the other side, the Alberta Medical Association, which represents doctors, feels pretty strongly that family doctors with more training and a wider scope of practice
deserve to be paid better than MPs. And Alberta is actually in the midst of putting the finishing
touches on a revamped model for how it pays family doctors and family doctors are expected to get
a considerable raise in that province. But the Nurse Practitioner Association tells me that
what they negotiate
with this 80% number is that it will move in lockstep when the family doctors get a raise.
Gotcha. How are people responding to this news? Do they have a preference of whether they
go to a doctor or say a nurse practitioner in Alberta?
It's hard to say. This is quite new. None of these new practices are open.
I know that from the professionals, like I said,
the Nurse Practitioner Association in Alberta said they've already had 60 expressions of interest to
the government. So there's nurse practitioners who want to take part and there are existing
clinics who want to take part. I have a feeling that when it comes to patients, they just want
primary care. We talked a bit about the pay equity here and the doctor's response, but what about how doctors feel about nurse practitioners coming in and playing more of NPs in solo practice or in groups that
are only made up of NPs. They feel it's important that the NPs have close access to doctors in case
they see a patient whose illness goes outside their scope. Of course, NPs can refer just like
a family doctor if they saw a patient whose needs were beyond their own scope.
At the same time, I mean, I have talked to a lot of doctors individually who seem quite fine with
the idea of adding NPs to the primary care world because they look around and they know so many
people who can't get a doctor, right? They really see and feel they're out for lunch, taking a walk at their kid's school.
And everywhere they look, they see people saying, please, doctor, can you add me to your roster?
Is there any way I can get in?
So I find doctors right now, especially those in primary care, are just so attuned to the fact that so many people can't get care that my experience in talking to them is that even if their official
associations don't necessarily feel this way, that they're more open to the idea of NPs than
perhaps historically they would have been. Yeah, just to get people to see somebody at least.
Could we see what Alberta is doing, could we see this approach be applied elsewhere in Canada?
We might. I think it's going to depend on how things go in Alberta. But if it works well, I could see other provinces considering maybe not the exact same funding model, but something similar.
So we've talked about how nurse practitioners might be a solution to our primary care crisis. But of course, right now, there's just under 10,000 nurse practitioners in the country. Most of them are in Ontario as well.
So is this enough to address this crisis?
Oh, not on its own, for sure.
Right.
It is one piece.
We need more of everything.
I'm also wondering, because you talked about RNs, right?
So there's about 255,000 registered nurses.
I'm just wondering, if we advertise that they could go back to school for two years to become a nurse practitioner, why couldn't that be kind of part of the way to solve this crisis?
Well, that's already being done.
But there's a couple of different things you have to think about there.
One, it depends on how many seats in universities for NPs each province decides to fund.
Right.
So it's not just about saying, hey, RNs, come on out, like,
train to be an NP. There also has to be a scaling up in the number of university seats for them.
And that is happening in several provinces. They are adding seats. They're aware of wanting to
expand this program. But then there has to be the funding models in place so that people who work as RNs can see a future where they can get a job as an NP and where
that job pays in a way that's reflective of the fact that they've got extra education.
Because I'll tell you one thing is that, you know, there are some cases where the NP pay scale is not
all that much higher than the RN pay scale. And especially RNs who are working like shift work
and can pick up a few overtime shifts,
they can make pretty decent money.
And if you take an NP job that's a bit more nine to five,
you may just not have the ability
to sort of like squirrel away the extra money
that comes with picking up a few overtime shifts
at the hospital.
So there's a lot of factors that go into this.
It has to be enticing.
And of course, there's also the factor that if you take away RNs, then we also have an
RN shortage and you'd have to replace them as well.
We do have a huge RN shortage.
And so we have to think about a health human resources strategy nationally, and we have
to think about sort of every stage in the pipeline.
So Kelly, what would be the best solution
to our shortage of primary care providers?
Well, there's no silver bullet.
I wish I had one to offer for you, but I don't.
I think it is safe to say that
a stronger, well-staffed primary care system
that involves more family doctors,
including family doctors who we recruit from overseas,
training more family doctors by increasing the number of seats in medical school and the number
of seats in residency, which is happening, but perhaps not on as steep a scale as we need.
And then expanding the amount of training that or the number of training spots, I should say,
we have for NPs. And then having all of these professionals work together in teams
where they can support each other and where patients can see
the right professional for their needs.
That seems to be, among people who work in the healthcare system,
an ideal model for how they would like things to work.
Now, how you get there, that's always a bit tricky.
But the idea is we need more of everything,
and that includes more MDs and more NPs.
Still a lot of work to be done, but might be possible in the near future.
Well, we can always hope.
Kelly, thank you so much for coming on the show.
Thanks for having me.
That's it for today.
I'm Cheryl Sutherland.
Aja Sauter is our intern.
Our producers are Madeline White and Rachel Levy-McLaughlin. David Crosby edits the show. Thanks so much for listening.