Government & Medicine

What ever happened to the super nurses?

Everybody's keen on nurse practitioners to lighten doctors' loads, but first they want to know ? who's gonna pay for it?

By Susan Usher

Remember that bright and shiny idea being bandied about a few years ago? You know the one, where nurse practitioners (NPs) would swoop in and take over the tedious tasks that clutter your day, leaving you free to do what you and your student loans intended ? practise medicine.

There's ample evidence that NPs can play a valuable role in primary care, but Canada's been pretty slow off the mark getting them into practice. NP training is now available at most major Canadian universities, so why are there less than 1,000 NPs currently working here, compared with over 70,000 in the US?

As usual, it comes down to those old health-reform roadblocks: red tape and money.

ON WHOSE DIME?
Most provinces have passed legislation to define NPs' roles, including diagnosing and treating common medical disorders, ordering some diagnostic tests and prescribing certain drugs; some also include performing minor surgical and invasive procedures. NPs are usually authorized to work with their own caseload, but some provinces, such as Ontario, require them to demonstrate an ongoing consultation relationship with a doctor.

Some questions remain: if they're carrying their own caseload, how should NPs be paid? And how will that affect physicians' caseload and earning potential? The answer? "At this time," reports the Canadian Nurses' Association (CNA), "there is no public policy in Canada supporting a strategy for funding NPs over the long term."

That's not for lack of suggestions. Nova Scotia at one time toyed with the idea of having physician groups hire NPs directly, but that didn't fly with docs. New Brunswick thought NPs adopting a fee-for-service arrangement might be the ticket; that model is no longer so much as mentioned in polite company. The reality in Canada is that most NPs are salaried and working for clinics, health centres or health authorities.

TESTING, TESTING...
A pilot project has been underway in Nova Scotia since 2000 to evaluate the success of integrating NPs in tertiary care centres, small hospitals, community clinics and long-term care facilities. Already, followup by Doctors Nova Scotia (formerly the Medical Society of Nova Scotia) shows that both patients and physicians are very happy with things so far.

Nevertheless, Dr Maria Alexiadis, newly-elected President of Doctors Nova Scotia, isn't ready to go out on a limb and extol the virtues of NPs, preferring to wait until she sees the final report on the now four-year-old pilot. She's especially cautious about what effect NPs will have on physician billing and what degree of autonomy they should have. "We need the actual evidence from the report to see whether this collaborative FP/NP model is a viable approach," she cautions.

Meanwhile, in New Brunswick, a similar pilot launched in February is relying on nurses (not just NPs) to improve access to primary care services at five sites. Nurses and NPs will see patients with chronic conditions to free up doctors to take on new patients and deal with existing, more complex cases. This time, the docs are fully on board ? according to a spokesperson for the New Brunswick Medical Society, the money to fund this initiative came out of the last physician contract negotiations.

HEDGING THEIR BETS
Ontario is currently tabling legislation on expanding the role of NPs in their Family Health Teams. The province has the benefit of a recent report commissioned jointly by the Ontario Medical Association (OMA) and the Registered Nurses Association of Ontario that looked at what works and what doesn't.

Some of the problems have to do with definition of roles, but most are rooted in economics. For doctors working fee-for-service, incorporating NPs can become a "time-management issue," according to Paul McIvor, Communications Advisor at the Ontario Ministry of Health and Longterm Care. That's a polite way of saying that if physicians spend time consulting with NPs, they'll have less time to see their own patients and consequently be able to bill less. But in places where everyone is salaried ? like community health centres (CHCs) ? it "works rather well," admits Mr McIvor. "The positive characteristics of the NP/FP collaboration in the CHCs will likely be replicated in the Family Health Teams."

WE'RE NO (GUARDIAN) ANGELS
The CNA is trying to move away from the idea of NPs as physician substitutes. "That's not what we're advocating," says Lucille Auffrey, Executive Director. "Workers should not be pitted against each other for doing what needs to be done." The CNA's goal is to change the position of between one and 10% of the nursing workforce in Canada and see more NPs integrated into settings like longterm care facilities, community clinics and hospitals. The CNA is currently working with the federal and provincial health ministers to determine the future of NPs, says Ms Auffrey. "We've set a two-year plan and will involve physician groups as well."