Proponents of a greater role for nurse practitioners are hoping shortages in the healthcare system — from hospital beds to primary care physicians — will ease as nurse practitioners start to manage their own practices in the new year.
“We can spend more and more on hospitals, or we can get smart and put more money into keeping the chronically ill at home, into services in the community, into high-quality nursing homes with a nurse practitioner on site so the moment someone gets sick, they’re not in an ambulance,” said University of Alberta professor and researcher Donna Wilson.
She said Alberta’s health care should be proactive, not reactive.
Almost 80 per cent of patients admitted to hospital in Canada come through the emergency room doors. That tells Wilson patients aren’t being seen by primary care providers in time to nip things in the bud.
“How can you book a patient in for surgery or a medical workup when 80 per cent of the patients in the ER are there over something that hasn’t been tended to? Now they’re acutely ill and you have to admit them,” Wilson said.
The system’s been reactive — not proactive — for a long time, she said.
“These people haven’t been properly cared for. It’s not a car accident but a chronic illness that’s been getting a bit worse and a bit worse. Alberta has not looked at what other provinces and countries are doing — there are alternatives,” she said, citing the widespread use of nurse practitioners in Ireland.
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“You can get a nurse practitioner in for half (what a doctor is paid.) They’re going to be on salary, which means instead of a six-minute doctor visit, you may get an hour to sort out why the patient has five conditions that are interrelated,” Wilson said.
In England and Ireland, seldom-used small rural hospitals have been turned into sub-acute “cottage hospitals,” where recuperating patients get up and walk after surgery, Wilson said.
“When you look at what the U.K. and the U.S. did in terms of putting more emphasis on wellness, and nurse practitioners working independently — we are way behind,” Wilson said.
“They have nurse practitioner clinics for small stuff and for elders.”
Where the dollars go
In Alberta, health care spending ran $24.5 billion last year. Doctors cost $6 billion, the province’s 106 hospitals (80 per cent of them small rural facilities) cost $4 billion. Continuing care cost $3 billion, Wilson said.
Just under 12 per cent of what Alberta spends on health care is for chronic illness. Most provinces spend 15 per cent on continuing care and home care, recognizing that people mostly have chronic illness, Wilson said.
“This is a big indicator that we put our money into hospitals.”
Back when then-premier Ralph Klein got rid of half the province’s hospital beds, health care ate up just 25 per cent of the province’s budget — and Klein thought that was too big a chunk.
Now, the health care system consumes almost 40 per cent of Alberta’s budget. The provincial population is approaching double the numbers than under Klein, and the number of hospital beds is still just two-thirds of what it was when Klein took his budget axe to them.
“It would be tough now to open more beds as we are so short of nurses and we have such an expensive health care system,” Wilson said.
So much of the health care dollar goes into acute care, to hospitals and doctors, and there is very little left for home care and continuing care to keep people stable outside of the hospital, Wilson said.
The (UCP) government has quietly set up groups to advise on what the new acute care should look like, and they’re having meetings for continuing care too, Wilson said.
Dozens of private consultations are going on around the province as the UCP government shapes its plan to rejig the Alberta health care system from stern to stethoscope.
Hospice groups, home care researchers, business people — all are asked to ponder the same questions, Wilson said. “What should we be spending our money on? How much money do we need?”
Nurse practitioners deepen primary care pool
Under the province’s new plan, hundreds of thousands of Albertans without a primary care provider will soon be able to make successive medical appointments with the same nursing practitioner.
Independent nursing practitioners will soon carry their own panels of patients, like a primary care physician does, and bill AHS directly for their salary — not specifically paid a fee per each visit as doctors have been — but paid by the roster.
“The fee-for-service model is good if you need a one-off appointment, if you’re in and out quickly,” said Susan Prendergast, president of the Nurse Practitioner Association of Alberta.
In November, the NPAA received a $2 million grant from the UCP government to develop the model and to recruit and to help nurse practitioners implement it.
“They’ll be setting up clinics in small communities that don’t have anybody, or continue to work as is but they’ll have their own panel, so you’re opening up the doors to thousands and thousands of people who don’t have anybody,” she said.
Prendergast has a doctorate in nursing, and has taught at Dalhousie and the University of Victoria. She currently teaches undergrads advanced pharmacy, pathology and health assessment — and she’s a nurse practitioner with her own business. She has had her own specialized private practice “for a long time” and plans to stay in private practice.
Pay-for-fee billing and the proposed flat salary shouldn’t be conflated, Prendergast said.
Between the physicians and the nurse practitioners, there have been competitive sparks in the wake of Premier Danielle Smith’s announcement of bigger roles for nurse practitioners.
Estimates for scope-of-practice cross-over between the two roles may be as high as 95 per cent of the same things, Wilson said.
Ontario, New Brunswick, Nova Scotia, British Columbia and Quebec all have embraced some form of nurse practitioner independence — scopes of practice vary among the provinces.
According to the Canadian Institute of Health Information, as of 2020 Alberta nurse practitioners were able to conduct advanced health assessment and diagnosis. They can order and interpret diagnostic tests, consult with and refer to other health care professionals, prescribe medical supplies, roster and manage patients, and prescribe pharmacotherapy.
Alberta nurse practitioners are restricted from prescribing controlled substances, having full hospital privileges, admitting patients to long-term care facilities, and completing Form 1 for involuntary admission to hospital.
“We have the exactly same scope of practice, and we can do the same thing,” Prendergast said.