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Addressing disparities in access to primary care in Canada will require communities to cultivate their own nurse practitioner (NP) rosters.
Published on June 21, 2024 • Last updated 33 minutes ago • 3 minute read
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Few clinics offer the kind of multidisciplinary team-based care that is essential for older adults and other patients with high needs.
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You're tired of reading, and I'm tired of writing, about how Canada's primary care access crisis means there's no hope of improving the health care system.
One in five adults lacks regular access to medical care. Few clinics offer the multidisciplinary team care that is essential for older adults and other high-need patients. Many patients are referred to specialists, creating backlogs, long wait times, and inevitable health decline that leads to admission to hospitals and nursing homes, straining capacity and raising costs.
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No one disputes this, and there is a sad consensus on what to do about it: increase the salaries of family doctors, open new medical schools, license more foreign medical graduates, etc. Unfortunately, these solutions are a repetition of compounding errors in logic and history.
There is a solution. It may not be a solution for everything, but it is the only sure way to provide a primary care home for everyone who wants one. It is not as elusive as the Higgs boson, the “God particle” proposed in 1964 and discovered 48 years later. It is a practical, ready-to-use solution with a track record of success spanning half a century.
The solution is for communities to develop their own rosters of nurse practitioners (NPs) to fill the capacity gap in primary care. NPs are trained across Canada and typically in two-year master's degree programs that are open to registered nurses (RNs) with a minimum of three years' experience. Most NPs offer distance education and on-site preceptorship, allowing students to train primarily on-site.
Here's how it works:
States would identify unmet primary care needs locally, develop funding models for NP-intensive clinics, negotiate NP scopes of practice and contracts, and provide the new infrastructure needed. Communities would sign on to the care model, define who they served, and recruit RNs from their local area to train as NPs.
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To make the move attractive, trainees would be paid $60,000 per year for the two years of their training, with tuition waived. In return, the trainees, already established in the community, would work in local primary care practices for several years. Currently, NPs earn at least 30-50% more than RNs. The move would be attractive to many.
There are more than 300,000 RNs in Canada. The program aims to recruit 1% (3,000) into NP training each year for at least three years. Over four years, that would result in 9,000 new primary care NPs. At 800 patient visits per NP, that would amount to 7.2 million patient visits, more than the 6.5 million people currently without regular care.
With an additional training cost of $25,000 per student per year, the total cost per graduate would be $170,000, a fraction of the cost of training a family physician, for a total four-year cost of $1.53 billion, or roughly $400 million per year.
The Canadian government currently sends more than $45 billion a year to the provinces, so a breakthrough solution for just 1 percent of that amount is a rare bargain.
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It may take a year or two to scale up educational programs and apprenticeship capacity for 3,000 new candidates. Some jurisdictions and communities may be more enthusiastic than others. It may take four or five years before the public sees a significant impact. That's much sooner than never seeing it at all.
Most physicians view the NP option in the same way that the Catholic Church views the ordination of women: as an existential threat to the sacred realm, a threat that would not exist if family physicians had not embraced interprofessional practice and abandoned rural Canada so many years ago.
The key existential threat is to our health care system, which is endangered by a health care access crisis that has spun out of control under the watch of government and physicians.
Family medicine's problem isn't NPs, it's that its value proposition is declining. The future of family medicine is evolving to play a central and unique role in the system. Family medicine should be willing to cede areas of practice to NPs and other skilled specialists and focus on the more complex patients returning from the specialists.
The NP option would not only be a major win for the general public, it would propel family medicine toward long-overdue reform, transforming it into a rewarding and irreplaceable profession. To paraphrase the late Sinead O'Connor, family physicians would be fighting their real enemy: the frightening prospect of their own looming obsolescence.
Stephen Lewis has been a health policy analyst and health researcher in Saskatchewan for 45 years and is currently an adjunct professor of health policy at Simon Fraser University. He can be contacted at slewistoon1@gmail.com.
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