Nurse Practitioners - An Effective Intervention to Address Primary Care Access Concerns in Alberta
This is a guest article written by Anne Summach, President of the Nurse Practitioners Association of Alberta.
In recent years, Alberta has found itself facing an ever-increasing access to care gap and has undertaken attempts to address the gap through mobilizing multiple professionals to provide access throughout the system. This has been accomplished through optimization of pharmacists, working to recruit physicians to rural or hard to recruit areas of the province, and incorporation of Nurse Practitioners (NPs) into primary care. These efforts have been moderately successful, but there is more work to be done to ensure that the approximately 25% of Albertans without access to primary care can receive the care that they need.
The Role of the Nurse Practitioner
NPs are not new professionals in the healthcare landscape. The role was first introduced in the 1960s to address access issues in rural and remote communities in Canada’s north. However, in the 1990s, the role was supported as one way to reform primary care delivery (RhPAP, 2020). NP-led clinics have been integrated in Ontario since 2006 and assist the Ministry of Health there to provide cost-effective care to residents across the lifespan.
NPs provide advanced clinical care which aligns most closely with family physicians within the community. NPs are one of the most studied professions within healthcare and have been proven to provide equitable care to other clinicians, and improved client satisfaction (McMaster Health Forum, 2011). However, NPs have done a notoriously poor job promoting their role within the public, which has led to confusion about their role. Certainly, we need to raise awareness of the role that NPs can play in primary healthcare, and their ability to provide care that is as safe and effective as primary care physicians - a role that is well known in Canada. NPs are able to practice primary care independently but can also participate in interprofessional care teams which provide holistic support for Albertans.
Nurse Practitioners as a cost-effective primary care addition
Evaluations of healthcare systems have been conducted which demonstrate significant concerns with efficiency, cost effectiveness and optimization of care provision across work areas. Hospitals struggle with cost containment, primary care services are often redundant and duplicative, and professionals well suited to support primary care are not funded in a way that allows them to address community needs. NPs can contribute to solutions to these problems if government works together to remove barriers and enable novel methods of delivering cost-effective care to Albertans.
According to much of the literature, a key method of reducing costs and improving health outcomes is to shift care out of institutions and back into communities, where a network of supportive organizations and healthcare professionals can optimize wellness and prevent illness or functional decline. Optimizing NPs within this type of framework requires clarity of their role, and innovative solutions to incorporating them into care delivery (FPT Committee on Health Workforce, 2020). Incorporating NPs in primary healthcare is not a novel concept but has been proposed since the early 2000s. A brief from McMaster University in 2011 identifies the problem: integration of NPs into primary care settings is critical due to the increase in chronic disease, the aging of the population, and a lack of cohesion nationally in how NPs are used and supported by governments.
A paper published that reviewed NP practice across multiple countries, including Canada, described how mobilizing NPs in primary care achieved the following (McMaster Health Forum, 2011):
● Improved access to care and reduced wait times
● Patient satisfaction remained stable or increased
● Moving some care from physicians to NPs did not reduce patient safety or impair outcomes
● Stable physician income and improved physician satisfaction where NPs were added to communities where physicians were closed to new patients.
In Ontario, projections for healthcare spending by 2030 estimated that four-fifths of the provincial budget would be allocated to healthcare, a financial situation which is untenable (TD Bank Financial Group, 2010) and has been analyzed by various commissions over the years. In Alberta, the recent AHS evaluation delivered by Ernst & Young in 2020 also highlighted the need for NPs to be more thoughtfully integrated into care frameworks in order to improve quality and access to care for our province’s residents. In fact, the report highlights NP roles as “critical to providing consistent and high-quality patient care” (p. 24). Currently, relative inequity in pay between primary care providers (NPs and physicians) is a disincentive to enhancing the primary care NP workforce (Ernst & Young, 2019).
NPs in Alberta
Alberta has not moved aggressively to incorporate NPs in the community, and other provinces have surpassed us in their use of NPs. Both British Columbia and Ontario have well established programs to fund NP positions in primary care, leading to 70% of their NP workforce being situated in communities rather than hospitals or specialty clinics. In Alberta, distribution of our over 700 NPs is completely opposite, with most NPs working in acute care of outpatient clinics. This has occurred due to the lack of a funding structure for non-employee NPs. Though the Government of Alberta has initiated some programs to fund NPs in primary care, they do not sufficiently reduce barriers to deployment, nor do they recruit skilled NPs from other provinces (Black, Fadaak & Leslie, 2020). Those NP graduates who are interested in primary care medicine often leave Alberta to take positions in more supportive provinces or south of the border. Instances where NPs have been added to Alberta communities have found their cost-effective care relieved strain on the primary care system, and also allowed for a greater focus on preventive care and wellness services (Hunter et al, 2016). Truly, NPs are often the “right provider, in the right place”, to address the needs of Albertans.
It is essential for the future success of healthcare ventures in Alberta, and for the goal of ongoing fiscal sustainability, that government consider formalizing the position of NPs within healthcare in the province. Also crucial is establishing a framework for funding and distribution of NPs within the system that is competitive nationally. Recruiting NPs who are experienced at primary care delivery will ensure strong initial performance and contribute to acceptance of the role by Albertans. Often what will be convincing is a story of care by NPs heard from a friend, and these stories abound. Where NPs have been incorporated into primary care structures, Albertans love them.
The Nurse Practitioner Association of Alberta (NPAA) regularly fields questions from individuals eager to find an NP for their primary care, and regularly disappoints them. Elected officials will advance change and ensure access for their constituents by raising awareness of access issues within their jurisdictions, by educating themselves on the role of NPs, and by lobbying decision makers to address barriers to full and widespread integration of NPs within primary care. For more information on NPs, their role, and how you can help, go to albertanps.com. You can also reach out to the NPAA for specific guidance on how to address access issues for Albertans within your neighborhoods (secretary@albertanps.com).
References
Black, S., Fadaak, R. & Leslie, M. (2020). Integrating nurse practitioners into primary care: policy considerations from a Canadian province. BMC Family Practice, 21:254. https://doi.org/10.1186/s12875-020-01318-3
Ernst & Young LLP (2019). Alberta Health Services Performance Review. Ernst & Young Global Limited. https://open.alberta.ca/dataset/c0724ccd-832e-41bc-90d6-a0cd16bc6954/resource/1e03ea8a-7948-48c4-bca4-109c20ce0f02/download/health-ahs-review-summary-report.pdf
FPT Committee on Health Workforce (2020). A vision for the future of nursing in Canada. Principal Nursing Advisors Task Force, April 2020.
Hunter, K., Murphy, R., Babb, M. & Vallee, C. (2016). Benefits and challenges faced by a nurse practitioner working in an interprofessional setting in rural Alberta. Nursing Leadership, 29(3), 61-71. https://doi.10.12927/cjnl.2016.24893
Myers-Connors, M (2020). Nurse Practitioners in Rural and Remote Communities. RhPAP, retrieved from: https://rhpap.ca/news-events/ruralnps/
McMaster Health Forum (2011). Addressing the integration of nurse practitioners in primary healthcare settings in Canada.
TD Bank Financial Group (2010). Charting a path to sustainable healthcare in Ontario: 10 proposals to restrain cost growth without compromising quality of care.