Sudbury District Nurse Practitioner Clinics

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Ontario Hansard- 10-December2015

MmeFrance Gélinas: It is my pleasure, this morning, to add a few comments on the record regarding Bill 144, the budget bill. The first thing I want to put on the record: I will quote from a letter from Jennifer Clement, a nurse practitioner from my riding who is the director of the very first nurse practitioner-led clinic. I'm very proud that the very first nurse practitioner-led clinic was in Sudbury. It is a great place. They do great work. They look after thousands of people who did not have access to primary care before, and they do this in a way that is rated top-notch. Whenever they do a survey of their clients, it always comes out that clients love them, the system loves them and the clinic works.

But we have an issue-and I'll quote from Jennifer. She had discussed with me the problem the clinic had "recruiting a nurse practitioner for a vacant maternity leave position which has necessitated the entire team pitching in to cover that patient load and the strain it has placed on the team. We also discussed the fact that due to financial constraints, our budget has remained unchanged for over six years yet costs around us continue to rise due to cost-of-living increases."

Things have not improved. Throughout the system, one in five nurse practitioner positions in primary care is vacant. Why is that? It's because the government made a promise during the last election campaign. They promised that they were going to look at the salaries and compensation of nurse practitioners. Nurse practitioners working in primary care haven't seen a penny of change in their compensation for the last eight years. Yet, during those eight years, the scope of practice of nurse practitioners has changed dramatically.

You will remember, Speaker, that they used to prescribe from a list-I don't know who ever dreamed that up, but it certainly did not work. They now have open prescribing, and prescribe whatever is most appropriate, except for narcotics. They never used to be able to look after a patient in the hospital; now they are often the primary providers of care in our hospitals. They work in our emergency rooms. They work in our CCACs. They work in our long-term-care homes.

But the problem is that as new positions were created in our hospitals, in the CCACs and in our long-term-care homes-those salaries were basically rolled out with an understanding that they should be paid more, given that the scope of practice and responsibility had increased. But the salaries of the ones in primary care, the ones who give us access to the rest of the health care system, have been frozen for eight years, and that's wrong. If you look through the different primary care models, whether it be community health centres, aboriginal health access centres, community-led nurse practitioner clinics or community family health teams, their salaries have not moved.

All of the primary care sector has been frozen. I highlighted nurse practitioners, but things are no better for dietitians. If you go through the health care system and you look at the number of vacant positions for a nutritionist or dietitian, it is really hard for an interdisciplinary team to do their work the way they're supposed to when they cannot recruit. Why is that, Speaker? It's because they have not seen a penny increase in one sector of the health care system, that is primary care-while the other sectors haven't seen a bonanza or anything like that; don't get me wrong. We're talking about a very modest increase. But over the eight-year period, those modest increases make a discrepancy of over tens of thousands of dollars sometimes between what you would get for Jennifer, who has been a nurse practitioner for the last eight years.

Had she stayed in her position at the hospital as a registered nurse, she would have better wages, she would have a good pension plan with HOOPP, and she would have a good set of benefits. She has chosen to go back to work, pay for her schooling, become a nurse practitioner, offer access to thousands of people who did not have access to primary care before by working in an underserviced area, and yet how do we compensate her for that? Less than she would have made. This has to be changed. We have a budget coming, and those issues have to be addressed.

I'm not the only one saying this, Speaker. We have received-and I'm sure all of us have received-hundreds of emails. We've received letters from physicians. Dr. Lori Chalklin, Dr. Stephen Duncan, Dr. Alicia Gallaccio, Dr. Dana Pintea, Dr. Kim Walsh, Dr. David Wallik, Dr. Chris Williams-and the list goes on and on, Speaker-all say the same thing: that if you want primary care to do what it's meant to do, to offer access, to help with disease prevention and health promotion, to help people take charge of their own health, then you need to fund those teams in a way that allows them to do recruitment and retention of their highly capable staff. But none of this is happening in Bill 144, in the budget bill.

This week I had the opportunity to talk with the occupational therapists. They have put forward a very good model that would make interdisciplinary rehab teams-so think physiotherapists, occupational therapists, speech-language pathologists, kinesiologists, and I am missing one that will come to me shortly-and make sure that those teams are available to people who live in long-term-care homes. The way the changes have been made to physiotherapy payments has wiped out access for the people in long-term care to an interdisciplinary rehab team. But they make such a big difference, Speaker. If you can give the patient in long-term care access to an interdisciplinary rehab team, people who need to be fed will be able to feed themselves because the occupational therapist will show them adaptations they can make so that they can hold their fork or their spoon and they can hold their bowl and feed themself even if they are hemiplegic or had a stroke. They have a lifetime of knowledge and skills that help people stay as functional and independent as possible.

It's the same thing with-rather than having a two-person transfer, if the person can help themself, you only need a one-person transfer. It's the same thing with toileting, transferring in and out of the tub; it's the same thing with a number of activities of daily living that occupational therapists, physiotherapists, speech-language pathologists certainly-you know, we look at how frustrating it is for people who cannot communicate what their needs are. If you can't communicate, no wonder you get angry and act out, and then they get overmedicated and we spend millions of dollars on anti-psychotic drugs for people who just need an opportunity to communicate.

This is what speech-language pathologists do. They give people who cannot communicate an opportunity to say what they want, to be heard, to be understood. And all of a sudden, once you're able to communicate, the frustration goes away. The acting out goes away. The need for anti-psychotic medication-that was not needed in the first place-goes away-and the number of falls. They make a huge difference.

But yet again, we have a budget that has changed the way rehab dollars are allocated, in the worst possible format, so that none of those services are available to people living in long-term-care homes anymore, and that's wrong.

This budget bill had an opportunity to right this wrong, and it needs to be changed so that the funding model-we're not asking for more dollars here, Speaker. I want you to fully understand that. We're not asking for more dollars. We're asking for dollars that already flow, to be accessible in ways that are not accessible right now, so that it would change the level of activity, the level of independence, of tens of thousands of people in our long-term-care homes. But this budget bill does not allow us to do that.

I have to put a little bit on the record regarding the OMA and physician compensation. Speaker, nothing good comes from a unilateral agreement. Nothing good comes when you refuse to talk. What they're asking for is the same thing as every other workers' group. Yes, I know that physicians are well compensated, and, yes, I know that they are part of the 10%. This is not what the discussion is about. The discussion is about a group of very important workers in our communities-physicians-being able to have an opportunity to negotiate an agreement-an agreement that nobody will like, but everybody will be able to live with.

This is wrong. The fact that the government won't let them have their say, won't let them have a chance to negotiate, is bringing all sorts of unrest into our health care system that is not good. I know the Minister of Health will be interested in changing that. He understands the importance of having a good and trusting relationship between the care providers and the patients. You do this by bringing forward respect. You do this by bringing forward opportunities to be heard and to settle things so that everybody has an agreement they can live with.

Speaker, I also have to bring forward that flatlining the budgets of our hospitals for year after year-we're looking at year five and year six-is causing a lot of hardship. Some of our bigger ones are still managing relatively okay, but most of our community hospitals are having a tough time. What has been happening is that anything that is not acute hospital care is being shifted into the community, where it has no oversight, where it has no accountability, where it has no transparency. We're not opposed to transferring care into the community where it makes sense, but we are opposed to having it done when there is no framework for transparency, accountability, and maintaining quality.

I have nothing but respect for the College of Physicians and Surgeons of Ontario. They're trying hard. But their mandate for out-of-hospital services is very narrow. To have this one agency that is supposed to be the guardian of quality care, of transparency, of accountability-this is not happening, Speaker. CPSO does a good job; they do a good job within their mandate.

But what we had before in our hospitals, with freedom of access of information, with Ombudsman oversight-which I hope will come pretty soon-with boards of directors, with being able to have a person or a department in place that looks at your complaint-all of this is gone.

I cannot FOI the out-of-hospital premises. I cannot be sure that there will be a person there who will handle a complaint if there is one. I certainly know that you cannot escalate this anywhere. There is no transparency; there is no accountability. This is wrong. It has to be fixed. This bill would allow us to make those kinds of changes because of the number of bills that it opens up, but it is not in there.

Another promise that was made through a budget-as you will remember, Speaker, when we were in a minority Parliament, we were able to negotiate a five-day wait time for people waiting for home care. We did not like many parts of what they had in their budget, but we agreed to support a Liberal budget on the promise that the tens of thousands of people who were waiting for home care would receive it within five days. Well, the Auditor General told us the result of that. The result of that is that people wait 195 days before they get home care.

For children waiting for children's services, we're talking over two years for speech-language pathology, and over two years for occupational therapy and physiotherapy. For a kid who is two, three or four years old, this is half their life that they have spent on a wait-list to get the services they need. Those are opportunities lost. This is a promise that is being broken each and every day.

We have an opportunity with this budget bill to fix that, to say that there will be a commitment that nobody who needs home care will wait more than five days. Most people are being discharged from hospital with the promise that home care will follow. But if home care doesn't follow, their needs don't go away. It's not because they've been discharged from the hospital that a miracle has happened going through the threshold of those doors and all of a sudden all is fine. They were discharged with a promise of a care plan that included home care, which doesn't show up.

If it does finally come together, the number of missed visits, the number of missed appointments, the number of appointments that do not come when they're supposed to come-because if you're supposed to be getting home care to help you get out of bed in the morning and it's 3 o'clock in the afternoon before the PSW shows up, it is no good. If you're supposed to get somebody to help put you to bed at night but the PSW comes at 3 o'clock in the afternoon, it's still no good. This is what we're facing.

We have an opportunity to commit to a five-day wait time for home care. This was a commitment that was made through a budget. This was a commitment that was made very publicly. This is a commitment that is being broken each and every day for the tens of thousands of people who are waiting for home care.

There are other things that I wanted to talk about but I see that time is going away. Right now, we have a campaign led by our midwives that says that we don't need to put antibiotics in the eyes of newborns. There are very limited cases where this could help, but most of the time-99% of the time-we should not do this. If we stop doing this, as the best practice is telling us, we would save $618,000 a year on medication that is not appropriate for newborns and should not be used.

The $618,000 means that-remember the $200,000 that the OPP is going to save by moving the helicopter from Sudbury to Orillia, putting the people of the northeast at risk each and every day? Lots of us like to go into the bush. Winter is coming. There will be snowshoeing, skiing, trappers and snowmobilers, and sometimes we get in trouble-and it's dark at 4 o'clock at night in my neck of the woods. This helicopter is going to be no good to us. Well, that $618,000 would pay for that helicopter three times, because they're saving $200,000.

There is lots of opportunity for saving. It is disappointing that it is not being acted upon and that the opportunity to make modifications to that bill is next to nil.

In the News

Nurse practitioners have come a long way

There were struggles when nurse practitioners were introduced into Ontario's health care system, but, looking back, Roberta Heale can scarcely believe how far the profession has come in 20 years.

Heale is an associate professor in Laurentian University's nursing program and a practising nurse practitioner who works one day a week at the Sudbury East Community Health Centre.

Heale wasn't an NP in 1995 when a consortium of 10 universities, among them Laurentian, worked together to develop and deliver a nurse practitioner program for the province.

Nine universities continue to offer the program, Laurentian and the University of Ottawa teaching it in both official languages.

A registered nurse, Heale enrolled in the Laurentian program in 1998, graduating in 1999. She reflected this week, which the Ontario Nurses' Association is marking as Nurse Practitioner Week, on how her profession has changed in two decades.

When Heale entered the program, you had to be a registered nurse with two years' full-time equivalent work on the front lines, and the NP program was a graduate certificate that was completed in one year.

Those same entry qualifications are still required, but the program has been merged with master's and other programs and takes at least two years to complete at Laurentian.

It was three years after the nurse practitioner program was developed in Ontario universities before NPs were regulated by the Government of Ontario and given the authority to practise.

"There were huge struggles at the beginning," said Heale of those first years. Pioneering nurse practitioners like Sudbury's Marilyn Butcher knew licensing and regulation of nurse practitioners was "on the way" so she and many other NPs did regular nursing duties or volunteered until legislation allowed NPs to work in an autonomous role.

"It was kind of a vicious circle there for awhile," said Heale. "Things progressed. It seemed slow at the time, but looking back, it was quick."

It would be 2011, after minor tweaks to the first legislation, before regulations were changed to significantly broaden nurse practitioners' scope of practice. The changes gave them the authority to prescribe a wider range of medications, and to order blood work, ultrasounds and some other diagnostic tests.

"That made a huge difference," said Heale.

Before that, Heale and Butcher had embarked upon a campaign to create a new model of primary health care delivery that was led by nurse practitioners and not physicians, as was the practice at the time.

The women presented different proposals to the Ministry of Health and Long-Term Care, one of them for a nurse practitioner-led family health team. That idea was rejected, but Heale and Butcher didn't give up.

They proposed the first nurse practitioner-led clinic in Ontario here in Sudbury. The Sudbury District Nurse Practitioner Clinic offered the same collaborative approach to health care that emerging family health teams did.

"Marilyn and I understood there was a huge gap in primary health care services at the time," said Heale, "and that there were unemployed and underemployed NPs who could be utilized."

That first clinic, on Riverside Drive, opened in July 2007. A second site, in Lively, opened in 2010.

Then Premier Dalton McGuinty attended a late grand opening for the Riverside site in April 2008, an event then Health Minister George Smitherman also was at.

The day after that visit, the province announced that 25 more nurse practitioner-led clinics would be established in Ontario, following the model of the Sudbury clinic that hadn't even been open a year at that point.

Butcher and Heale had realized NP-led clinics could help address the issue of 30,000 people in Sudbury not having a family doctor.

There are now five more NP-led clinics in the area covered by the North East Local Health Integration Network -- in Capreol, French River/Alban, North Bay, Thessalon and Sault Ste. Marie.

Heale was one of many NPs who celebrated the 20th anniversary of Laurentian's program a few months ago. It was a time to look back on the development of the profession, although Heale is looking forward to changes that will again expand NPs' scope of practice.

Nurse practitioners are now working in nearly every sector of the health care system. In Sudbury, those sectors include the emergency department at Health Sciences North, the eating disorders program, the diabetes education centre, the bariatric centre and in pediatrics.

Heale calls that "a huge and wonderful change."

NPs are fulfilling an especially important role in northern and rural communities where they may be the only health care professionals offering care.

There is one issue, however, that is causing some NPs to leave community practices to work in hospitals and community care access centres. For eight years, the Government of Ontario has imposed a wage freeze on NPs and other professionals working in the community. That is making it harder to recruit NPs to community practices, said Heale.

"Remuneration is a big issue," she said, because the difference in salary between a community and institutional NP position can be as great as $20,000 a year.

"It's a bit frustrating when you know other health care centres and other health care providers have had increases, then we get caught in this age of austerity," she said.

Still, Heale feels good about the future. There have been amazing accomplishments in the last 20 years and the environment in which NPs work is mostly good.

"I'm happy to be able to say that at this point. There were a lot of hurdles along the way," she said.

Nurse Practitioner Week is being celebrated Nov. 8-14 to bring awareness and recognition to the exceptional care provided by the province's 2,669 nurse practitioners, said ONA president Linda Haslam-Stroud.

"Nurse practitioners provide high-quality health care in hospitals, long-term care facilities and the community each and every day," said Haslam-Stroud.

Originally published in The Sudbury Star

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