Published in the Financial Post.
The crisis in Canada’s primary care is reaching a breaking point. A staggering 6.5 million Canadians are without a family doctor or nurse-practitioner (NP). A recent C.D. Howe report by one of us (Zhang) calculates we would need at least 7,844 more family physicians to meet current demand — an increase that could take up to a decade to achieve. With the population both growing and aging, waiting that long simply isn’t an option. It’s time to explore alternative solutions. More NPs should be one of them.
The International Council of Nurses defines nurse-practitioners as integrating “clinical skills associated with nursing and medicine in order to assess, diagnose and manage patients” receiving both primary and acute care as well as ongoing care for chronic illness. Repeated rigorous evaluations have shown that in most situations NPs deliver the same (if not better) quality care as family physicians while costing less. Given the serious shortage of doctors, we need an aggressive provincial strategy to train many more NPs.
At the moment, there are almost six times as many family physicians in Canada as there are NPs. Only five per cent of Canadians reported having an NP as their primary-care clinician, though 31 per cent indicated their primary-care practice did include an NP. In Ontario, however, NPs are roughly twice as common as in Quebec, Alberta, and B.C. More NPs would not be a silver bullet. But an aggressive NP strategy would be better than the current strategy of spending heavily on new medical colleges and more family physicians.
Survey after survey indicates Canadians are frustrated with the health-care status quo. The OECD runs an international poll on health care every two years. In 2019, 78 per cent of Canadians said “they were satisfied with the availability of quality health care,” this versus an OECD average of 71 per cent. Just two years later, however, in the 2021 survey, only 56 per cent of us said we were satisfied, a decline of 22 points. The OECD average declined as well, but only by four points (from 71 per cent to 67).
What explains the steep drop in Canadians’ satisfaction with their health-care system?
Over the past two decades, physicians have reduced their hours worked per week. On the other hand, the number of physicians per 1,000 people has increased, and the number of services provided per 1,000 people has been stable. As widely reported in the media, the pandemic led to exhaustion and stress among caregivers. But the number of COVID cases per million in Canada was well below the average among OECD countries. The aging of the Canadian population is increasing the demand for health services, but aging is not occurring at a faster pace here than in other OECD countries. Nor is spending likely to be a major factor. Public plus private health spending in Canada has been consistently above the OECD average.
None of these factors seems to explain Canadians’ seemingly sudden disenchantment with their health-care system. Another factor may be the reluctance of provincial governments to undertake major institutional reforms. Since the 1990s, when serious budget deficits necessitated action, most provinces have been reluctant to provoke opposition from powerful interest groups, in particular physicians’ associations, by introducing major changes in systems. As for the expanded use of NPs in primary care, there have been a few exceptions but in general physicians’ organizations have been strongly opposed.
As a result of this opposition, some NPs are underemployed in rural and remote communities or underutilized in urban hospitals. Despite having the skills to operate independently, many are still required to work under the supervision of family physicians. To maximize NPs’ potential, the remaining regulatory and remuneration barriers to their fuller participation in the system need to be addressed. There is some progress in this area. Alberta, for one, is developing a new compensation model to encourage NPs to take on patients and operate independently.
Universal health insurance with no payment at the point of delivery is an honourable egalitarian goal, first realized in Saskatchewan in the 1960s. For it to survive, provincial governments and physicians’ associations must work out better arrangements. In our view, an aggressive NP strategy is part of the solution.
John Richards, professor emeritus at Simon Fraser University, is author of the recent C.D. Howe Institute report: Addressing the Crisis in Access to Primary Care: A Targeted Approach. Tingting Zhang is a junior policy analyst at the C.D. Howe Institute.
