Canada needs a new Health Accord to liberate health-care talent
A common approach to scope-of-practice reform will be a huge challenge under any circumstances, but close to impossible without Ottawa playing a major role.
The Council of the Federation has identified both coordinated health human resource planning and scope of practice reforms as a central part of its improvement agenda. Scope-of-practice refers to the range of decisions, actions and procedures a licensed professional is entitled to undertake. Often there is overlap: nurse practitioners, therapists, and pharmacists can and do provide many primary care services as well as family doctors in parts of Canada, and more widely around the world. The health-care workforce is more highly educated than ever before. Yet, because of antiquated regulatory provisions and rigid workplace cultures, many health-care professionals are unable to use all of their knowledge and skills in the workplace. Everyone seems to support team-based care and competency-based scope of practice in principle, but progress is slow.
We applaud the provinces for coming together to align scope of practice with proven competency, but good intentions and optimistic announcements do not guarantee success. It is no accident that too many health-care professionals are working below their capabilities. Health care is a big field that costs $200-billion annually. All professions want to claim as much of that turf as possible as their exclusive domain. Regulating health-care activities and defining what various professions can and cannot do is supposed to ensure public safety, but at times the distinction between the public interest and professional self-interest blurs. Every profession wants to do more but none willingly cedes to or shares terrain with others.
The health-care system is all the poorer for it. As the population ages, the greatest health care need is the management of chronic conditions, accounting for over 60 per cent of spending. Many people have three and more conditions. This is not the domain of TV show House detective work and dramatic cures. It is about coaching and behaviour change, exercise, and nutrition, and empowering patients to take charge of their own health destiny. Success requires multidisciplinary teamwork, effective communication, and coordinated care plans. No single profession can possibly master all of the skills and knowledge needed to do this work well. The era of the omniscient independent practitioner is over. Needs have changed, and so must the organization of care and the roles of professionals.
The practical question is whether the provinces will be able to clear the scope of practice gridlock entirely on their own, through multilateral consensus. History would suggest that this is a very long shot indeed. The provinces have for a decade expressed concern about the lack of consistency in entry-to-practice credentials for various professions but have been unwilling to give up any autonomy to go their ways. Every province has separately gone through an arduous, long, and contentious process to make modest enhancements to the scope of practice of pharmacists and nurse practitioners. Every jurisdiction wrestles with an obsolete collective agreement with physicians that inhibits team-based primary health care. The inconsistencies and inefficiencies have been long recognized but without resolution.
It is encouraging that the premiers have cooperated to address such a critical topic. But premiers and health ministers and their deputies come and go, and priorities change. Scope of practice is a difficult and long-haul issue. Either it will be dealt with nationally in a coordinated and evidence-based fashion, or it will evolve in fits and starts, with a modest advance here and a setback there, shaped by local politics, deal-making, and expediency. If the public interest is to be served, there must be an honest broker to support and at times discipline the development of options, identify barriers to constructive change, invest in and sustain effort, and nudge the parties into a progressive consensus.
That honest broker can only be the federal government, and the goals for scope-of-practice reform should be articulated in a new accord. This is not a prescription to meddle in how the provinces deliver health care or impose an agenda, but a role and a vehicle to help the provinces to translate their own declared priorities into action. It is a waste and a tragedy to underuse so much talent, and the triumph of hope over experience to imagine that the provinces will entirely on their own reach agreement in this hotly contested arena. A common approach to scope-of-practice reform will accelerate change, energize the workforce, simplify and streamline standards and processes, and improve health care for Canadians. A great leap forward will be a huge challenge under any circumstances, but close to impossible without Ottawa playing a major role.
Linda Silas is president of the Canadian Federation of Nurses Unions and Steven Lewis is a health policy consultant.
Published in The Hill Times July 30, 2012.
Reprinted with permission.