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Independent Nurse-led Clinics

Posted Apr 09 2009 7:13pm 2 Comments

Well, I could hardly let this topic go by without commenting so here we go.

Most of you will know that the MOHLTC rolled out its first Independent Nurse-led Clinic not so long ago in Sudbury. There are plans for 24 more and one is in the works in or around the town of Lively.  While I can certainly see the position that the Ministry is in when so many patients in that area are without a family doctor and that it may, quite frankly, feel forced to provide primary care by nurses because of lack of other alternatives,  the reality is there ARE other alternatives.

One alternative is that these nurse practitioners  be integrated into already existing primary care physician teams who are ready and willing to accept them. Local doctors have indicated that this is the case but they have apparently been ignored.

Evidently, the nurses involved want their own show and so much for the sweet talk about team work and all that they can provide in a team setting. Why else would government pour perhaps hundreds of thousands if not millions into refurbishing facilities and providing operational costs to the nurses?

And I suppose they could argue that they are going to work in a team setting with a "collaborating" physician but let's be clear....a "collaborating" physician that is in the office once a week or is functioning at arms length is hardly going to be a "hands on" physician and the availability is questionable.

So really, these nurses will be acting independently without the supervision of a physician...which is exactly what they appear to be after whether patients know what they are getting or not. Will the patients have a  choice of who they see-nurse or physician? Probably not.

Numerous studies show the advantages of nurse practitioners in delivering services for chronic care and even their cost-effectiveness in this area.   Numerous studies show that they can enhance preventative care. But this does not mean they should be providing care independently or that they will be cost-effective providing primary care independently. Primary care is not just prevention or just chronic care.

Looking at the numbers based on  320 days per year and considered very conservatively and I admit without all the details:

A Nurse-practitioner seeing 7-12 patients per day at $85,000 to $110,000 works out to about $22 to $37 dollars per patient. But don't forget that their package typically includes benefits and no  overhead plus recently announced  renovation of office space and operational costs at government expense plus the cost of a collaborating physician which has not been factored in nor has the possibility of increased referrals to specialists been considered.

What happens to the wait times of specialists if more patients are referred?

What happens to  interest in family medicine when primary care appears to be taken over by nurse practitioners?

What happens when government ignores dedicated family physicians in the community who are overlooked as a solution to primary care access?

What happens to availability of nurses in hospital settings, particularly rural hospitals, when nurses are diverted to more primary care?

I don't think the MOHLTC has thought this through very well and in my opinion is pandering to the nursing unions.

The nursing unions may want to be careful what they wish for because as the entire health care system is squeezed for cash they will be squeezed as well. Indeed, if  nurses take over primary care over the next decade as the CNA announced in its vision for 2020, they may see their salaries shrink while they take on more and more responsibility that is beyond just nursing training with a smatter of primary care thrown in.

No disrespect intended but I don' t think they realize what they are getting to.

As for our FHTs, I've commented on them before here under the heading of "Cost-effectiveness of Family Health Teams". I admit that I think the funding for these groups is unnecessarily high with $500,000 for governance programs and such that wouldn't be necessary in other settings but I guess if government is willing to throw money around like that then so be it. But that seems to have stopped now in a setting of deficit financing although the nurse practitioner clinics are rolling out with all of their attached funding.

Seems a bit strange to be flitting from one program to another but it is perhaps because government realizes the bind that it is in with the created an entity ill-suited to pragmatism, touted it as the solution and then was swayed by various experts whispering in its ears.

I doubt that Nurse-practitioner clinics will do any better from a cost point of view. They are likely to be more expensive from a cost perspective even though the obvious expectation is that they will be cheaper.

When government has to step in and provide all the support you just have to know that the costs are going to soar. Family doctors running their own offices had incentive to save costs where they could. Not so if government is footing the bill for the np salary and the facility and everything else that will be said to be needed.

This is quite clear with Community Health Centres. A new report by Dr. William Hogg out of Ottawa showed that compared to FFS, FHNs and HSOs, that CHCs provided superior care but at a higher cost-adjusted for case mix, CHCs are more than twice as expensive as other models of care.

Regardless of the model, there are things that can improve care including having a nurse-practitioner and a small practice, according to Dr. Hogg's study.

So it looks like in an attempt to save costs that government will likely spend even more. How ironic.

As an anecdote, an ex-staff member once again came back to our clinic to report her good fortune of finding a position in a CHC. It appears that they have offered her language training on the government dime so that she can learn French. She already speaks English and Spanish but the administrator thinks it would be helpful if she could speak French as well.

Shades of French language training and all its associated costs (and if you live in Ottawa you know too well that language training in government requires at least three salaries to be paid while one is on training....the person filling in will be paid, the person providing the training will be paid and the person taking the training will be paid). And this is likely the tip of the iceberg as I am told the others are offered training of various kinds as well...paid for by government.

CHCs and Indpendent Nurse-led Clinics don`t sound like solutions on a big scale to me and all the while the government ignores the group most likely to be able to provide efficient and cost-effective care...the family physician.

While the costs of primary care can be expected to soar with government`s new initiatives,  the unintended consequence is likely to be more elderly patients who are going to have to pay more for their long term care for more years.  I can explain if you don`t understand but I hate to make things sound  crass. Think about it.







Comments (2)
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Well written and presented. Nurses are not trained as medical students or junior doctors. They lack in-depth knowledge of disease and not trained in pharmacology. Most illness present initially with a symptom which are common. With no wide knowledge it is difficult to diagnose illness and so people miss them as my teachers said “Your eyes don’t see what your mind cant think”. This can have devastating effect on the patients due to delay in diagnosis or implementing treatment.

I am sure the authorities will soon realize that it’s not worth trying to save some cost and not reduce morbidity.

This article lacks education and is full of misinformation.  There are plenty of studies illustrating the benefits of NP led clinics.  This initiative took many years in the making, and the research backs the decisions.  You can't deny patient's actual responses stating they are happier with their care.   No one is trying to squeeze anyone out of a job, they are trying to increase accessability.  So next time your family doctor retires, and no one will take you, I hope you find yourself being treated at an NP clinic, and perhaps you too will have a positive experience. 
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