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SPHA 510- Health Care Policy Genevieve Marier St-Onge

Strengthening Primary Healthcare with Nurse Practitioners

1. Background
The Ministry of Health has been interested in the nurse practitioner role within primary
health care since the 1970s. The first nurse practitioner (NP) program in Canada started at
Dalhousie University (Nova Scotia) in 1967 (Health Canada, 2006). Despite this early
Canadian introduction, this interest did not sustain the 1980s and the initiatives ended due to a
perceived oversupply of physicians, and the lack of a remuneration mechanism for NPs,
applicable legislation, public awareness regarding the role of NPs and support from both
medicine and nursing (Health Canada, 2006). The NP role in British Columbia is relatively
new. BC began graduating NPs in 2005 at a rate of 45 per year.
In 1997, the Ministry of Health and the College of Registered Nurses of British Columbia
(CRNBC) began working together trying to define the role of NPs for BCs context. Between
2000 and 2005, the Ministry of Health partnered with the CRNBC and other key stakeholders
to develop a regulatory and legislative framework for NPs. In 2005, the government passed
the regulation outlining the scope of practice for NP allowing for a professional practice
model of autonomous NP practice (CRNBC, 2006). NPs are registered nurses with a masters
degree who focus on health promotion and disease prevention. They autonomously diagnose,
order and interpret tests, prescribe medications and perform special clinical procedures for
acute and chronic illnesses. While NPs are practicing in most provinces and territories in
Canada, Canadians are more likely to receive care from NPs if they live in areas that may
have difficulty attracting physician like rural and remote areas. (Health Canada, 2006)
In May 2012, the Ministry of Health announced ongoing funding for 135 new nurse
practitioners positions to be implemented over three years through the NP4BC program.
However, the BC job market is unable to absorb that amount of new-graduate NPs and a
number of issues have occurred related to the overall integration of NPs in the province.

2. Policy goals
The implementation of NPs in the healthcare system in 2005 were expected to
increase accessibility to acute, long-term and primary health care services, expand health
SPHA 510- Health Care Policy Genevieve Marier St-Onge
care options and fill gaps in the BC health system while reducing the cost of healthcare.
(RNABC, 2004)
In May 2012, the Ministry of Health implemented the NP4BC program to again
increase the access to primary health care services. They specified that the use of NP
skills and competencies was for high need populations and to close local gaps for frail and
elderly, people with chronic disease, mental illness and substance problems, maternity
and, unattached patients. (Ministry of Health, 2013)
NPs have the potential to achieve better health for the population by enhancing
continuity of care when working together with physicians and increasing access to
primary healthcare. The Canadian healthcare system is experiencing a chronic shortage of
family doctors; increasing NPs role in primary care services can ease the build-up of
patients unable to find family doctors and provide comprehensive and coordinated
healthcare services to the population. Among the shortage of healthcare human resources
and the aging of the population leading to an increase incidence of chronic disease, the
presence of NPs in primary health care is fundamental and associated with high-quality
disease management and reduces costs.

3. Key influences
3.1 Agenda setting influences
As mentioned above, the predecessors of todays primary healthcare nurse
practitioners began their practice a long time ago. In the mid-1980s to the early 1990s,
primary health care in Canada was at the periphery of the system rather than at its core,
partially due to the fiscal consequences from the recession. In the late 1990s, Canadas
improved fiscal climate and higher federal health care funding made investments in
primary health care easier. The primary care reform agenda was given further
motivation due to the findings and recommendations of two national reviews of health
care, Commission on the Future of Health Care in Canada 2002 and Senate Standing
Committee on Social Affairs, Science and Technology 2002 (Hutchinson & Al., 2011).
The declining interest in family medicine in medical school, long wait time in
emergency related to increasing difficulty in accessing family physicians were
reflected by the media. Moreover, the growing political and public concern about
SPHA 510- Health Care Policy Genevieve Marier St-Onge
health care access and quality and their ability to provide high-quality care were
largely questioned at that time. In relation to those events, in 2003, Paul Martin,
recently elected Prime Minister, signed the Health Accord and established a goal of 50
percent of Canadians having 24/7 accesses to multidisciplinary primary health care
teams by 2011.
Numerous federal and provincial governments reports identified that the use of
nurses and other healthcare professionals could improve patient access to health
services. (Kirby, 2002) In addition, abundant research had shown that NPs are
effective practitioners that positively influence patient and health system outcomes.
This context encouraged the government to increase their interest in the primary
health care nurse practitioner role and initiated the wave of nurse practitioner role
implementation by developing legislation, regulation, remuneration mechanisms and
funded education programs. In British Columbia, the first nurse practitioners
graduated in 2005 and were hired into regional health authorities.

3.2 Decision-making influences
Since the 1970s, different primary healthcare innovations have tried to make the
system more accessible and cost-effective but these attempts have been unsuccessful.
The NP4BC program implementation in 2012 was a respectable initiative from the
Ministry of Health but the BC job market was unable to absorb that amount of new-
graduate NPs and a number of issues have influenced the overall integration of NPs
in the province and the long-term sustainability of the role.
One of the main hindrances was the lack of knowledge and role of the NP by
managers, physicians, staff and the general public. This was mainly attributed to the
lack of understanding of the NPs role, the general public are not valuing and utilizing
NPs to their optimal potential. On their side, physicians representatives remained
strongly opposed to adding nurse practitioners, which can be autonomous care
providers within the multidisciplinary team. Moreover, policy legacies have put
physicians in a fortunate position for policy-making thus reducing the place for
healthcare improvement and a better integration of NPs in the system.
SPHA 510- Health Care Policy Genevieve Marier St-Onge
The current NPs scope of practice and regulations are limiting the potential
influence that could have NPs on the Canadian primary health care system. NPs are
practicing to their current legislated scope of practice, but are unable to complete
various governmental forms or prescribe controlled substances until pending
legislative changes are initiated.
Finally, the Canadian healthcare system is still managing chronic disease within
an illness model which is focusing on diagnosis, treatment and cure. Due to this old
and sustained way of thinking, primary health care systems including NPs is still not
the center of the Canadian health system.

4. Reform details
There is a need to develop effective models of inter-professional primary
healthcare service delivery, change in scope of practice and other legislation to support
effective use of the NPs role and to give the opportunity to fully utilize their skills. The
managers and key stakeholders, like physicians, need to be more involved in the
definition of the NPs role. NPs are still relatively new in Canadian health care settings; a
strong organizational leadership is needed to assure a good implementation in practice
In transitioning from an illness approach to a wellness orientation, health
promotion and prevention becomes the new priority, which NPs excel in. To achieve this
transition, a long-term sustainable funding for nurse practitioners and primary healthcare
would be needed.
To date, BC does not have a viable business model to support the positive feature
of NPs model of delivery of care. A government program supporting the implementation
of nurse practitioner-led clinics would help achieve the primary reform goals: link the gap
in continuity of care between the acute setting and community living, reduce the
utilization of human resources lacking, improve access to primary healthcare while being
This implementation of twenty NPs-led clinics in British Columbia would increase
the Nurse Practitioners for BC Program budget by approximately $30 millions at $1.5
millions per clinic.
SPHA 510- Health Care Policy Genevieve Marier St-Onge

5. Evaluation
Since British Columbia began graduating NPs in 2005, there have been a lack of
opportunities for the NPs to enter their profession in the province. The key Accord goals
of ensuring that 50 percent of Canadians had 24/7 accesses to multidisciplinary teams by
2011 has failed. Currently, 252 nurse practitioners are registered with the College of
Registered Nurses of B.C. Ontario count more than 1200 in 2013 and NPs are the fastest-
growing health profession in Alberta with a 25 percent increase in their numbers in 2012
over 2011. Moreover, there will be approximately 600 nurse practitioners in Alberta in
the next few years from the current 315 NPs, where the population there is lower than in
BC (Alberta Chambers of Commerce, 2013). Ontario and Alberta still have more
advanced programs and easiest access to NPs.
Moreover, that $22.2 million substantial injection from B.C. government to pay
for 45 new NP positions per year over the next three years have not guaranteed that that
kind of money will be there in the future. Even with the NP4BC program initiative in
2012, many of the 252 NPs are not yet fully deployed in the community-based primary
care roles for which they are qualified. As WHO (2013), Canada ranked behind Australia,
France, Sweden, the United Kingdom and the United States in term of patient experience
with waiting times for physicians care. Lets point out that the United States count more
than 56 000 NPs in 2013 compare to 2,454 NPs in Canada, which is 23 times more NPs in
US for a population only 9 times bigger than Canada (Agency for Healthcare Research
and Quality, 2011).

6. Conclusion
Nurse practitioners were implemented to B.C. in 2005 to assist in improving
patient access to primary health care services. One positive feature is that B.C government
is still interested in improving the implementation of nurse practitioners and has put the
subject on their agenda setting recently. In May 2012, the Ministry of health announced
the funding for 135 new nurse practitioner positions to be implemented over three years
through the NP4BC. Even if the NPs situation in B.C. is developing slowly and have
SPHA 510- Health Care Policy Genevieve Marier St-Onge
some major barriers, some steps are still being made to improve primary healthcare
As of 2013, the overall problem is the lack of full integration of nurse practitioners
in primary healthcare setting. The burden of chronic disease is growing and effective
programs and services are inaccessible to all patients, which place greater demands on
ensuring optimal access to primary healthcare. The biggest weakness is the failure to
proficiently address barriers related to the implementation of NPs. Some large barriers
include the lack of knowledge of NPs role and the lack of support from other healthcare
professionals and managers.
Some opportunities can be explored to address these problems and increase the
effectiveness of NPs implementation. There is a need for a multi-stakeholder strategies
planning initiative to deal with the overall introduction of NPs in primary healthcare
settings. Wider and more defined regulatory standards and scope of practice for NPs need
to be readjusted for the actual context. Finally, launching an information campaign at a
provincial or national level would be useful to raise awareness about the role and
innovations of NPs.
The lack of knowledge of NPs role from healthcare professionals and the general
public is certainly one of the major threats for NPs position. Like any relatively new role,
a strong organizational leadership plan needs to be in place and support from healthcare
professionals and managers are needed to assure the sustainability and prevent the failure
of optimal implementation in practical settings.

SPHA 510- Health Care Policy Genevieve Marier St-Onge

Agency for Healthcare Research and Quality. (2011). The Number of Nurse Practitioners and
Physician Assistants Practicing Primary Care in the United States: Primary Care
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CRNBC. (2006). Creating a regulatory framework for nurse practitioners in British Columbia.
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Hutchinson, B., Levesque, J., Strumpf, E., & Coyle, N. (2011). Primary Health Care in Canada:
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Kirby, M. (2002). The Health of Canadians The Federal Role. Final Report. Ottawa, ON:
Parliament of Canada. Retrieved November 15,2013.

Ministry of Health. (2013) Advancing Nurse Practitioner Integration in Community Based
Primary Care Survey to Inform October 29th Workshop Agenda. Nurse Practitioners
Program. Retrieved November 15, 2013, from

RNABC (2004). Nurse Practitioners: BCs newest providers of health care services. Nursing BC,
June, 5-7.