Is medical personnel shortage a deficit of personnel or an under-utilization of available health professionals?
As Roy Romanow wrote in his report on the future of Canadian health care, “The problem is only partly about supply. It is also about distribution, scope of practice, patterns and the right mix of skills among various health care providers.”
And as Senator Michael Kirby heard during a Senate committee’s parallel hearings on the federal government’s role in health care, the distribution of work can sometimes be described as follows:
“Having a doctor do work that a nurse practitioner or nurse could do is like calling an electrician to change a light bulb or a licensed mechanic out of the garage to fill your tank and check the oil and tire pressure. But would it be a good use of their time, training and expertise? It would not! It would constitute an expensive and inefficient use of scarce resources, both of money and the expertise of very talented people.”
With respect to health human resources issues, recommendations from both Romanow and Kirby call for a review of the organization of work among health professionals. In Kirby’s recommendations, the goal is improving the productivity of physicians. In the Romanow Report, work reorganization is about responding to changes in the way care is delivered.
Granted, reviewing job descriptions and scopes is only one of a mix of solutions. Other needed changes to health HR are increased training of medical personnel, a better integration of qualified health professionals trained abroad and improved co-ordination of labour market information across the provinces.
The organization of work among health professionals is just one piece of a complex puzzle.
But it’s not an insignificant piece. After visiting the Sault Ste. Marie Group Health Centre in northern Ontario, Romanow held the centre as a model of what primary health care should look like by 2020.
“One of our practices is to have all of our employees working at the highest level of their scope of practice and bring in support to enable them to do that,” said Teresa D’Angelo, manager of human resources at the centre.
“What the rest of Ontario is facing in terms of a shortage of health-care professionals, we’ve always felt it in the North. So we’ve always had to adapt to that.”
For example, instead of having the more qualified registered nurses staff the offices of physicians, as is done in most settings, the job is given to registered practical nurses at the centre, allowing registered nurses to support the offices of specialists.
Nurse practitioners, to take another example, have been employed at the Sault Ste. Marie Group Health Centre for more than 30 years, well before the job category was recognized across the province. In Ontario, nurse practitioners are allowed to perform duties that were once the exclusive prerogative of physicians, such as making early diagnoses, ordering tests and prescribing certain drugs.
At the group health centre, some nurse practitioners are responsible for their own panel of patients. “When a patient gets beyond their scope, then a physician steps in and takes over that patient’s care,” said D’Angelo. Others work alongside physicians to take care of a panel of patients, and “on a day-to-day basis, they decide which patients the nurse practitioner will see and which the physician will see.”
These models of job sharing alleviate the demand on physicians and help cut down the time patients have to wait to receive treatment.
Unlike most physicians in Ontario who are paid on a fee-for-service basis, the physicians at the centre are paid a pre-determined amount through the alternative payment plan of the health ministry, minimizing competition for caseloads.
D’Angelo stressed that the key to making collaboration work is a clear definition of roles and responsibilities right at the outset. When there are disputes over responsibilities and scope of practice, they’re discussed at the joint-management level, composed of members of the Algoma Medical Group, which is responsible for 60 physicians, and representatives of the Group Health Association, which is responsible for the 310 support staff. Joint discussion ensures that physicians have input, which is essential in any health reform, added D’Angelo.
Working at the highest level of their abilities helps give staff a sense of work engagement, she said. That’s why, even with 70 per cent of nurses working part time, the centre is able to maintain low turnover rates. This type of work sharing also allows physicians more of a balance between work and personal life, added centre spokesperson Elizabeth Bodnar.
Administrators at St. Mary’s Hospital in New Westminster, British Columbia are pressed to consider such collaborative models in the face of a 60-per-cent funding cut this year, said chief executive officer Larry Odegard.
“We’re looking at all kinds of alternatives to retain people but also to see the professionals through the transition into a new role. We’re just starting the process now,” said Odegard.
“There are skills that nurses or nutritionists or physiotherapists have that are under-utilized. We need to have a greater respect and understanding of the capacity of these people to contribute to the health of the patients, and I’m not sure that we’ve had the incentives to do this.”
In anticipating this possible development, Odegard said one of the key challenges for the HR manager is to “interpret the collective agreements and traditions and contracts in a new way. It’s about looking at these as tools for change rather than as restrictive documents.” For example, jobs at the hospital could be opened up to a range of disciplines rather than specifically to this or that category, said Odegard.
“I think these are areas that are new and challenging to us. You’d have a licensed practical nurse who wants to do more complex duties, but then you’d have a nurse who would have to give those duties up and she can see that as an opportunity to broaden her role in complementing the work of the physician.”
The looming cutback is just one reason for expanding the scope of practice of a number of disciplines, he said.
“The pressures and the opportunities of technology are another motivator. What will telehealth services do, for example, to services provided in remote locations? Will there be a need for greater support locally to keep patients at home and use telehealth capacity? And with shorter lengths of stay, the treatment at the hospital is more intensive. So what would that do to the nature of the work?”
As the hospital holds collective agreement talks to explore options such as new roles and responsibilities for professionals, the HR manager “can facilitate and provoke discussion,” Odegard said. “It’s about being at the table where these professionals are meeting and being the facilitator who asks, ‘Have you considered this?’ or ‘Are you ready for this?’”
But chief among his concerns is the instability of the health system that results from a lack of leadership at the political level. “There’s no clarity of vision as to where we’re going with the whole system. And that’s causing some people to opt out early.”
Again, the HR manager has a role to play in addressing this instability, Odegard said. It’s HR that has “the facts and the statistics and they can do the projections. We need to put things in terms that shock the politicians and the senior civil servants, and the people who can do that are the HR leaders at the front line who can be very specific about what the emerging issues are.”
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