Accessing nurse practitioners – a double standard?

My friend Ron is an energetic seventy-year-old who is diabetic. We live in northwestern Ontario, in a town called Kenora, two hundred kilometers east of Winnipeg, Manitoba. Ron's life has just been complicated by the fact that his family doctor moved away recently. Why is this a particular complication for him? Because the lab in Kenora has refused to do his blood tests now that he doesn't have a family doctor. To get his bloodwork done, Ron has to make the two hundred kilometer trip west to Winnipeg.

His other problem? He may qualify for a Northern Health Travel Grant but has no one to sign the "from" portion of the form. So in addition to the inconvenience, and sometimes the danger of travel in bad weather, he now has to personally bear the cost of a two and half hour trip from Kenora to Winnipeg and back.

What about a nurse practitioner? We do have a nurse practitioner in Kenora, who works with a family doctor who isn't taking on any new patients. Ministry of Health “rules” prohibit Ron from being seen by this NP. The explanation that I received from the Ontario Ministry of Health and Long-Term Care was, and I quote, "In settings where a NP works in a practice with family physicians, a person must be a patient of a physician within the practice to see the NP. The physician is the lead provider of primary health care in these settings.”

It's amazing to me that less than five hundred kilometers to the east, in Thunder Bay, the Lakehead Nurse Practitioner-Led Clinic has four nurse practitioners seeing a total of 3,200 patients. These NPs work in a stand-alone facility as independent primary care providers and are not under the supervision of family doctors. I assume that their training has been identical to that of the nurse practitioner in Kenora, but residents here are penalized because in Kenora, the nurse practitioner and doctors work in the same building.

Kenora is a community of 15,000 people. We have no community health centre, no walk-in clinic, no urgent care clinic, no nurse practitioner-led clinic, and ER wait times average five to six hours. We have one clinic in Kenora and a smaller one in nearby Keewatin, so it seems that, even with our critical doctor shortage, there is no way around this arbitrary edict of the Ministry of Health.

I have explored the Ministry’s websites and spoken to several service representatives at the Ministry of Health and Long-Term Care as well as Service Ontario about this double standard, and have not been able to get an explanation. Apparently, nurse practitioners can provide primary care in Thunder Bay, on remote reserves and out in communities, but they are not allowed to provide primary care in this area of northwestern Ontario where they are so sorely needed.

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  1. Catherine Richards

    Wow, Carolyn, thanks for enlightening us all about this situation which is exceedingly unfair, not only to your friend, but to all those living in the Northern region.

    The Ministry of Health and Long-Term Care (MOHLTC) in my view lacks any accountability when it comes to patients’ safety and well-being. Not everyone can afford to do as your friends does when paying the cost for long distance travel and it makes absolutely no sense that his expenses would not be covered by the MOHLTC if they cannot accommodate his needs closer to home. And the part of him not having the required signature for the expense forms, I think that is the lamest thing I have ever heard. Surely, someone at the MOHLTC can come up with a creative solution one would think.

    And when he gets the blood test done, does he get it assessed by a MD or NP in Winnipeg? Who is overseeing his health?

    I feel for the people in the North having to put up with such unjust circumstances.

    Keep shining a light on the injustices until someone at the MOHLTC grabs a brain and decides to use it to make better and more practical decisions for the benefit of those in need. It actually makes me think this is a situation where Northerners are being discriminated against. Am I wrong? Would Torontonians accept having to travel to Kingston for test results? I hardly think so.

  2. Jennifer Jilks

    Unfortunately, when it comes to the MOHLTC, they are driven by politics, not my common sense. Rural healthcare is a whole different kettle of fish than in Toronto.
    This is awful for all of us in rural Ontario. A real eye opener for the navel-gazing Toronto politicians. I have long advocated for friends in long-term care in Central Ontario. This is a ridiculous situation in northern Ontario.

  3. Rob Fraser MN RN

    Thanks for sharing this perfect example of the craziness that is our health care “system”. This is another perfect example of where all healthcare providers and policy makers need to focus on the patients, not the the politics. Although Ontario has doubled the number of NPs from 2006 to 2010 (~2500) there is still a lot of work to ensure access to these providers, especially in rural communities.

    For anyone interested in further reading the NPAO has some good resources:

    Thanks for the great article Carolyn!

  4. Andrew Holt

    Although there is considerable work still required to re-balance the health system to more effectively make use of the growing numbers of nurse practitioners it is encouraging the debate is focused on this very real need. For decades(1980’s and 90’s) there were endless debates for and against the merits of establishing this profession and sorting out how the profession would in fact be regulated, trained and established in a sustainable way. Slow as it is progress is being made through the many efforts of many dedicated health professionals, health policy, economic and politicians of all stripes to wrestle through this issue.

  5. Donna Clare

    Why are Canadians held hostage trying to access basic primary care, while perfectly competent health care providers are kept inaccessible by governments and by the turf protection of other professionals? This is happening all across the country. It is shameful.

  6. Joanne Gordash

    Sadly, this is reflective of the “smoke and mirrors” that governments and their agencies use to control their turf. Justice will not be done until we have an accountable government, one that is accountable to the people. The very fact that there is a stand alone NP clinic in Thunder Bay as well as other areas of Ontario, makes the “Physician in the house” requirement redundant. It is discriminatory.

    The gentleman in question (an example of many without health care providers) is an elderly diabetic for whom reasonable and prudent care requires that he have regular follow up.

    The bureaucratic quibblers that are placing roadblocks on this Ontarian’s access to Nurse Practitioners should be held accountable for ANY adverse events a patient experiences due to access issues.

    Vote accordingly.

    “The time is NOW!’

  7. ian

    I realize I am late joining the discussion. I have been doing some research, and many do not know how the funding all works….very interesting and I am still learning.

    Why do the NPs at the Family Health Team (FHT) only see patients who already have physicians in the clinic?

    With a FHT the family physicians “roster” patients (in Ontario there is a recent freeze on this as it seems many physicians abuse this and it is costing too much for tax payers). Once a patient is “rostered” by the family physician the doctor gets a lump sum (a larger sum if the person has a chronic diseases) per patient, whether they are seen weekly or never ever (ER does not count). This is different than fee for service. However, if the patient cannot get in to see the family MD and uses an independent walk-in clinic, the doctor looses money from the total roster fee. In Kenora, there is not a walk-in clinic available, so there is not the same incentive for doctors to see patients quickly as in southern Ontario (as they would quickly lose money as patients would go elsewhere for medical attention). It seems to me that some doctors do not spend a lot of time in the clinic despite a large amount of rostered patients, and are involved in other aspects of health care (it is more lucrative to do both in this case).

    With the FHT, the doctors get bonuses if certain percentages of their patients have, screening such as paps, colon cancer screening, and chronic disease management. So in this model of care, the clinic makes more money if NPs see rostered patients.

    NP led clinics are a very different model. Although NPs are generally paid a salary or per hour whether in the NP lead clinic or FHT. However the NP clinics do not have constraints as the FHT does due to the difference in funds/rostering. To keep the funds coming through, they need to be accountable by seeing patients (stats), regardless of rostered or not.

    Hope this makes sense

  8. TapOut

    “…so it seems that, even with our critical doctor shortage, there is no way around this arbitrary edict of the Ministry of Health….”
    It is a physician (lobby) driven market noncompetiton clause. Although I thought we had a not for profit model this is decreasingly true. Particularly when our modern biomedical health care and public health systems offer the scientific evidence, some technological improvement and some increase in general population (mean) quality of life and longevity. Allowing for time taken for careful evidence based evaluations, ‘we’ are slow to adopt the machinations of policy makers and enforcers in individual provinces, we the public health care payer and consumer are still lobbied both by without and within system special interest groups. The economy of politics of cost and the generation of scarcity. And then there is the patient.

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