Nurse practitioners are a key plank of government efforts to improve access to primary care.
However, a continuing gap in pay and benefits for nurse practitioners who choose to work in primary care compared to those who work in hospitals, limits recruitment and retention to community settings.
From a zippy online campaign to an economist-authored report, there’s been a groundswell of attention lately to the key role that nurse practitioners (NPs) can play in providing community-level health care.
NPs are registered nurses (RNs) with advanced university education. They can perform many of the same tasks as doctors currently perform, such as diagnosing illness and injury and ordering tests and procedures, and it is widely acknowledged that they can play a key role in helping patients to manage chronic diseases.
Just last month, major reports from two nursing organizations called for greater use of NPs in primary care : Primary Solutions for Primary Care, from the Registered Nurses Association of Ontario, and A Nursing Call to Action produced by an expert committee convened by the Canadian Nurses Association (CNA).
And earlier this year the Commission on the Reform of Ontario Public Services, chaired by economist Don Drummond, recommended that the government maximize opportunities to use NPs in all areas of the health care system in order to “increase efficiency while maintaining excellent care.”
Greater use of NPs in delivering health care services is expected to free up doctors to be able to focus on the more complicated patients who require their expertise.
“There’s been a lot of advocacy for what NPs are able to contribute to the system,” acknowledges Debra Bournes, Chief Nursing Officer for Ontario’s Ministry of Health and Long Term Care.
All this endorsement of NPs fits neatly into the Ontario government’s pledge for a “transformation” that will shift more health care into the community — a commitment articulated in the Excellent Care for All Act.
But there is a snag.
A roadblock to the plans to increase NPs’ presence in community care is the significant salary and benefits gap between the hospital (acute care) sector and the community (primary care) sector. And that gap contributes to NP jobs in primary care going unfilled. While nurse practitioners are not the only professionals where there is a pay gap between the hospital and community sector, this story focuses on the impact of this pay gap on recruiting NPs to work in the community sector.
Salary gap and unfilled community positions
“The government has made a commitment to move programs out of hospitals and into the community, but how are they going to do that without addressing the issue of wages and pensions?” asks Adrianna Tetley, executive director of the Association of Ontario Health Centres. The province hasn’t put forward any strategy to address these issues, she says.
NPs aren’t the only health professionals who are paid less in the community than in hospitals, but they are a key piece to the puzzle.
In late summer 2011, 19% of NP positions were vacant, according to a 2012 report co-authored by the Association of Ontario Health Centres , the Nurse Practitioners Association of Ontario and the Association of Family Health Teams. Comparable figures for NP vacancies in hospitals and public health units were not available.
That report, Toward a Primary Care Recruitment and Retention Strategy for Ontario,which provided information on vacancies and salary disparity for nurse practitioners along with pharmacists, dieticians, registered nurses and social workers, noted that salaries for these professionals are 5-30% lower in primary care than in hospitals.
For example, the pay range for NPs who work in Family Health Teams delivering primary care was between about $78,000 to $89,000 a year in May 2010. However, key informants who spoke with healthydebate.ca suggested that NPs in the hospital and public health sector earn anywhere from about $10,000 to over $30,000 more a year in base salary.
“You don’t do this job to get rich, you do it to make a difference,” says Claudia Mariano, the president of the Nurse Practitioners Association of Ontario, a voluntary organization that represents about 1400 of the 2,072 NPs who are registered in Ontario.
“But the current situation has created a lot of disparity,” says Mariano, who’s been an NP for 13 years and a registered nurse (RN) for 25.
They can also join the Healthcare of Ontario Pension Plan, a defined benefit pension plan, while only small number of NPs who work in the community sector can access HOOPP and their access typically comes at the expense of other benefits.
Lack of access to HOOPP creates a “barrier to labour mobility”, states the Strategy report, as hospital- based NPs are reluctant to shift from the hospital to the community sector.
“I’ve been working all my life and never had a pension plan and we are all getting older, thinking about retirement. The last [salary] increase I saw was almost seven years ago,” says Mariano.
Mariano says that, as an NP, and in the current economic climate, she has some discomfort talking about money, but adds that the disparity with the acute care sector affects people’s access to care.
Ontario Family Health Teams that include a nurse practitioner are able to accept an additional 800 patients into the practice, according to the report, A Nursing Call to Action.
Before 2005, most NPs in Ontario worked in Community Health Centres. But more NP jobs opened up in 2005 when Family Health Teams were created and in 2007 when the province opened the first NP-led clinic in Sudbury (there are now 22 such clinics in Ontario). The largest proportion of NPs now work in community care (about 44%), while about 38% work in hospitals, with the balance in other health care settings, Bournes said.
Expanding scope of practice for NPs
Recent Ontario legislation has expanded and clarified the NPs’ scope of practice — instead of waiting for medical directives from a doctor, NPs now have full access to diagnostic testing, can treat, transfer and discharge both in-patients and community out-patients from hospital and, as of this month, admit patients to hospital. Mariano said that this increased responsibility has not been accompanied by any increase in pay.
One of three key strategies in Ontario’s Action Plan for Health Care is to provide better access to primary care, home care and community care so patients can receive the care they need, in the most appropriate place and in a timely manner. Bournes noted that the provincial budget stated that the government is focused on enhancing community-based care to treat patients in alternative settings, like non-profit clinics and at home instead of hospitals, where appropriate.
To address the issue of the vacancy rate for NP positions in the community, the province introduced a Grow your Own NP program in 2006, so that organizations can use the salary allocated to the NP position to support an RN to return to university and upgrade to become an NP, Bournes said. She says that since the program started over 65 RNs have participated in the program, with a majority of positions being in the community.
To address the acute care/community care gap, the first priority of government should be to boost benefits package (from about 20% of salary to 23%) so that health professionals in the community have access to HOOPP pension plan, states the Strategy report from the community care organizations.
While there is a great deal of government efforts to improve access to primary care in the community, and to fund more NPs, the salary and benefits gap continues to be a significant barrier to having more NPs and other providers working in the community.