Quebec Health Minister Danielle McCann wants the province’s specialized nurse practitioners (SNPs) to be able to make diagnoses, as is the case everywhere else in Canada. The Collège des médecins du Québec, after a little arm-twisting, ended up making its peace with the idea, while the union of general practitioners is still not on board. Is this resistance justified?
As in many other areas of health care, Quebec lags behind other provinces. There were barely five nurse practitioners per 100,000 residents here in 2017, whereas the Canadian average was 15, and the figure was greater than 22 in Ontario. The total number of nurse practitioners in Ontario last year was just over 3,300, versus 484 in Quebec. (So we can forget about reaching the objective of having 2,000 nurse practitioners by 2024.)
Yet it’s not as if the Quebec system was succeeding in meeting the demand for front-line care. Quebec (and the rest of Canada, too) has few doctors compared to most industrialized countries. One in five Quebecers still does not a family doctor, and on the Island of Montreal, it’s one in three. The province is also at the back of the pack among industrialized countries in terms of access to a consultation the same day or the next. As for emergency wait times in Quebec, they are legendary. Allowing nurse practitioners to do more would not solve every problem, but let’s just say it wouldn’t hurt.
We know, thanks to many studies, that nurse practitioners can provide a wide range of front-line care, which varies from 60 per cent to 90 per cent, depending on the case. These figures were confirmed by the American College of Physicians. One obvious advantage is to free up doctors from having to handle relatively simple cases so that they can focus on those for which they have a particular expertise.
That takes care of quantity, but what about quality? Well, patients aren’t complaining. A survey of some 20 studies carried out in OECD countries noted very high satisfaction rates on the part of patients who consulted nurse practitioners. This sentiment was corroborated by health indicators, which were found to be generally similar to those of patients treated by doctors. Notably, the longer consultations typically provided by nurse practitioners and the extra attention devoted to prevention led to improvements in certain indicators, particularly in the case of chronic diseases like diabetes. A reduction in wait times for accessing care and medication was also observed.
People who worry about possible frictions or divergence of opinions can rest easy: A study that compared the decisions of nurse practitioners with those of physicians for 600 patients in the United Kingdom found that they had agreed on 94 per cent of diagnoses, and on 96 per cent of treatments. In short, there is no problem.
The case of diagnoses for everyday health problems and certain chronic diseases has now been resolved, but some barriers remain, and Quebecers still don’t have access to the full range of nurse practitioners’ skills. Why? Beneath the argument of “protecting the public,” there is in fact a good dose of groups protecting their interests. The restrictions imposed on SNPs in Quebec are a typical example of regulatory capture in favour of a small influential group (medical doctors, through certain groups that represent them), to the detriment of the Quebec public as a whole.
The health minister is right to want to remove these barriers. The same spirit of openness should apply to all health professionals. For example, we could apply the same reasoning to pharmacists or to dental hygienists; Quebec is again an outlier in prohibiting the former from administering vaccines, and the latter from practising their profession without the supervision of a dentist. In sum, the point is not to pit health professionals against one another, but to ensure that everyone has the best possible access to care.
Patrick Déry est analyste senior en politiques publiques à l'Institut économique de Montréal. Il est l'auteur de « Doit-on permettre aux superinfirmières de poser des diagnostics? » et signe ce texte à titre personnel.