Nurse Practitioner Erin Lamphier wants to work in primary care but can’t find a publicly funded job in Windsor, opting to instead provide medical care to refugees.Sammy Kogan /The Globe and Mail
Erin Lamphier is frustrated that she can’t be the primary-care provider she wants to be in a city desperately in need of more primary care.
Ms. Lamphier has a dozen years of experience as a nurse practitioner, a professional designation that allows her to perform many of the same tasks as a family doctor, including diagnosing illnesses, writing prescriptions, ordering tests, and making referrals to specialists.
She would love to provide those services on a full-time, permanent basis in the southwestern Ontario region of Windsor-Essex, where she was born and raised, and where 44,000 people were without a family doctor as of 2022.
When Ms. Lamphier finished covering a maternity leave at a Windsor practice last fall, she found there were no publicly funded job openings for primary-care NPs in her area. If she were a doctor, she could hang a shingle and start billing the Ontario Health Insurance Plan. But NPs aren’t allowed to bill OHIP.
That left Ms. Lamphier scant options beyond joining the small ranks of NPs asking patients to pay out of pocket for medically necessary care – something Ms. Lamphier has so far refused to do.
“They need primary-care providers,” Ms. Lamphier said of the Ontario government. “I’m looking around and I’m saying, ‘Okay, I’m ready, willing, and able.’ There needs to be funding.”
Ms. Lamphier’s predicament puts her smack in the middle of a national debate about the role and remuneration of nurse practitioners at a time when as many as 6.5 million Canadians say they don’t have a family doctor or other primary-care provider.
Nurse practitioners could help fill the void, advocates for the profession say, if more provinces would adopt policies to integrate them into primary care and pay them fairly for their work. Some physicians’ organizations have pushed back against that approach, arguing that NPs don’t have as much training or education as family doctors and therefore should only be funded publicly when they’re embedded in interdisciplinary teams with MDs.
“It’s in the interests of provincial governments to ensure that the patients that can’t get family doctors get a nurse practitioner, and it will cost less,” said Greg Marchildon, a professor emeritus in the Institute of Health Policy, Management and Evaluation at the University of Toronto and a former deputy health minister in Saskatchewan.
“It won’t cost a lot less – I don’t want to overemphasize that – but it will cost a bit less, so why not do it? It really is an important way of addressing this need.”
Last month, Alberta unveiled a first-of-its-kind program allowing NPs to open their own publicly funded practices with compensation plans that pay 80 per cent of what a family doctor makes, with some important strings attached, including a stipulation that NPs enroll at least 900 patients.
Alberta’s announcement came shortly after Ontario Health Minister Sylvia Jones sent a letter to her federal counterpart, Mark Holland, asking his government to clarify how the Canada Health Act applies to NPs in private practice who ask patients to pay out of pocket for care that would be covered by the Act if it were provided by a physician.
“While provinces may have tools at their disposal to bring in some provisions to put this practice to an end, this may lead to non-physician providers, like nurse practitioners, leaving Ontario to work in another province,” Ms. Jones wrote on April 15.
Christopher Aoun, a spokesman for Mr. Holland, said in a statement that a new “interpretation letter” would be released in the coming weeks. “While I can’t comment on its specific contents, I can say that this letter will continue the work we’re doing to strengthen our universal healthcare system by ensuring compliance to the Canada Health Act. All Canadians must be able to access medically necessary care without having to pay out of pocket.”
Stan Marchuk, the chief executive officer of the Nurse Practitioner Association of Canada, worries about the consequences of a national ban on NPs charging patients if the move isn’t accompanied by adequate public funding models for NPs in every province. Patients currently paying NPs for primary care could be left with nothing, he warned.
“If you are going to graduate someone from a program, and you do not create an opportunity for them to practise, what do you think they will do?” he asked. “They will need to become an entrepreneur of some sort in order to practice their profession, and also to be able then to serve the needs of a community.”
The Canada Health Act was enacted in 1984, when the profession of nurse practitioner barely existed. The Act doesn’t mention them.
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In the decades since, provinces have expanded NPs’ scope of practice to cover many of the same functions as family doctors working in primary care. However, family doctors in Canada still have a far wider scope than NPs beyond primary care; in rural areas, the doctors running emergency rooms and delivering babies are often trained as GPs.
Family doctors generally require an undergraduate degree, four years of medical school and at least two years of residency training. NPs must obtain a bachelor’s degree in nursing, practise as a registered nurse for at least two years, then complete a two-year postgraduate degree to become an NP.
In Ontario, NPs working in primary care are paid a salary to work in several different models, including family health teams, community health centres, and nurse practitioner-led clinics, a model that Ontario pioneered two decades ago. The province has 25 NP-led clinics, and is planning to add five new ones as part of a $110-million expansion of primary care services announced in February.
Ontario already has more licensed NPs than the rest of the country combined – just over 5,000 of the approximately 9,800 NPs in Canada are located in Ontario. Of those, 2,746 are working in publicly funded primary care in Ontario, according to Michelle Acorn, CEO of the Nurse Practitioners’ Association of Ontario. She said the association was aware of only about 25 NPs in private practice charging patients out of pocket for medically necessary care.
In Alberta, the government has set aside $15-million this year to pay approximately 50 NPs to start their own primary-care practices. NPs who work full-time, including on some nights and weekends, and put between 900 and 1,099 patients on their rosters will earn $246,662 in gross compensation. That figure rises to $361,144 for NPs who enroll 1,500 or more patients.
Like family doctors, NPs joining the new model will have to pay their own overhead, including rent, staff and supplies.
When the Alberta government announced the broad strokes of the NP plan last November, the Alberta Medical Association took to the social media site X to say the news “made many family medicine specialists feel less valued.”
After Premier Danielle Smith fleshed out the NP plan at a news conference on April 25, Paul Parks, the president of the association, said in an interview that it could work well if it bolsters team care with physicians.
“On the flip side, if the intent is to have standalone, totally independent nurse practitioner clinics, then it’s concerning,” Dr. Parks said. “What happens when the nurse practitioners clearly realize that a patient may be out of their scope?”
Jennifer Mador, the president of the Nurse Practitioner Association of Alberta, said it’s unlikely that NPs will start solo practices under the new model, although she stressed that NPs are capable of independently providing the same quality primary care as family physicians and deserve pay equity.
“None of our NPs are saying that they’re going to go out and use this money in a silo by themselves,” she said. “That’s not financially viable. They will have to team up.” Sixty NPs have already sent expressions of interest to the Alberta government about joining the program, she added – more NPs than there are spots in the first year of the plan.
If Alberta were to add 50 NPs who enrolled an average of 1,000 patients each, that would take 50,000 people off the waiting list in a province where an estimated 700,000 people don’t have a family doctor. Those figures serve as a reminder that although the number of NPs in Canada is rising at a faster rate – about 10 per cent a year – than any other health profession, NPs are not a panacea for the primary-care crisis.
Nonetheless, Erin Lamphier wants to be part of the solution in her corner of Canada. Until she can find a publicly funded job in Windsor as a primary-care NP, she is picking up hours in walk-in clinics and physicians’ offices and trying to find funding to provide medical care for refugees.