Living Well Integrative Health Center

2176 Windsor Street, Halifax, Nova Scotia, Canada. (902) 406-1500

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Big picture of health system missing and the new nurses act. An exchange between Living Well's MD and NP

On Apr 11, 2019, at 8:40 PM, Lesley MacGregor my dear colleague, NP now running the INSPIRE program wrote:
Other than Nova Scotia - I have never been required to identify a “collaborating physician” as part of my licensing.  It was a huge hurdle to me 3 years ago when we arrived and I didn’t know any physicians!
It’s not necessary... all health care providers are required to consult in their practice - but only NPs were required to formally identify this. 
I don’t think this changes the way NPs have, and always will practice - that is, being part of an interdisciplinary team.  Collaborating and consulting with all health care members (including physicians) as it applies to patient care.  Working within their scope of practice in a safe and effective manner.  This change only removes the paperwork in my view.  I have always had a group of clinicians whom I consult and work collaboratively with.  As have all NPs I have had the pleasure to work with. 
NPs are autonomous healthcare providers in all of Canada - and do not require supervision or “having work checked” as part of licensing.
In our case Maria - in order for you to Bill MSI, you yourself needed to have some interaction with the patients - not as a supervisor to an NP, but as a fee for service provider.  Annoying...yes, however if we had applied and been awarded provincial funding that would have required another X amount of patients to join the practice...and that was certainly not the solution.
I sit in the Ottawa airport now, having spent the day with physicians, nurse practitioners, registers nurses, respiratory therapists, social workers, spiritual care workers AND patient advocates from across the country.   Discussing health care delivery models and changes we need to make to improve patient care. Collaborating is KEY - among all providers and service areas...
NPs won’t stop collaborating.  Patient care is always at the center of what drives us and what shapes the type of care provided.  The new bill just removes a bit of red tape.
On Thu, Apr 11, 2019 at 09:32 maria patriquin <> wrote:
Lesley after two years one would think in two years of work they would have given me the heads up while doing policy work for them. Though on the surface it appears a win, the challenge is NP’s will inherit patients who are complex, have had little to no care and high needs. I tell all police makers PCWs are doing RN work RNs Family doc work family docs are doing specialist work and specialists are carrying patients without family docs as they fear they’ll have no one for the diabetes etc. The reality is everyone is working out of their scope and not together. There are simple sustainable solutions but quick fixes and crisis mode alarm system decisions paired with mis-allocated resources will make further demise and more lives lost. Technical solutions don’t address what are predominantly adaptive challenges that relate to cultural shifts in a hierarchical disease based model. Time for us to speak up. In Ottawa they care. Time for them to here as well. 
Sent from I phone 
Dr. Maria Patriquin MD CCFP
Founder, Living Well integrative Health Center
Collaborative Care consultant 
Mental Health Committee Atlantic Rep/CFPC
Collaborative Working Group Shared Mental Health Care CFPC/CPA
Canadian Paediatric Society Strategic Mental Health Task Force CFPC/CPS
Assistant Professor Dalhousie University Department of Family Medicine 

Begin forwarded message:
From: "Lynda Coe" <>
Date: April 11, 2019 at 7:43:05 AM ADT
To: "maria patriquin" <>
Subject: Thursday's Herald - 2

Big picture of health system missing

Journalist and writer Jim Vibert has worked as a communications adviser to five Nova Scotia governments.

Nova Scotia’s Auditor General Michael Pickup wants the health bureaucracies to keep their word and tell Nova Scotians where the system is headed.

It’s one of the undone recommendations from his 2016 report on the management of Nova Scotia’s hospitals. The smart money says when Pickup goes back to check next year, it will remain undone.

Nova Scotia’s Deputy Minister of Health Denise Perret once compared changes to, and contemplated for, the health system to building an airplane while flying it.

At the risk of torturing her metaphor, the health bureaucracies will let us know where the system will land just as soon as they figure out how to assemble the landing gear.

Pickup’s recommendation was that the Health Department and the Nova Scotia Health Authority “should tell Nova Scotians what they should expect from their health-care system. This includes determining and communicating which services will be delivered in hospital and in other locations, and what level of service to expect in communities across the province.”

When they accepted that recommendation almost three years ago, the department and the authority no doubt believed that when the auditor general checked back, they’d have something to show him. After all, they’re all about “system planning” and Pickup was basically asking them to let Nova Scotians in on the plan.

So, why haven’t they?

It could be that since 2016 the attention of the health bureaucracies has been focused more on trying to keep the plane in the air than determining its flight path or ultimate destination.

Back in ’16, the department seemed particularly enthusiastic about Pickup’s recommendation, and talked about “engaging communities and a variety of stakeholders to get input into their health needs to better develop systems and services of quality, sustainable, patient-centred care to best meet the needs of our citizens and communities.” Whew.

The department’s zeal is understandable, given it also noted that the NSHA would do the work. The department, however, would be there with guidance and airplane glue. In 2016 the talk was all about collaborative care teams that would coalesce and somehow collectively solve the big problem then and now, of access to primary care.

Fast forward to the present, and we discover collaboration is no longer the secret sauce. There is a government bill in the legislature that actually removes the requirement that nurse practitioners (NP) collaborate with physicians, as prescribed in the existing Registered Nurses Act, but not in its replacement, the new Nurses Act that will pass into law any minute.

Doctors Nova Scotia isn’t happy about that change, which they say could negatively impact patient care.

With the shortage of family docs, we can see where this is headed and a good many Nova Scotians looking for a family doctor — or family “practice” — will take a NP tomorrow, but most want to know there’s a direct line to an MD when that’s what the doctor ordered, so to speak. Whether there will be is another of those questions Pickup thinks you deserve an answer for.

“As changes take place, full and clear engagement and communication will be necessary to help ensure all stakeholders understand what is happening and why it is necessary,” Pickup said in that 2016 report.

Ideally. Except it seems that the authority, at least, is fully engaged just in responding to the healthcare crisis of the day. Currently, that would be the politically unpalatable picture of ambulances lined up outside emergency rooms waiting to offload patients and the corresponding scarcity of them around the province answering emergency calls.

Throw in the shortage of anesthesiologists and the cancelled surgeries that result, and the ever-present list of Nova Scotians who want a family doc, and it might not be a stretch to conclude the health bureaucracies don’t help Nova Scotians understand what’s happening in health care because they’re not entirely certain themselves.

Or, it could be that the crisis du- jour is merely the tip of a very large and — as we are constantly reminded by the health bureaucrats — very complex iceberg, but just beneath the surface is the master design for the system. Nah. If they had one, we’d see one.

The government would quite correctly point out that, as far as plans go, it has some big ones with the redevelopment of medical facilities in the Halifax and Cape Breton regions. Those plans were nowhere in sight when the auditor general made his recommendations back in 2016.

There’s another reason why Nova Scotians haven’t been shown the big picture for the system. It keeps changing.

Nova Scotia auditor general Michael Pickup reports the province failed to fulfil many of the recommendations stemming from audits conducted in 2015 and 2016, including one asking that the government keep Nova Scotians up to date on the state of the health-care system.



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