Part of the Solution not Part of the Problem

Last week’s article on nurse practitioners prompted diverse responses. Most of them were enthusiastic, but a couple were decidedly dissatisfied.

The article argued that nurse practitioners should not be required by legislation to establish formal relationships with family physicians as a condition of their right to practice. Secondly, it argued that the system should experiment more broadly with letting various health professionals expand their roles.

Those who were positive agreed that nurse practitioners should not have a legislated obligation to link to a family physician. Nurses are regulated by the College of Nursing of Nova Scotia. In the past 15 years there have been 163 proceedings that resulted in reprimands, suspensions, or revocations of license.

One observed that experienced nurses in senior roles are often an important source of development advice for newly minted physicians.

In addition, most of the responders focused on the broader idea of more flexibility in roles for health professionals.

For example, one correspondent describes “a program of Clinical Assistants in Mental Health and Addiction services in the Eastern and Northern zones. The candidates are currently in the initial phase: assessment and training. So far so good, not an overall solution but a big help to an overwhelmed system in these two zones.”

Another idea, widely used elsewhere, is Family Practice Anesthetists. They are fully licensed and certified family physicians who have done one year of extra training. They can handle a lot of the load that would otherwise require anesthetists with several more years of training.

Two correspondents expressed serious concerns. They were not about the explicit issue of what the legislation should require but rather viewed the article as promoting a further deterioration of the status of physicians.

Worries expressed included:

  1. Nurse practitioners take work away from family physicians. They don’t always keep the family physician informed about changes they make to treatments. Delivering care through nurse practitioners is more expensive than through family physicians.
  2. When the family physicians are notified of decisions—say a prescription—by a pharmacist or nurse practitioner, they have to review it for no fee and may be responsible if things go badly.
  3. The article was promoting more power for nurses’ unions who already have too much. Management of the healthcare system is dominated by nurses. Nova Scotian nurses are among the highest paid in the country, while doctors are among the lowest.

Not all of the assertions in the correspondence are accurate.

Nevertheless, there are valid issues.

  1. When a doctor sees a patient, she gets a fee for service. The economic pressure is to get it done as quickly as possible. The time allotment is 15 minutes. A nurse practitioner is paid a salary and has no reason to hurry. He is supposed to spend 30 minutes with each patient, but still gets paid if there are not enough patients to fill the day.
  2. Family physicians in Nova Scotia continue to be poorly paid. The government made some useful interim steps last March, but more needs to be done.
  3. In some of our rural areas, the population is shrinking but the workload is not because those remaining are much older than the provincial average.
  4. Decision-making is still far too concentrated at the top of the NSHA pyramid. A position of Vice President and Chief, Zone Operations has been established, but it will not be filled until June. It is not clear whether or how this will result in downloaded decision making.
  5. When there is an unexpected departure from a small group of practitioners outside of Halifax, be they specialists or family physicians, it takes a long time for a replacement to be found. Given that we are already understaffed in many areas, there is no bench strength.
    The added seats at Dalhousie Medical School are welcome, but it takes a long time for them to graduate active practitioners.
  6. Family physicians and many specialists are independent business operators. The province is a contractor, not an employer, and cannot direct them to move to the areas of greatest need. Many feel no responsibility for succession planning. This makes resource planning difficult for health authorities.
  7. Patients and their families view doctors as their core resource. Nurse practitioners and others are viewed as welcome adjuncts, but complaints are focused on the shortage of doctors.

Family physicians are understandably concerned about their pay and working environment. They should view the growing contributions of other health care professionals as part of the solution, not part of the problem.

To make it work, all of the health professions need to understand that collaboration is more than a “nice to have.” And the health authority needs to be much nimbler and more responsive in its decision making.


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The noise bylaw passed by Halifax Regional Municipality’s Council has caused quite a fracas. None of the players come out of it looking good.

Communities throughout Nova Scotia need more housing, as quickly as possible. That is what happens when population grows by 2% or more. Halifax gets at least half of that growth—more than 10,000 people per year.

There is a constant tension between the desire of existing residents for the peaceable enjoyment of their homes and the noise that inevitably accompanies heavy construction.

The fracas began with a recommendation by HRM staff that the noise bylaw be amended to disallow rock breaking on weekends. This should have been harmless enough; it is the noisiest part of new construction.

Builders typically take a pause on weekends anyway. Most of those that currently work through the weekend might need an extra week or two to finish their rock breaking, the rare exceptions being the convention centre or the rare project that begins with the demolition of a substantial existing building.

On its own this may not have stimulated too much reaction. But council chose to also reduce the hours that building noise could occur. They begin at 7 AM, and council voted to stop work at 8 PM instead of 9:30. This might affect a minority of projects. Most building sites stop work by 5 PM or earlier.

Duncan Williams, president and CEO of the Construction Association of Nova Scotia, claims the new rules would be devastating to the construction industry. For big projects, he predicts costs could shoot up by 15-20 percent and construction could take six months to a year longer to complete. He seems to believe that construction workers would be demoralized that they can only work 13 hours a day instead of 14.5.

Working that long every day would entitle workers to time-and-a-half overtime pay, so it is hard to understand the assertion that cutting hours would add to cost. Repeated requests to the association to explain how Williams reached his conclusions went unanswered.

Municipal Affairs and Housing Minster John Lohr introduced, without consultation with the mayor or council, legislation that gives the minister the authority to nullify any HRM bylaw in whole or in part. He was quoted as saying that HRM’s changes to the noise bylaw could add up to two months to a two-year build, wouldn’t reduce the noise, and would add to the shortage of skilled trade workers.

The two-month delay calculation is overstated unless the project would otherwise have worked the full 14.5-hour day from beginning to end.

A knowledgeable source in the building trades was asked about adding to the trades shortage. He strongly disagrees: “That makes no sense at all. No one is sitting home that wants to work. To suggest workers are going to leave to go west because they can’t work till 9:30 at night? Who wants to work 14.5 hours a day?”

To no one’s surprise, the mayor and council were deeply upset. Councilor Waye Mason says staff can make exemptions for rock breaking not near residences and have already provided dozens.

He cites, as an example of those hurt by construction noise, a resident near Pepperell and Preston streets who can expect to have construction near her for 10-12 years. The weekend exclusion for rock breaking makes sense for her but the weekday limit on work will be of minimal benefit. Very few projects are active after 5 PM, let alone 8.

Council’s decision to reduce weekday hours in addition to the rock breaking limitations proposed by staff was ill-considered. The province’s response is like using a ten-ton truck to deliver a pizza. The one redeeming feature is that the authority to annul in whole or in part only exists for the first six months after the bylaw is in force, and has not happened so far.

The province and the municipality have a shared goal of rapid population growth. HRM estimates of 525,000 residents by 2027, growing to 650,000 in the following ten years. Unlike the number in last spring’s provincial budget, that is consistent with the provincial goal of doubling by 2060.

A better example of how they should work together is the Deloitte Housing Development Barrier Review. It identifies the need to complete 7,600 units per year between now and 2027, compared to the historical rate of only 3,000 per year, and prioritizes steps needed to accelerate the pace.

The panel that sponsored the report is a creature of the province but HRM is heavily involved. Cooperatively pursuing the recommendations represents the best chance to produce enough housing.

In the meantime, the two governments must have an effective working relationship. For that to happen they need to stop surprising each other.

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