Consultation on Re-Building Health Care Together Brief submitted by The New Brunswick Nurses Union July 2012
Introduction The New Brunswick Nurses Union (NBNU) is a labour organization, representing over 6800 registered nurses in the Province of New Brunswick. The nurses we represent practice in acute care facilities, long-term care facilities, correctional facilities and the community. As an organization, we acknowledge the direction the government is taking on this very important matter and we thank the Department of Health for this opportunity to participate in this consultation process and provide our views from the perspective of public health policy. We are pleased that this plan will allow input and discussion around all provisions of this very key program. We look forward to playing an active role in the ongoing development process of a Health Care Program that is equitable, inclusive and fair for all New Brunswickers. NBNU welcomes the government s commitment to direct their attention towards rebuilding our health care system. We are acutely aware of the challenges and financial pressures within our health care system. We value our system enough to know that if nothing changes, then nothing changes. Registered nurses have valuable front line knowledge, expertise and experience in all areas of health care in this province. As strong patient advocates, we support a collaborative process for health care changes that values shared goals of publically delivered, quality, sustainable patient centered care. We need reform that addresses accessible acute and preventative health at all stages of the health care continuum. We commend the New Brunswick government for embarking on this consultation in hopes that it will provide additional details required to move forward with a blueprint or a manifesto for action. We need to invest now in our ability to bring actual performance in line with our aspirations, expectations and the rapidly changing realities of our communities. The time is ripe, now more than ever, to chart the most direct course towards these reforms. NBNU would also like to respectfully highlight that this brief is not exhaustive as we feel we have stated our standpoint along with many recommendations in previously submitted briefs on the issue of New Brunswick s health care system. Those are notably: Brief on Improving Access and Delivery of Primary Health Care Services in New Brunswick (September 2011); Brief on Budget Consultation Process (February 2012); and Brief on Prescription Drug Plan for Uninsured New Brunswickers (May 2012). You will find all three briefs attached for your review and consideration. 2
Support for Primary Health Care It is clear: New Brunswick s health care system is not performing as well as it could or as it should. People are increasingly impatient with the inability of our health care system to deliver a level of coverage that meets stated demands and changing needs, and with its failure to provide services in ways that correspond to their expectations. Few would disagree that our health care system needs to respond better and faster to the challenges of a changing society. Primary Health Care (PHC) can do that. There is a recognition that strengthening and improving the way in which primary health care is provided is vital in determining how well our health system responds to current and emerging pressures. NBNU believes that our health care system needs to put people at the center of health care. In other words, what people consider desirable ways of living as individuals and what they expect for their communities i.e. what they value constitute important parameters for governing our health sector. PHC brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface between the population and the health system. We need to put people first, to give balanced consideration to health and well-being as well as to the values and capacities of the population and the health care workers. PHC must be our benchmark on health because it provides rational, evidence-based and anticipatory responses to health needs and to social expectations. 1 Achieving this requires exchanges that must start by taking into account New Brunswick s expectations about health and health care and ensuring that New Brunswickers voice and choice decisively influence the way in which health services are designed and operate. New Brunswickers have a right to the highest attainable level of health while being guided by responsiveness to people s needs. Moving towards health for all requires that our health system responds to the challenges of a changing community and growing expectations for better performance. This involves substantial reorientation and reform of the ways our health system operates today. This reform must constitute the agenda for New Brunswick s health care system. 1 Renewing primary health care in the Americas: a position paper of the Pan American Health Organization. Washington DC, Pan American Health Organization, 2007 3
The Problem New Brunswick s health care system is valued by its citizens. At the same time, it is increasingly recognized that the system is inadequate to meet the 21 st century needs and is in urgent need of reform. New Brunswickers wait too long for care. Care providers feel overworked and discouraged. There are insufficient mechanisms to monitor system performance. Technical support needs modernizing. While there is universal coverage for a narrow range of medically-necessary services, access to other essential health care services is inconsistent, both within and across the province. Exceedingly long waits for necessary medical care is prevalent; our current patchwork of public and private drug plans is inequitable and inaccessible for many; inadequate long term care strategies are manifest and home care should be an option to allow people to live in their own homes as long as they possibly can with homecare services. Efficiencies in the management of our health care system must be found to achieve value for money spent. The 2011 New Brunswick Health Council survey indicates that 62% of New Brunswickers are highly satisfied with the overall health services they receive. 2 However, there are some concerns about the lack of timely access to see their family physicians, the long wait times for diagnostic testing, a widespread lack of access to specialist and specialized treatment, and the compromised quality of care in overburdened emergency rooms. With our aging population, end of life issues are becoming increasingly important. The founding principles of Medicare are not being met today in New Brunswick. New Brunswickers are not receiving the value they deserve from their health care system. Issues such as quality of care, accountability and sustainability are now recognized as key aspects of a high-performance health system. Health by today s standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health. Also missing in our current system, but vitally important to proper care, is health information technology. In this area, New Brunswick seems to be miserably lacking in both resources and coordination efforts towards an implementation plan, especially as it relates to the electronic medical record. 2 New Brunswick Health Council. New Brunswickers Experience with Primary Health Care, 2011 Survey Results (NBHC 2011) 4
Health care insurance plans are another area of concern. These plans must be administered and operated on a non-profit basis. The principle of public administration is often misinterpreted to mean public financing of publicly delivered services. In fact, while Medicare services (hospital and physicians) are publicly financed, many services are privately delivered, as in health care plans, most notably, our prescription drug program. Our health care system is underperforming on several key measures, such as timely access, despite the large amounts we spend on health care. New governance models should be considered to improve both health system effectiveness and accountability. The ability to pay for health care is increasingly in question. The challenge of sustaining our health care system is what makes it imperative to move forward now with health care transformation. Sustainability in health care may be defined as the ability to deliver universal publicly-funded health care services without compromising other government programs or the ability of future generations to pay. Challenges for Transformation NBNU believes that any transformation plan must have three core goals: 1) improving population health; 2) improving the patient s experience of health care; and 3) improving the value of money spent on health care. We further believe this can be done by building a culture of patient-centered care; by enhancing access and improving quality of care (by enhancing timely access and supporting quality care); by enhancing patient access along the continuum of care, including primary health care, health promotion and disease prevention; by ensuring New Brunswick has adequate supply of health human resources and a more effective health information technology; and by building accountability/responsibility at all levels. Crucial to improved care is the full implementation of a primary health care program, including universal access to comprehensive prescription drug coverage and improving access to continuing care (long-term care, home care and palliative care). Many New Brunswickers do not have access to necessary prescription drugs and much time and effort is spent on trying to place patients in long-term care facilities or secure assistance in the home. Improving access in these two areas for New Brunswickers would help create a more patient-centered health care system, and enhance efficiency for providers. 5
NBNU is of the opinion that for effective transformation to occur, the following principles should be considered: 1) Patients need to take an active part in developing their care and treatment plan, and in monitoring their health status; 2) Support systems need to be established to allow elderly and disabled to optimize their ability to live in the community; 3) Strategies need to be implemented to reduce wait times for accessing publicly funded home and community care services; 4) Integrated services delivery systems must be created for home and community care services. Models of Care New Brunswick health care must shift from a model of acute care to a model of preventative care including healthy lifestyles. We need to have a system that promotes good health and provides expanded access to preventative care interventions including supporting individuals with the behavioral changes required to reduce the risks of disease. PHC has an important role to play in helping lower risk of disease and in preventing, delaying the onset or reducing the severity of many health conditions including the complications or recurrence of disease. NBNU is of the opinion that this potential is currently only partially fulfilled and would benefit from greater expansion. Re-orienting our health care system towards prevention needs to be a key objective of our health care reform processes. An expanded role for nurses and allied health professionals in preventative health care is imperative. Nurses who work in primary care nursing aren't being utilized effectively. There is an incredible amount of untapped potential and we need to change that so nurses can do more for their patients and make our system more efficient. There needs to be more involvement in prevention activities that highlight the importance of healthy lifestyles and of health promotion, early detection, timely treatment and management of risk factors and early stages of disease at every stage. 6
Information Technology Electronic medical records (EMR) and other technologies are key enablers for change in primary health care. EMR allow information to be available when and where a patient needs care, reduce the risks of adverse events and reduce costs. EMR also support multi-disciplinary primary health care collaboration and enable efficient exchange of information between primary health care, community and specialist health care settings. This is a significant resource for health care professionals and their patients, particularly those with complex or chronic health conditions. For patients, better management of their health information is essential to the safety and quality of their health care. The availability of clinical information electronically also has the potential to add to workforce productivity and provide economic efficiencies across the PHC sector. 3 Fundamental is the availability of personal health information such as medications, pathology results and discharge information which will contribute to significant improvements in patient health outcomes. The value of electronic enablement in PHC needs be highly acknowledged and a framework to take this forward needs to be implemented. Long Term Vision NBNU strongly believes that it is difficult to envision viable solutions for health care in New Brunswick without a real public debate on a crucial question: Are health and health care in New Brunswick common goods of public and general interest or simply commodity-services open to political parties for election? The solutions depend upon the answer to that question. We believe that an important program such as health care should not be subject to any political change and that the implementation plan should be built on long-term goals and objectives, and not be at the mercy of a political climate change. We need to implement real solutions that will sustain our public health care system now and in the future. The citizens, users/payers, of New Brunswick must organise themselves and become directly involved in the development and implementation of solutions. The same citizens should understand that the government is neither rich nor poor, and the money it spends comes from taxpayers pockets. Continuing to request services and at the same time asking for more tax reductions is totally nonsensical. 3 The Allen Consulting Group 2008. Economic Impacts of a national individual Electronic Health Records System. Report to the National E-Health Transition Authority. 7
In turn, government should act in the common good and general interest and stop yielding to powerful political pressures. Our government should have the courage to implement the solutions already suggested in the recent years by numerous reports. It would take too long to list all of the proposals made therein, however, of note that just the establishment of a provincial pharmacare program would save billions on what is currently being spent on drugs. The most important is that the government should have an overview of the system and act in favour of a long-term vision and not only to save some money until the next crisis or until the next election. It is encouraging to see that lately, more and more of the proposed solutions to maintain the viability of the public health care are coming from within the system. More and more professional practitioners are offering viable solutions, based on their practical experience. Some facts we must consider while devising our plan: The aging population does not make the cost of health care unaffordable. The aging population, which is increasing on a yearly basis, costs less than the costs driven by the population growth or inflation. Speaking of a gray tsunami is only diverting attention from the rapidly rising cost of drugs and equipment. The privatization of health care will not solve the problem. The private system does not form or train physicians or nurses. It recruits among those working in the public sector. In areas where private clinics have already been installed, it was found that the shortage of professionals is worsening, waiting times become longer, costs increase because the public sector must raise wages to retain staff and the dependence on professionals trained outside of New Brunswick is growing. It is essential to highlight that the delivery of these services by the public system does not have as an objective making a profit and that these services are offered at cost. The solutions are there and the government must have the courage to act now to implement them for the well-being of all New Brunswickers, instead of for political gains or private corporate interests. 8
Conclusion Our system is based on an illness model and we need to shift it to one that places greater emphasis on health promotion, disease prevention, and chronic disease management. There are many solutions to make our health care system sustainable, but NBNU strongly believes the full utilization of registered nurses is the key to our primary health care success. New Brunswick s Primary Health Care needs to recognize the significant role of nurses in delivering team-based primary care to patients. NBNU feels strongly that nurses and all health professionals must be supported to deliver the best value possible to New Brunswick patients. We need to examine the evidence and explore how our health system can reap the full benefit of the competencies, knowledge, and skills of our primary care nurses. We further believe that having registered nurses and all other health professionals working to their full scope of practice in primary care teams produces better health outcomes, improves access to services, and will help sustain NB s health care and strengthen it for future generations. As the province faces a ballooning deficit and crippling debt, it's critical that both government and stakeholders come together to find cost savings and innovative solutions. NBNU, other professional bodies and stakeholders have put legitimate ideas on the table, now it's up to the government to develop these ideas into good policies. It is time for the New Brunswick government to make our health care system strong and sustainable. 9