The Centre for Health Services and Policy Research is a University of British Columbia senate-approved centre. It was established in 1990. The mission of CHSPR is to produce and communicate high-quality health services and policy research relevant to the organization, financing, and delivery of health care.
It also has a mission to train students, as well as in knowledge translation and exchange through its publications, media interactions, and exchanges with local, regional, national, and international health policy and health services decision-makers. It is unique in its focus on broader macrosystem challenges and policies that might normally be relevant to just one or a few regional health authorities.
I'll open by saying there is a changing landscape. The provincially and territorially based health care systems within Canada continue to undergo major reforms in response to new technologies and to demographic changes such as an aging population, advances in health care and disease management strategies, and the recognition of the importance of social determinants of health and ensuring the health of the population.
There has been relatively little attention paid to the impact of system and organizational change on health human resources in comparison to the extent to which such changes have occurred during the past decade. Much of the past literature completed for a scoping review for a report completed for the Health Services and Policy Research Support Network discusses the impact of the major acute care restructuring and downsizing of the acute care sector during the 1990s on health human resources, primarily in urban environments.
Less attention has been paid to innovation in the use of different health professionals’ scopes of practice in the non-hospital sector. There is little work on the health human resource implications of the increasing use of multidisciplinary teams and interprofessional collaboration, the use of other types of health professionals working to their full scopes of practice, or the increased use of a wide range of technology.
As a community of academics and clinicians, we know much about how health care services might best be organized and delivered, as well as the different health professions’ scopes of practice. We know little about the interaction of these two areas. We know much less about how best to deploy our health human resources for optimal organization and delivery of health care services.
As an example, primary health care delivery across Canada is associated with better and more equitable health outcomes. However, many of the reforms remain incomplete and the potential improvement for patients, communities, and the health system has yet to occur.
A central component of these reforms was the implementation of interprofessional team-based care. Provinces from coast to coast have embraced interprofessional primary health care teams resulting in many diverse models of teams now serving Canadian communities. Despite rising demands and expectations, the primary health care system remains ill-prepared to deliver the expected benefits of interprofessional primary health care.
A major obstacle to improving primary health care through interprofessional teams is the lack of understanding team members have of the scopes of practice and potential roles of other team members. Many of the professions that are part of these interprofessional primary health care teams such as pharmacists and psychologists, and even ones which have long been a part of these teams such as nurses, have only recently developed frameworks delineating the competencies of these professionals delivering primary health care services.
As the primary health care system faces growing demands for efficient and effective patient-centred care for increasingly complex patients, it is essential that these interprofessional primary health care teams develop better approaches to assessing and deploying their team skills to improve the care they deliver and better meet their patients’ needs.
To answer your specific questions, I've drawn on our expertise at CHSPR as well as our colleagues from across the country, namely the Canadian Academy of Health Sciences, which recently re-released a report on scopes of practice.
Your first question was what the federal role is in the scope of practice of Canadian health care professionals. There are a couple of things that I have decided to come up with in terms of this.
One would be to invest in an infrastructure to measure and monitor scopes of practice of Canadian health care professionals linked to appropriate dimensions of care. A federal role is needed to implement systematic monitoring and evaluation, with a specific focus on inputs and outputs, to estimate costs incurred for introducing change and the long-term return on investments. A federal role is needed to enable a broader application of collaborative performance measures and an overall quality assurance framework through involvement of accrediting bodies.
As an example, in community-based primary health care most agree that we need responsive first contact care for emerging problems, capacity to resolve common health problems, ongoing care for most chronic conditions, routine delivery of preventive and health promotion services, timely coordination with other actors concerning specific diseases, and action on the social determinants of health. However, performance reporting in community-based primary health care is challenging because of the dearth of concise and synthesized information and because many clinicians prefer to be accountable only to their individual role and do not view themselves as elements or actors within a larger system.
That would be the first recommendation.
The second one would be to earmark research funds to address gaps in the literature and our knowledge in a number of areas. We know that payment models do not support changes in scopes of practice, so one area of research is to look at alternative funding, such as bundled or mixed-payment schemes, to include all health care professionals and to be aligned with desired outcomes. We also know that care is moving into the communities and multiple-care settings, so we need to understand the implementation and upkeep of electronic medical records, since it is essential for all health care professionals and patients to have timely and up-to-date information on treatment and status. We know there’s a lot of professional protectionism that goes on, so we need to do work to understand how there could be better representation of interests of professions in the context of collaborative care arrangements and interprofessional standards and overlapping scopes of practice.
Another area is to earmark funds for educating professionals and courts on changes to legislation that recognize the principles of shared-care models. Right now health care professionals are worried about their accountability and liability. There is a federal role in addressing currently rigid legislation and regulations. If we could expand adoption of more flexible legislative frameworks that could be interpreted at local settings, that would greatly help. As well, there is a need to support the development and ongoing implementation of umbrella health professional regulatory legislation across provinces and territories.
The second area that you asked me to address was to highlight best practices on the use of scopes of practice, both in Canada and internationally.
Did you want me to continue, or do you want to ask questions now?