Beyond imagining: A nursing perspective on the future health-care system

Imagine a health-care system that goes beyond primary care, beyond acute care, beyond differentiated care services. Imagine a health-care system in which there is appropriate use of health professionals with a local network of health-care sectors, including primary care, long-term care, home care, community care, public health, and acute care—accessible to all.

These scenarios resonate with nurses, as they do for other health professionals, health authorities, and governments. They are based on our Canadian value of health care as a public good—considered important for the well-being of the population and for the productivity of society and enshrined, in part, in the Canada Health Act. Health policymakers are faced with the task of reconciling this with objectives of maximized health outcomes and cost-effectiveness.

Reform of health systems must be directed toward one or more of the following goals: efficacy, efficiency, equity, and quality of the system, as these will become increasingly important to all actors in the health policy field, including decision-makers, analysts, nurses, physicians and other practitioners, and the public.[1] The health-care system must become more responsive to the public’s value of a holistic approach toward the determinants of health—factors that determine why some people are healthy and others are not. Improvement of primary health-care services will be a common response to challenges facing health-care systems.

Nurses across Canada have endorsed the World Health Organization[2] definition of primary health care as essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation, and at a cost that the community and country can afford. It forms an integral nucleus of the country’s health-care system.

It is the first level of contact of individuals, family, and community with the health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health-care process. Primary health care addresses the main health problems in the community, providing promotive, preventative, curative, supportive, and rehabilitative services.

Evaluations of several BC demonstration and pilot projects indicate that registered nurses have essential roles in primary health care. The Comox Valley Nursing Centre, developed to demonstrate registered nurses’ scope of practice in a community-based health centre, is now an integral component of health-care services in the region. The evaluation indicated that registered nurses are an essential point of entry to a primary health-care system and that this is a cost-effective service for clients, especially those with particular health-care needs such as chronic illness and pain management, self-care knowledge, and attention to determinants of health. RN First Call, begun as a pilot project in 1996 in one BC hospital, has expanded to 10 hospitals.

This program uses registered nurses to, on their own authority, assess, diagnose, and treat patients who present to emergency care settings with minor, uncomplicated health problems. Interim evaluation indicates the program has potential to provide useful, acceptable, and appropriate services to patients who present to emergency settings for non-urgent reasons. In addition, the RN First Call program offers patients access to an alternative health-care provider with different perspectives and competencies that include patient education, health promotion, and disease and injury prevention.

The self-care pilot project Partnerships for Better Health in the Capital Health Region has also demonstrated that registered nurses are acceptable points of entry to the health-care system for the public and are appropriate health professionals to provide telephone support to help people make decisions regarding their health care and to provide information on health topics and local resources. Phone support has reduced the number of patient visits to emergency rooms and improved the appropriateness of physician visits. Implementation of a provincial phone support component of the health-care system would increase the appropriate use of registered nurses, as well as provide the public with expanded sources of knowledge for improved self-care and empowerment—a cost-effective, acceptable approach to health care.

However, there are a number of challenges to be addressed to improve primary health care, which includes services such as the one mentioned above, to provide multiple points of entry to the health-care system, meet health needs of populations and individuals, ensure availability and accessibility of both primary health care and appropriate referral services, and increase resources spent on health promotion and illness and injury prevention. These challenges include:

• Developing integrated models of service delivery that include both vertical integration of inter-dependent sectors (hospitals, primary care, home care, and long-term services) and horizontal integration of entities within the same sector. 
• Developing alternative funding and payment mechanisms that are effective and fairly reflect the range of responsibilities undertaken by health professionals, including nurses, physicians, and therapists to ensure that needed services are delivered in the most cost-effective way possible. 
• Focusing on public education for accessing care from the most appropriate health professional and increasing knowledge about ways to improve health and prevent disease and injury. 
• Implementing information technology systems to generate data that will enable a higher degree of coordination and planning of primary health care. 
• Rigorously evaluating to improve actual outcomes.

As these challenges are addressed, the health-care system of the future will move beyond imaginings, with registered nurses continuing to demonstrate in various teams and settings how quality primary health care can be delivered cost-effectively with equity and efficacy.

Registered nurses will continue to develop new roles in the health system to increase its efficacy, efficiency, equity, and quality. While control over their own practice will continue to increase, nurses’ relationships with physicians and other health professionals will become more collaborative and team oriented. This is beyond imagining—it is happening now!

References

1. Jennifer Stewart. Primary Care Reform in Canada: An Overview. Calgary: Canada West Foundation, 2000.
2. WHO. The Alma Ata Conference on Primary Health Care. WHO Chronical, 1978;32:409-430.

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Ms Gillespie is president of the Registered Nurses Association of British Columbia.