For years, doctors have been at the centre of public attention in the medicare debate. Nurses, on the other hand, have gone relatively unnoticed. But that situation is changing rapidly, as nurses mount a vigorous campaign to influence Canadian health care policy. And their proposals are placing them increasingly in opposition to the doctors. Last week, as physicians denounced the new federal health care act, which calls for penalties on provinces that allow hospital user fees and extra-billing by doctors, the Canadian Nurses Association (CNA) praised it, although arguing that it should have gone further. The association, which represents 165,000 nurses across the country, wants to end the practice of
extra billing because it says that it violates the principle of universal access to comprehensive medical care. But doctors are angered by the charge from within the medical ranks that their system of extra billing is undermining medicare. Said Dr. Marc Baltzan, former head of the Canadian Medical Association: “That is absolute and utter garbage.”
Nurses also do not want hospitals to charge user fees, as they do in British Columbia. And they argue that medicare should be financed out of general tax revenues, which are geared to income, not by charging premiums. Currently, Ontario, Alberta and British Columbia charge premiums to all but those who qualify for special exemptions, leaving lowand high-income
earners paying the same health bills.
Those suggestions are unpopular with some provincial governments, but the nurses’ real confrontation may take place within the medical profession itself. Nurses insist that they do not want to antagonize doctors. But some of the nurses’ recommendations conflict sharply with the wishes of physicians. In addition to opposing extra billing, the nurses want a reorganization of much of the health care system.
They are pressing for community health clinics in which nurses would see patients before deciding whether their illnesses are severe enough to refer them to a doctor. Many doctors contend that nurses are not qualified to make such assessments and that patients have traditionally gone first to family physicians. But Helen Glass, a pro-
fessor of nursing at the University of Manitoba and CNA president, said that nurses are not trying to take over doctors’ functions. Said she: “If a patient walks in with high blood pressure, we would refer him to a doctor immediately. We are an excellent way of bringing people into the health care system.” The main advantage in seeing a nurse first, the CNA argues, is that it would be much cheaper because nurses earn less than one-third of what doctors earn. According to Health and Welfare Canada, the average Canadian nurse earned $25,000 in 1982, while the average Canadian doctor netted roughly $90,000 after expenses.
Dr. Ralph Sutherland, who is associate professor in the health administration program at the University of Otta-
wa, argues that in every area of medicine nurses could do far more than doctors currently allow them to do. In the United States there used to be—and still are in some parts—nurse anesthetists who, with a year or two of extra training, were able to carry out full anesthetic services during an operation. Over the years doctors increasingly took that role over exclusively for themselves. Sutherland says that nurses could still act as anesthetists, as long as a fully trained medical specialist was on call nearby. Said Sutherland: “Nurses could take over administering one-third to two-thirds of anesthetics.”
Sutherland added that part of the medicare financing problem is that there are too many doctors in Canada. As a result, he says, physicians are reluctant to give up work to nurses—or even to admit that nurses are capable of handling it. For his part, Baltzan says that nurses are not capable of doing a
great deal more than they now do. But nurses insist that they can handle many more tasks—and already do in situations in which doctors are not readily available, such as in hospitals on weekends and in remote northern areas where doctors are reluctant to settle.
As the medicare debate grows more intense, doctors argue that more of the burgeoning costs of health care should be transferred to private citizens. But the increasingly vocal nurses’ lobby is determined to convince the public that it makes more sense to simply reduce the costs. With a stagnant economy and a mounting national health bill, the nurses’ plea has a good chance of falling on sympathetic ears.
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