On August 28, 2012, the Registered Nurses’ Association of Ontario (RNAO) applauded the Ontario College of Pharmacists (OCP) for proposing the draft Bill 179 Regulation and subsequent amendments, to improve population health outcomes. Increasing access to care by expanding the scope of practice for pharmacists to administer influenza vaccine by inhalation or injection and to adapt or extend a prescription or administer a substance, will strengthen our health-care system to achieve higher quality and safety at a reduced cost. RNAO, however, will only support this increased scope of practice if 1)cost-effectiveness to tax payers is neutral and patients will not need to pay out of pocket, 2) delegation to an unregulated care provider is removed, and 3) mitigation strategies are required to protect the very sick and immunocompromised individuals for treatment in public places, such as grocery stores and other public places, that are not commonly considered as having significant risk.
Barbara Cadotte, Senior Policy Advisor
Ontario College of Pharmacists
483 Huron Street
August 28, 2012
Dear Ms. Cadotte:
The Registered Nurses’ Association of Ontario (RNAO) applauds the Ontario College of Pharmacists (OCP) for proposing the draft Bill 179 Regulation and subsequent amendments, to improve population health outcomes. Increasing access to care by expanding the scope of practice for pharmacists, nurses and members of the inter-professional health-care care team will strengthen our health-care system to achieve higher quality and safety at a reduced cost. However, RNAO will only support this increase scope of practice if 1) Cost-effectiveness to tax payers is neutral and patients will not need to pay out of pocket, 2) Delegation to an unregulated care provider is removed, and 3) mitigation strategies to protect the very sick and immunocompromised individuals for treatment in public places such as grocery stores and other public places that are not commonly considered as having significant risk.
Impact of Pharmacists’ Expanded Scope on Health, Health Care and Nursing
RNAO supports increasing the scope of practice for pharmacists as this aligns with health policy that enables timely access to the most appropriate health-care provider when considering the complexity of the client’s care, the competencies of the care provider and the stability of the environment. Overall, the proposed regulations will significantly improve access to care and promote better health-care processes and outcomes across the population, which include:
• Immediate treatment and improved client support by pharmacists for chronic health conditions, thereby reducing delays of scheduling treatments with another provider. This expanded practice is particularly needed among the most vulnerable and marginalized of our society, who experience barriers to scheduling additional appointments for regular injections / inhalations due to lack of transportation, time, or inclination;
• Greater access for flu vaccinations for those five years of age and older, while freeing up capacity and reducing costs in the system (e.g., physicians can focus on acute care needs);
• Enhanced coordination of multiple injections that support greater adherence to prescribed treatments;
• Improved immunization rates, which provide well-documented and significant population health benefits;
• Relevant expert advice for nurses and other health-care providers, who already enjoy a collaborative and trusting relationship with pharmacists, and benefit from their expertise in preventing disease and managing chronic disease through immunization and routine injection and inhalation.
Given that pharmacists are willing to expand their scope as they have in 50 US states as well as Alberta, BC and New Brunswick, Ontario pharmacists are well positioned to expand their scope of practice in a manner that is consistent with the mission, vision and values of the OCP.
Concerns that Must be Addressed
• It is unclear how pharmacists will absorb the costs associated with their expanded scope of practice. Although pharmacists can reduce the need for health-care professionals who are in high demand (e.g., nurses and physicians), and higher publically-funded cost for administration, it is unclear how pharmacists will be reimbursed for the significant changes this expanded scope will require for their practice (i.e. reconfiguring rooms to provide sufficient privacy to inject). Are pharmacists expected to absorb these costs from sufficient revenue gained from an anticipated increase in purchased medication or will pharmacists eventually forward these costs to patients by charging higher drug dispensing fees? If the latter occurs and patients are expected to pay for their own injections / inhalations, access to care may actually decrease for those who cannot afford these additional costs, further burdening those who rely on our publically funded health-care services.
• Section 3 (3) of the draft Bill 179 regulations allows pharmacists to delegate injections and states: “No pharmacy technician shall perform a procedure on tissue below the dermis, however nothing in this Part shall prevent a pharmacy technician from performing such a procedure under delegation from a pharmacist listed in Part A of the register who is authorized to perform it.” Caution should be exercised when permitting delegation, given that the most appropriate care provider should not delegate care to a less qualified care provider when another regulated care provider (e.g., a nurse) can be available. The OCP should either remove the pharmacist’s authority to delegate performance of procedures on tissue below the dermis, or explore measures to strengthen accountability and maximize patient safety and quality care when delegation is taking place.
• In addition, RNAO is concerned with a potential public health risk when pharmacies attract an even greater volume of sick and immunocompromised individuals for treatment in public places such as grocery stores. Regulations should address mitigating strategies for protecting the public in places that are not commonly considered as having significant risk.
RNAO strongly supports all health professionals working to full scope and expanding scopes of practice, where appropriate and supported by evidence, as a means of transforming our current health-care system and promoting greater value of health-care services (see RNAO. 2012. Primary solutions for primary care: Maximizing and expanding the role of the primary care nurse in Ontario, www.rnao.ca/primary_care_report ).
Thank you for the opportunity to support this important regulatory change and receive our comments and concerns for further consideration.
With warm regards,
Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer, Registered Nurses’ Association of Ontario