The recent decision to close several of the main primary care clinics in Vancouver Coastal Health has brought to the forefront grave concerns for not only the public but those of us in higher levels of education who are teaching the principles of primary health care and population health.
The UBC School of Nursing has had a long standing partnership with Pine Clinic where our nursing students at both the undergraduate and graduate levels have had an opportunity to work with the expert nurses at the clinic. As a result, there are a few points which are of particular concern to me.
We believe that it is important to discuss the clinic as a regional service for youth – not just a Westside or Kitsilano clinic. Young people access the Pine Clinic from across the city – it serves the 'community of Youth' without barriers of residency, insurance, diagnoses or other barriers such a fear of judgment, lack of privacy/confidentiality - perceived or real - which youth fear at walk-in clinics or family physicians’ offices. Youth often present with a medical concern or sexual health concern but, once trust has developed with the expert professionals at Pine, they are able to disclose other concerns such as high risk behaviours, mental health or addiction concerns. Early identification of concerns during this vulnerable age is a critical part of the work that is carried out at Pine.
The benefits of a broad approach to youth care in terms of prevention and early treatment is the crux of primary prevention and can result in long term savings for the health care system. If services become targeted only to high risk youth, there is concern that other youth, vulnerable youth, may not feel comfortable accessing care. There may be a corresponding impact on STI rates, associated complications, and pregnancy rates. Opportunities to work with youth with early mental health and substance abuse issues may also be missed. It should be noted that the current professional staff at Pine have specialized training and experience in addictions, eating disorders, street involved youth, LGBT care, primary care, psychiatry, post sexual assault care, HIV care, Emergency Room care. Youth benefit from this spectrum of skills because they are able to follow through at one site and often with one clinician.
Pine is currently configured as a stand-alone clinic that the younger generation trusts - it is not affiliated with schools or other agencies. Youth appreciate the casual and very youth friendly environment and organization of the clinic. If they require referral to other agencies they are assisted in navigating the complex systems which increases trust, compliance and better outcomes.
The Clinic provides a team approach - collaboration between nurses in an expanded role, physicians with a specialized youth focus and counselors. Youth benefit from the urgent care model of the drop-in format and the ability to spend time with a clinician regarding several concerns in one visit.
Research clearly indicates that outcomes for healthier populations rely on accessibility, equity, creating a supportive environment, appropriate technology, attention to health promotion and protection, intersectoral cooperation, public participation and focus on the determinants of health. Pine clinic for the past 40 years has adhered to these components of Population Health.
It is truly a travesty that the professionals who are passionate about youth health were not involved in the decision to close Pine and that the individuals who are served by this agency were not given a voice. Short term gain does not equate with long term savings when it comes to the health of our populations!
ABOUT JOANNE RICCI
Joanne Ricci is a tenured Senior Instructor at the UBC School of Nursing. She received her BScN and MSN from UBC and has been teaching at UBC for 37 years. She has taught in various areas of nursing during her time at UBC from basic skills, maternity, surgical, Post RN and for the past 20 years in population and public health. Joanne has not only demonstrated expertise in the area of public health but is also an exemplary clinical instructor and has been instrumental in supervising masters and Nurse Practitioner students.
She has developed strong relationships with her partners in the community and has contributed to countless hours on many committees and boards. Her passion for health promotion and illness prevention of infant children and youth is evident in all aspects of her work.
This is an example of the kind of planning that is based on partial analysis, oriented toward available metrics rather than a more fulsome understanding of the implications of decisions. Nurses in the field see the complexity of populations such as those being served by Pine Clinic. Although it is always difficult to calculate the eventual economic impact of each individual “missed opportunity” or unmet need, we can clearly see the patterns across the populations we serve, and we know that failures in primary care cost the entire system plenty going forward. The health care system is best served by strengthening, not fracturing, the kinds of relational practices with complex populations that this particular clinic stood for. We clearly need to find better ways to help the public and those who manage our publicly funded system to recognize the wisdom in good comprehensive primary care across the board. Nurses and nurse practitioners in BC have so much to offer to fixing the current gaps, barriers and missed opportunities within the primary care system. In that context, dismantling community primary care clinics with a track record of excellence in reaching complex populations, especially without any meaningful consultation with nursing, is a serious blow. Thanks for putting this on the radar as an issue about which all nurses, whether in the Lower Mainland or anywhere else in the province, ought to be very concerned.
The closing of Pine Clinic is a decision that is NOT based on any good evidence, except perhaps a desire to save money. In the long run who will pay, unfortunately it is the youth who will suffer from short sighted decision making. As has been pointed out the Pine Clinic has been in existence for greater than 40 years and serving a diverse group of youth with a depth and breadth of health and social needs. VCH leadership recently presented to city council that youth were attending Pine from outside of their catchment area and felt that they should be accessing services from within their geographical area, thus they would look to "realign" youth health care needs. Unfortunately, consultation with youth and the community at large has been absent. The degradation of such services signals that health care is in crisis, with senior leadership making life altering decisions. I say engage the community, the health care providers, don't act in isolation, recognize that communities can and will come together to find a solution! Let's not break what not's broken, let fix an age old funding issue!
On June 25th, Vancouver City Councillor Kerry Jang introduced a motion regarding the closing of Vancouver's Urban Primary Care Clinics. A number of organizations, politicians and individuals spoke to the importance of these clinics, and the impacts of closing them on the community, including Stan Marchuk, President of the BCNPA who spoke on behalf of nurse practitioners and registered nurses.
To view the motion: https://www.nnpbc.com/blog/wp-content/uploads/2014/06/ptec5.pdf
To view video of the proceedings and the unanimous vote in support of the motion: http://cityofvan-as1.insinc.com/ibc/mp/md/open/c/317/2311/201406250915wv150en,003
As a male nursing student sent down to Pine Clinic to shadow one of the nurses on staff, I was surprised to have found the experience quite eye-opening. I had no idea these services were being offered! I remember entering through the front door and immediately noticing the amount of chairs that were filled and remained to be filled throughout the duration of my visit. Young person after young person walked in and were seen; some seeking answers to questions, others seeking solutions to problems. All arrived with an unmet need and all left that need addressed by a member of the Pine Clinic health care team.
One has to question the removal of a service that met the needs of a very unique - yet distinct - population representing the very future of this country.
I concur with Mr. Nicholson. I had a chance to shadow a nurse at The Pine Clinic and they definitely provided important services that were much needed by a significant portion of our population.
A specialized clinic like the Pine clinic acts as a tool to nip in the bud health problems that left un-detected or untreated, would become more unmanageable and costly in the future. The shut-down of this clinic will no doubt lead to serious and negative consequences for the long-term health of our population.
I am really concerned about the centralisation of primary health care services. If Pine Clinic closes, people may not want to travel farther to get services at another clinic. This plan may place more stress on our emergency care services.
Pine Clinic delivers a health care model that has proven successful for over 40 years and offers unparalleled accessibility to its clients in a safe, discreet, supportive environment. As a student nurse I had the honour of shadowing two nurses in the clinic and I witnessed the personalized care and attention delivered by staff and the sigh of relief clients would breathe knowing they were in a safe, non-judgmental environment. Clients feel comfortable opening up about their health challenges at Pine which facilitates early treatment and prevention of illness. Clients receive medical care as well as education on issues such as sexual health, prevention and treatment of communicable diseases, substance misuse and mental health challenges. Transitioning to a fee-for-service model would decrease the accessibility of the clinic to its clientele. This could lead to vulnerable youth and individuals in need of health care at further risk, thus increasing visits to emergency rooms, which in the end is more costly to the individual and the health care system. Why change a health care model that is clearly providing so many benefits to our population's health?
There is a larger question which is being missed here in the discussion about primary care clinics. Let's examine the original role/intent of Health Authorities: to operate hospitals, home care and public health. It was not supposed to be to provide primary health care. Whether you agree or not, the current system that is supported by our government is that family physicians are supposed to be the ones offering primary health care whilst Health Authorities operate the acute care services, home care and public health. Youth clinics were started by public health nurses who recognized that youth required contraceptive services as a way to prevent unintended teen pregnancies - a public health role. Public health clinics specific to STD testing and management were started as a way to respond to public health's responsibility of disease control. Youth clinics were never meant to take the place of a family doctor or general primary care services.
So, what happened? Why have HA's taken over primary care roles? For the answer we need to examine who the HA's primary care clinics were for: vulnerable populations (aka homeless, addicted, mentally ill, people with complex social needs, etc). HA's have filled the gap in primary care services that really were supposed to be the responsibility of family physicians. These gaps were created when vulnerable populations were unable to access a family doctor. A fee-for-service environment has created time limits and incentives for doctors to see only the least complex patients meanwhile leaving the vulnerable patients with complex social and medical needs to the HA's. And right or wrong, the HA's stepped up to fill in the gaps in service.
Please don't mistake my comments as "doctor blaming". Far from it. Rather, it's a systems issue that was created by our governments in creating a two-tiered health care service. The reality is that the HAs are realizing that they can't keep filling the ever widening gap and demand for care that is occurring. Anyone wonder why Pine's waiting room was full every day? It's because the health care providers at Pine had the time to both educate and advocate and they provided high quality care without a fee-for-service environment pushing the patient out the door. We need to shift the discussion from blaming HAs for closing primary care clinics to examining the underlying reasons that these clinics existed in the first place...and why they are still so necessary...but not technically the responsibility of HAs but of our current provincial government to solve.