When the federal government offered earlier this week to increase the amount of funding it sends to the country’s beleaguered provincial and territorial health care systems, it also made a few demands. Among them: that premiers make progress on reducing the regulatory barriers that prevent medical professionals from hopping over provincial boundaries.
Ottawa’s support for increased medical labour mobility may accelerate a fundamental shift that is already happening across the country.
Many of the medical organizations that represent Canada’s doctors, resident physicians and medical students have long called for a national licensing system that would allow their members to more easily work in multiple provinces. They have complained that working across jurisdictions can mean thousands of dollars in duplicate fees, and cumbersome paperwork that requires months of processing time.
As the provinces take stock of the new federal offer, support for licensing reform is gaining momentum.
“In the last two years, I think there’s been a real sense of urgency that we can’t keep doing what we’re doing. It’s gradually working less and less,” said Leisha Hawker, a Halifax family physician who is president of Doctors Nova Scotia, the professional association that represents all physicians in that province.
Atlantic Canada is just months away from announcing a regional licensing system for physicians in the four eastern provinces, Dr. Hawker said. British Columbia became the first province to open the door to national licensing for nurses in January, when its regulatory college revised its bylaws to allow for multi-jurisdictional registration. Ontario is also introducing legislative changes that would allow Canadian health care workers registered or licensed in other provinces to start practising in the province immediately.
“I think we have a bit of a catalytic moment, with a lot of pressure from government and the public,” said Cynthia Johansen, registrar and chief executive officer of the BC College of Nurses and Midwives.
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Although the provinces and territories agreed to a national standard of physician licensing in 2009, Ottawa wants them to do a lot more to loosen the rules around credential recognition. Some health care associations want Canada to build something like Australia’s national registration system, which created a uniform set of standards that allow medical professionals to work anywhere in the country, with national boards that regulate each profession.
Licensing red tape is a particularly pressing issue in northern communities, where health care workers often fly in from elsewhere. A more streamlined national system could also help create a pool of physicians who can be used to fill temporary vacancies around the country and open opportunities for more virtual care.
But some health care policy experts have cautioned against making these changes too quickly. Tinkering with licensing, they argue, could create a more transient work force, which could make it harder to retain health care professionals in communities where they’re needed most. There are also concerns that a national licensing system would make it easier for richer provinces to poach physicians and nurses from poorer ones.
Heidi Oetter, chair of a working group at the Federation of Medical Regulatory Authorities of Canada that deals with cross-jurisdictional co-ordination, said there would be value in a national registration system for doctors. But the difficulty of putting in place required constitutional changes and federal regulatory oversight may prevent it from becoming a reality, she added.
“I don’t know if we’ll ever see Ontario, Quebec and all the other provinces agree on a common statutory framework,” said Dr. Oetter, who is also registrar of the College of Physicians and Surgeons of BC. “Right now, the provinces are all competing with each other. The idea they might actually collaborate seems like a distant vision. We’re too big a country to do all this out of Ottawa.”
There are alternatives, she said, such as license portability agreements, which would allow provinces to license out-of-province physicians temporarily, while retaining the power to regulate. She said she believes the number of physicians who want to be mobile is small, and that many would balk at the higher dues and insurance costs that could come with a national license.
Ms. Johansen, of the BC College of Nurses and Midwives, said a national license for nurses could help improve patient safety. Canada’s nursing regulators are already building a national database for nurses, in part to help them better track those with disciplinary issues who move through jurisdictions.
That work has evolved into an effort to create a unique identification number for every nurse in the country, bringing the provinces one step closer to a streamlined, pan-Canadian registration system that would remove duplication of fees and paperwork.
“For us, there’s a huge public safety component to this work,” Ms. Johansen said. “But it’s also allowed us to start thinking about how we could support a different way to register people to minimize the bureaucratic burden on the nurse. We need to start thinking nationally.”
A truly national licensing system for nurses could be a reality in as soon as 18 months if provincial governments are motivated, she said. Some provinces will require legislative changes, while other jurisdictions, such as Alberta, have multiple regulators for nurses that would all need to support the change.
Canadian regulators are looking closely at the United States, where nurses registered through a “licensure compact” can work in 37 states without having to be licensed in each jurisdiction. Some American nursing unions have been opposed to the quasi-national license, worried it will allow out-of-state nurses to be brought into hospitals as a way of countering strikes.
A recent report by the U.S. Bureau of Labor Statistics suggests lowering barriers to licensing in multiple jurisdictions does not have a significant impact on cross-border nursing. Only a small minority of nurses are choosing to work outside their home states, it says.
Roy Kirkpatrick, a surgeon in Huntsville, Ont., said national licensing makes sense for rural and remote areas, which rely on temporary fill-in doctors, known as locums, to replace physicians who go on leave. Dr. Kirkpatrick said he is optimistic that the barriers that prevent doctors from helping out beyond their home provinces may finally be lifting.
“I feel like the army is at the gates of the city, and we’re about to crash through,” he said. “I think enough people in enough corners of the country have been sounding off about this that they’re finally starting to listen.”
Dr. Kirkpatrick, a general surgeon with 45 years of experience, described how bureaucratic hurdles prevented him from taking a locum post in rural Newfoundland and Labrador in 2021. The province’s medical regulator spent four months reviewing his application for a license, even though he had previously been licensed there, and then asked him to complete time-consuming educational modules that he has done many times before in other jurisdictions.
He was also going to be charged a full year’s licensing fee for just a few months of work, he said. Newfoundland has since introduced legislation to make medical licensing more streamlined for physicians trained outside the province.
“The rules were getting in the way of looking after the needs of the people,” Dr. Kirkpatrick said. “I finally just gave up. And I think that story is repeated all over the country, because people just get frustrated.”
Locum placements are also an important recruitment tool for rural communities, allowing young physicians to live in those places temporarily before taking more permanent positions, Dr. Kirkpatrick said. A national licensing system opens that up to a larger group of candidates, he added.
There are significant implications for virtual care, too. In some provinces, such as Manitoba, only doctors licensed in that province can provide care via video or over the phone. Virtual care companies are watching the country’s shifting stance on licensing requirements closely.
“I think we’ll eventually get there, but I think it has to be baby steps,” said Norman Silver, a pediatric physician who founded QDoc, a Winnipeg-based company that specializes in live video consultations with doctors for people in underserved communities.
Some provinces, such as B.C., already allow doctors who are licensed elsewhere in Canada to provide virtual care to patients. Dr. Silver argued that it’s best for patients to be served virtually by a doctor who lives in their area. But he added that sometimes that’s not an option.
“In a resource-limited area, where the only way they’re seeing a doc is to see a doctor from outside the province, I think that’s better than no care at all,” he said.
In the Atlantic provinces, where doctors will soon be able to travel around the region more easily, Dr. Hawker is hopeful a model can be developed that will also work across all of Canada. She said provincial boundaries shouldn’t stop doctors from helping out in a neighbouring emergency department, or doing follow-up care with a patient who has left the province.
“It just makes sense to start small, then hopefully have lessons learned, build on that success and expand it nationally,” she said. “This will allow us to fill urgent gaps around the province, and eventually around the country.”
Editor’s note: An earlier version of this article incorrectly referred to Roy Kirkpatrick, a general surgeon, as Roy Fitzpatrick. The article has been updated.