With Australia’s population growing, living longer, and experiencing more disease and disability, there’s no doubt demand for health services will increase. But how are we going to pay for it?
With this question in mind, the Commonwealth government is increasingly looking to the primary health care setting for solutions: to keep patients out of hospitals, prevent illness and improve the overall well-being of the population.
Policy changes have provided opportunities for nurses – the largest group of health-care providers – to take on services usually provided by the general practitioner (GP). This is a win for all involved: patients are seen quicker, practice nurses are able to use their knowledge and skills, and GPs have more time for other patients, which reduces their stress.
Practice nurses are now managing the care of patients with chronic illnesses such as diabetes, undertaking health assessments for children and older people, dressing wounds, performing pap smears and advising patients about lifestyle changes they can make to improve their health.
If nurses are unfamiliar with theses skills, they have access to further education (and assessment) in a range of flexible delivery modes. And with improved information technology in general practices, nurses can access summaries of the research evidence underpinning their practice.
But while this all sounds very promising, there are teething problems, particularly in small rural practices.
Time constraints
Recent research by my colleagues and I in rural NSW found that nurses in small practices don’t feel they’re ready to take on extra responsibilities. The majority of the nurses work part-time and family commitments preclude extra study. They’re committed to their current work patterns and believe they’re doing a good job, with little capacity to take on more.
These sentiments are valid – practice nurses are pivotal to the smooth running of general practices.
But the practice nurses identified that not all they do in their busy day requires their knowledge and skills. It is up to practice teams (managers, GPs, nurses, allied health professionals and administrative staff) to renegotiate roles and make sure there is adequate time and support for nurses to undertake advanced roles, in a safe environment. The practice team also must ensure that less-skilled work is still valued and appropriate people assigned to it.
Turf wars
Politics can be a barrier to nurses taking on advanced roles. In larger practices there is the potential for jostling for work between nurses and other professionals. A small action research study in an urban area reported instances where GPs did not support practice nurses undertaking pap smears despite recent support for them to undertake training and accreditation.
This type of problem is usually sorted out by skilled communication and mutual respect; practices with shared values and a commitment to teamwork and quality patient care are most likely to address these issues successfully.
Funding barriers
Funding is an important issue for general practices, as they run as small business. General practices receive funding from the Commonwealth government through the Medicare Benefits Schedule (MBS) for each item of service provided.
Last year new Commonwealth government funding scheme was introduced to support and expanded and enhanced roles for nurses working in general practice, called the Practice Nurse Incentive program (PNIP). It replaces payment for just six Medicare items and pays a lump sum for each nurse employed by the practice.
The scheme is still in the early stages of implementation and, like any change, needs a while to be appreciated. But so far, the PNIP model of funding appears to be reducing the uptake of advanced roles, because there is no longer a financial incentive linked to specific items.
The PNIP program was designed to provide flexibility for the work of practice nurses. This means the general practices could identify what activities they required the nurses to do, rather than the previous funding model which had a limited range of medicare items that could be undertaken by nurses and claimed against.
For the new scheme to work, managers and practice principals need to stop linking specific advanced practice to financial reward and concentrate on the benefits accrued by patients.
Future of nursing
There is no question that the nurses are able to take on advanced practice roles. They have the right educational background and quality assurance mechanisms to ensure they maintain their competence. There is evidence to show that clients are comfortable and accepting of nurses in general practice undertaking advanced roles.
Our research found that the practice nurses were generally members of the local community and therefore were known to patients. They interact with patients on a regular basis, providing many opportunities for patients to ask questions.
With better planing, training and funding models, these barriers are all surmountable. Nurses in advanced roles have an important role to play in helping to improve and extend general practice service for the Australian public.