Nurse Practitioners in General Practice
Nurse Practitioners (NP) are registered nurses endorsed to practice in an advanced and extended role through the Australian Health Practitioner Regulation Agency (AHPRA). With a minimum of 10 years’ clinical training and experience, including postgraduate and master’s qualifications that prepare them for autonomous clinical practice, NPs provide safe, effective and affordable access to healthcare.
NPs work autonomously and collaboratively with medical practitioners. In general practice, they provide advanced assessment, diagnosis and treatment of conditions traditionally treated by the medical profession. Such conditions include the treatment of minor illnesses and injuries (such as colds, skin infections, sprains and strains) to complex chronic health conditions, including diabetes, depression, anxiety, heart failure and chronic obstructive pulmonary disease. Their model of care emphasises opportunistic disease prevention strategies through lifestyle modification advice, adult health screening, childhood health checks and immunisations. In addition, they are able to perform the following activities within their scopes of practice:
- Prescribe medications
- Order and interpret diagnostic tests
- Perform minor therapeutic procedures
- Refer to medical specialists
In November 2010, national legislation was passed which allowed NP access to the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). It was anticipated this would facilitate the development of innovative NP service delivery models and afford greater patient choice in healthcare. Importantly, it provided an opportunity for general practices to redefine service provision, in an attempt to improve timeliness, accessibility, and affordability of primary healthcare services.
Unfortunately, NP expansion into general practices has been sluggish. This is primarily due to issues surrounding Department of Health policy, which governs the administration of the MBS. These policies provide significant financial and logistical barriers that preclude general practices from hiring NPs, and inhibit these highly trained and qualified professionals from working to their full scope of practice. These barriers introduce systems inefficiencies through the unnecessary duplication of care, which further compounds health systems costs. Such barriers include:
- The inability to provide referrals to allied health professionals, such as physiotherapists, dietitians or psychologists.
- The inability to request certain diagnostic imaging services, such as DEXA scans for the detection of osteoporosis, echocardiograms for the evaluation of heart failure, or pelvic ultrasounds for pregnancy dating or dysfunctional uterine bleeding.
Further, health systems policies made prior to the introduction of NPs into general practice preclude them from communicating or arranging further care for a significant proportion of their clients. For example, NPs are unable to use the National Translating and Interpreting Service (TIS). Additionally, they can diagnose and treat diabetes, but cannot sign the National Diabetes Services Scheme forms so their clients can obtain supplies for monitoring their condition.
NPs are reimbursed 42.5% of the scheduled general practitioner (GP) fee for professional attendances. They receive no incentives for bulk-billing concession card holders or children under the age of 16, do not receive higher MBS-reimbursement rates for working after hours and on weekends to offset the costs of support and administrative staff, and are not eligible for benefits awarded by the Practice Nurse Incentive Program.
Importantly, diagnostic and therapeutic procedures performed by NPs (such as performing and interpreting spirometry and electrocardiograms, inserting/removing contraceptive devices, suturing wounds and performing skin biopsies) are not reimbursed by the MBS. Empirical evidence has shown NPs provide equivalent outcomes when it comes to conducting such activities; however, they are unable to recover the costs associated with performing them.
These logistical and financial issues make it difficult to effectively utilise the NP workforce in a bulk-billing general practice. I feel there is potential for significant healthcare savings through the removal of such barriers, which would assist in maximising workforce potential and compliment primary healthcare delivery. I understand the reluctance of certain medical associations in endorsing the NP role; however, when working collaboratively in a general practice environment we have found the relationship symbiotic and beneficial to the holistic care of our clients.
I propose a trial to evaluate how the elimination of such barriers improves systems efficiencies, reduces healthcare spending and improves the patient experience. In order to maximise the effectiveness of this intervention, I propose three critical interventions for NPs working in AGPAL-accredited general practices:
- Allow NPs to provide MBS-reimbursable referrals to allied health providers
- Allow equivalent NP access to the MBS for health assessments, chronic disease management items, diagnostic and therapeutic procedures, at 85% the general practitioner schedule fee.
- Allow NPs to request equivalent MBS-reimbursable diagnostic imaging items to those allowed to GPs