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It is essential that we expand the role of nurses in the delivery of primary healthcare if we are to meet Australia’s future health needs.
Our healthcare system is under threat. Our ageing population and the way we live are producing an increasing burden of chronic disease. Our hospitals are already being overwhelmed. At the same time, the increasing proportion of retirees to taxpayers will make it ever harder to fund healthcare in coming years. On top of that we have the significant challenge of delivering access to quality care to people in rural and remote Australia.
How can we rise to these challenges?
Any sustainable solution must rely on keeping people well, out of hospital and able to live in the community for as long as possible. This objective also aligns with what people actually want. Studies consistently show the vast majority of people would prefer to stay in their own homes and be cared for in the community, rather than be admitted to hospital or residential aged care.
We need to reduce our reliance on acute and aged care and make a real investment in building the capacity of primary healthcare, including general practice. This will help us to deliver care in the most efficient and person-centred way, supporting Australians to live and age well.
And it can’t be all about doctors. There will never be enough doctors to do all that needs to be done in primary healthcare, nor would they want to do it; nor could the system afford that approach. We need to pay more than lip service to the concept of interdisciplinary primary healthcare teams.
The work nurses perform in primary healthcare is critical to sustainability in the healthcare system. Nurses are the largest health profession, and can deal with a wide range of health and wellbeing issues.
The potential for nurses to play a greater role in primary healthcare is enormous. There are now about 11,000 nurses working in general practice alone, one of the fastest growing workforces in Australia. The care these nurses most commonly provide – preventative health interventions, chronic disease management and coordination and care for the elderly – is vital in keeping people well and out of hospital and aged care.
But there are major barriers to realising the full potential of the primary healthcare nursing workforce.
The first is the lack of a national workforce plan to ensure the future sustainability of the profession. There are major risks to the capacity of the nursing workforce. The government’s Health Workforce 2025 report predicts a shortage of almost 110,000 nurses in Australia by 2025, and if this is not addressed it will undoubtedly affect primary healthcare. The nursing population in general practice is ageing: already, more than four in five are aged over 40, with the largest cohort being in their 50s.
We need better defined and supported pathways into and up through primary healthcare nursing, so we can attract young nurses to the profession and keep developing their skills and expertise over time. That way they will stay in the workforce and keep contributing.
Another barrier is the general practice financing system. Fee-for-service payments to GPs, alongside limited block grants for general practice nurses, perversely reward practices to maximise GP consultations and throughput, instead of rewarding quality team care.
The financing system must be reformed to promote high quality, person-centred interdisciplinary team care. The system should reward continuity and quality of care, achievement of targeted population health outcomes and efficiency. Growing out-of-pocket costs must also be addressed, as they are a real barrier to access for the disadvantaged.
Finally, there are major institutional and legislative barriers that inhibit the full development and utilisation of the skills and expertise of primary healthcare nurses. Some medical groups in Australia have voiced strong opposition to the development of advanced nursing roles.
A case in point is the recent controversy over the support by Australian health ministers for the Health Professionals Prescribing Pathway proposed by Health Workforce Australia, which would allow non-medical health professionals to prescribe medication in certain circumstances. It is disappointing that the Royal Australian College of General Practitioners has called for an “immediate reversal” of this decision on the basis that it poses “a real risk to patient safety”. This position echoes the alarmist responses by several medical groups to the Nursing and Midwifery Board of Australia’s recent consultation paper proposing the expansion of scheduled medicines endorsement to all nurses and midwives.
Primary healthcare nurses in Australia already play an important role in medication management. This role typically includes reviewing medication use in the context of a patient’s health assessment or chronic disease plan, advising patients on quality use of medicines, helping to identify patients at risk of adverse events, contributing to the patient’s health record, directly administering vaccines and managing stores of medications and vaccines. Some nurses in remote areas also take on more extended roles, including initiation of medication under standard protocols. However, very few nurses working in primary healthcare in Australia have independent prescribing rights: such rights are limited to nurse practitioners and eligible midwives.
By contrast, nurse prescribing is well established in the UK as a mainstream qualification, with more than 54,000 nurse and midwife prescribers, and more than 19,000 nurse independent and supplementary prescribers. “Nurse and pharmacist independent prescribing in England is becoming a well-integrated and established means of managing a patient’s condition and giving him/her access to medicines,” a recent review stated. It found that independent nurse and pharmacist prescribing, occurring predominantly in primary care, is safe and clinically appropriate, and managed through key clinical governance and risk management strategies. Acceptability to patients was also reported as high .
If it is safe for nurses with appropriate education, training and regulation to prescribe independently in the UK, why would independent nurse prescribing “pose a real risk to patient safety” in Australia? Are our nurses intrinsically less capable than those overseas? Surely not. We need to address barriers to the full utilisation of nursing skills in Australia, using a lens that focuses on what is best for the community, rather than being fixated on maintaining professional boundaries.
We need to ask ourselves why primary healthcare nursing roles and scope of practice in Australia are so under-developed, and why the ratio of primary healthcare nurses to primary care physicians is so low, compared with similar countries such as the UK. What price are we all paying for this? And can we afford to keep paying it?
Developing and utilising the full potential of the primary healthcare nursing workforce will help us deliver high quality, accessible and affordable primary healthcare now and into the future, keeping people well and out of hospital and aged care. That is in everybody’s interests.
Kathy Bell is chief executive of APNA, the peak professional body for nurses working in primary healthcare in Australia.
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I appreciate Kathy’s views and support of nurses in primary health. The power of the AMA is a big reason that practice nurses have been kept in subservient roles. But as the involvement of nurses in chronic disease management and health assessment is increasing, the profile will increase also. Post graduate studies in primary health will give a boost to the credibility of advanced nursing roles in primary health also.
I suppose though the bottom line will always be – do nurses have the knowledge to prescribe? The ‘right’ to nurse prescribing is limited at present (quite correctly I feel) to NPs and eligible midwives. These nurse have completed an ardous study path , pharmacology is not an easy subject, and are prepared and accountable for their prescribing. Then again, if there is sound evidence that some areas of medication prescribing can be performed by RNs safely through protocols, who am I to dispute. In the end – it is the patient that matters, and if this will provide better patient outcomes it should be seriously considered. If it doesn’t, it should not.
Thank you Kathy for a very interesting article and for your comments Angela. I support the view advanced by Kathy about the need to more fully utilising the skills of nurses within the primary care sector. Traditionally in Australia the skills of nurses have tended not to be fully utilised except outside of capital cities. I have been struck by the broad scope of nurses in many other countries with similar nursing education systems to that in Australia. Since 1986 I have had the opportunity to visit health services and spend extended periods of time with clinicians and educators, nursing and medical, in the UK, Canada, USA, Sweden amongst other places it was evident that nurses in Australia have not had the opportunities available to their peers. Attending international nursing conferences and hearing what peers overseas are doing can be eye opening.
Several examples illustrate this point – nurse run clinics, with support of GPs or specialists for decades, with limited prescribing rights for common conditions where treatment is routine; nurses routinely referring to nurse specialists within mental health for an opinion on care and management that was entered into the clients file and read by ALL clinicians; Community and district RNs working closely with small teams of ENs and care staff and local GPs; nurse anaesthetists. I could go on.
Angela I agree we do not want more clinicians prescribing unnecessarily however nurses can work effectively within set guidelines. We have guidelines that all prescribers ought to follow. Many nurses, now and in the past, suggest particular medication regimes to a doctor, directly or indirectly. Well trained and supported nurses can provide advanced care. Specialist diabetic nurses transformed the community care of people with diabetes, supported by medical specialists. Womens health nurses provide a great service. You note the impact of the AMA, clearly it has had an impact on the scope of nursing practice. However medical specialists have also supported expanding nurses roles.
Do nurses have the skills to take on more independent roles, yes and no. Are RNs currently educated to take a broader role – I sometimes wonder. I recall efforts made to teach nurses basic physical assessments in early degree floundered – it was not doctors who objected, it was colleagues in the health service. Nurses can be taught the knowledge and skills they require to work to the limit of their registration and be encouraged to undertake further education. I think it is great that nurses are taking more responsibility and working in teams. An example recently my husband recently saw the Nurse Practitioner who works with his cardiologist. She did a through and very competent examination, recorded it in detail, suggested some tests, ordered some and wrote to the GP to request others be undertaken. All at half cost to us and the tax payer. My sister-in-law in the UK sees the nurse at her GPs clinic, she examines her, monitors her health, prescribes and sends her for tests. The nurse consults the doctor as necessary. I would like to see more of this occurring. And I would like to see more nurses taking greater responsibility for planning and providing care within a team context. One of the most important developments in Australian nursing, in my view, is that practicing nurses are now teaching. Nursing students have some clinical role models, nurses who like their medical peers, manage units, provide care, research and teach.