Shaking up primary care

Australia's first standalone nurse practitioner-led clinic was launched in Brisbane last month. Linda Belardi speaks to the woman at the helm of the model.

"It's been a pretty hectic month," says Julie Farrelley, lead nurse practitioner at the Brisbane-based SmartClinics, just hours ahead of the facility's official launch.

From local drops in appointments to interstate fly-ins, the clinic's 10 nurse practitioners and four midwives have treated a wide variety of minor illnesses and injuries.

Since opening its doors to the public in September, Australia's first nurse practitioner-led medical clinic has seen an average of 18 patients a day - mostly women. Farrelley says patient feedback has been positive and about 75 per cent of patients reported a wait time shorter than five minutes.

To mark its opening, the federal Treasurer and local member for Lilley, Wayne Swan, officially launched SmartClinics at a ceremony on October 21. In its first weeks of operation, Farrelley says the clinic has consulted patients over a range of conditions including colds and flus, women's health issues, minor injuries, as well as emergencies.

"We're seeing a wide range of illnesses and injuries and emergencies at times. A lot of our female patients are coming in for pap smears. We're seeing mums with their children for routine vaccinations and also what we call the "worried well" - mums just wanting their kids to have a check up if their child has experienced a fever or sore throat overnight," she tells Nursing Review.

While the clinic is yet to operate at full capacity, with increased numbers, Farrelley anticipates it will still be able to maintain its short wait times. An online booking system is used to assess the needs of patients and to determine the consult time required.

"When patients book in online they are able to tell us exactly what condition they are booking in for, so whether they are booking in for a cough or a cold or for a pap smear - the booking system can understand how long a certain condition will take. The average appointment time is 20 minutes and if an appointment runs short, that amount of time then goes back into the booking system."

Ultimately, the clinic, which operates extended hours, will help increase community access to primary healthcare, she says.

"A lot of our patients don't even have a GP - they might be travelling from interstate or just haven't had a GP for a long time."

As a hybrid model between an emergency department and a medical clinic, Farrelley says SmartClinics can help to alleviate the pressure off busy emergency departments by treating conditions commonly referred to EDs.

"If someone does come through with a broken bone, we can put the plaster on and refer them to the fracture clinic, whereas the GPs would tend to refer to the emergency department for treatment."

If a patient presents with conditions out of their scope of practice such as a person with multiple co-morbidities, they will be linked in with a GP to best manage their treatment.

Farrelley says the rate of referral to specialists and other medical practitioners is very similar to that of GPs working in medical centres throughout the state. Approximately 20 per cent of patients would be referred to specialists and other health professionals for further treatment.

Traditionally medical centres have run on a GP model employing only one nurse practitioner.

However, SmartClinics inverts the ratio of GPs to nurse practitioners working in a primary care setting. By utilising the prescribing and medicare rights of nurse practitioners, the clinic is able to employ a team of nurse practitioners and only one doctor in an advisory role.

"Up until now the main option for nurse practitioners has been to either go into a highly specialised field or to work in an emergency department. Now with the extension of MPS and PBS rights to nurse practitioners last year, there are really important career opportunities for primary care nurse practitioners."

While Farrelly says the community is learning a lot about the role of the nurse practitioner, she acknowledges there is still a long way to go.

"Just talking to consumer advocates, we certainly do have to educate the community a lot more, but generally the patients that come through the clinic understand the service we can provide."

Farrelley says the nurse practitioners use the 20-minute consultation to examine the patients thoroughly, explain treatment plans and print off any supporting information.

A lack of awareness even amongst other health professionals has proven to be an initial challenge. "Some radiologists or pathology departments weren't exactly sure that we could order a lot of the things that we can, but we're clearing the way there."

Farrelley says her new role will build on her experience and skills working in the emergency department to focus on the whole of patient care.

All of the nurse practitioners employed by SmartClinics on a full-time or part-time basis have emergency department backgrounds, in addition to rural and remote experience.

Since 2007 Farrelley has been employed as a nurse practitioner in both a hospital and a medical centre. She has previously worked as a registered nurse in rural South Australia and in remote areas as part of the Royal Flying Doctor Service.

The clinic's opening in Chermside's Westfield Shopping Centre, however, has not been without criticism. Medical lobby groups including the president of the AMA and the Doctors Reform Society have raised vocal concerns around the impact on patient safety and the fragmentation of care.

"As a clinic of nurse practitioners with limited GP input, this is the exact opposite of the model of primary care that is needed to deal with the increasing complexity of community medical problems," said Tracy Schrader, president of Doctors Reform Society in a statement.

Farrelley says she was not surprised by the often-negative reaction from doctors groups, but she says the proof is the pudding. "Really we are proving that we are doing exactly the opposite. We are actually stopping the fragmentation," she says. "Patients have been referred to us via the 13 health line often after-hours when a GP is not available."

Helen Gosby, president of the Australian College of Nurse Practitioners, said it was important to dispel arguments that nurse practitioner-led clinics were unsafe.

"Patients will go there because they believe in the care that they receive - it's safe care. Nurse practitioners have scope of practice and they work within that," she told Nursing Review.

Gosby said nurse practitioner-led models increased community access to primary healthcare, especially for young adults who don't necessarily have a regular GP.

"Doctors can't provide healthcare for every patient. We need to set up a whole lot of different ways for people to be able to access care and this is just another option."

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