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Nurse cervical screening: Challenges to and opportunities for scope of practice
By Jo Millard, APNA Project Officer
Source: APNA Primary Times Summer 2021 (Volume 21, Issue 2)
Over the last 30 years, a block-funding arrangement between the Commonwealth Government and VCS Pathology enabled certified Victorian cervical screening nurses to provide cervical screening tests (CSTs) for patients without the need for sign off from a GP. This arrangement was unique to Victoria, with nurses in other states and territories not experiencing the same degree of autonomy.
Unfortunately, this arrangement came to an end in July 2021, and Victoria moved to a Medicare funding model. Under the new arrangements, VCS Pathology is only able to bill Medicare for CST requests that are signed by a practitioner with a Medicare provider number (e.g., a GP or nurse practitioner [NP]).
Nurses providing cervical screening in the primary health-care (PHC) setting in Victoria have faced an unexpected setback to their scope of practice and many are concerned about access to services and implications for health outcomes for patients who are eligible for screening.
Concerns arising from the change include:
- reduced autonomy for Victorian nurse cervical screening providers
- potential limitations on nurse providers’ access to practitioners with Medicare provider numbers to provide request forms, particularly in remote rural areas
- increased administrative tasks for nurses’ GP and NP colleagues
- missed opportunity to expand the block-funded arrangement nationwide to increase access to cervical screening services
- confusion about which provider will receive the patient’s results and will be responsible for follow-up of results. (This has traditionally been undertaken by the health professional providing the test.)
The change shines a light on the constraints of the current funding system, the lack of understanding around what a nurse’s scope of practice can include, the restriction of autonomous practice, and the reduction of equitable access to health care for eligible clients, particularly in remote rural areas.
Cervical screening nurse providers provide high-quality care, contributing to improved access to cervical screening and women’s health across Australia. APNA’s Building Nurse Capacity (BNC) Program (funded by the Australian Government Department of Health) and other primary health network nurse clinic projects support the development of nurse-delivered (team-based) models of care that improve patient outcomes in a range of primary health-care settings, to increase the capacity of the primary health-care team. Nationwide, nurses providing cervical screening clinics (including those participating in BNC projects) and their patients would benefit from a more flexible MBS funding approach.
Nurses who complete the endorsed Victorian training course are granted certification by Cancer Council Victoria as cervical screening providers. These nurses are eligible to access a ‘nurse provider number’ with VCS Pathology.
"Cervical screening nurse providers are known for proviing screening for underscreened and never-screened women."
When the Victorian Cervical Screening Register was operating, it used these unique nurse identifier numbers to monitor the number, quality and impact of cervical screening tests taken by Victorian nurse screening providers. The 2017 VCS report stated that ‘Tests collected by nurses represented 5.2% of all Victorian CSTs collected between January and November 2017’ and there were 504 certified nurses providing cervical screening in Victoria at that time. There are currently approximately 500 certified Victorian nurse cervical screening providers.
Informed by improved evidence and technology, Pap testing was replaced by human papillomavirus (HPV)-based cervical testing to provide best-practice evidence-based screening in 2017.
The quality of nurses’ practice in providing Pap testing and CST was reported by VCS annually from 2000 until the migration of the Victorian Cervical Screening Register data to the National Cancer Screening Register. Victoria was the only Australian state or territory that collected and reported nurse cervical screening data.
In 2020, the World Health Organization (WHO) called on countries to progress towards the elimination of cervical cancer as a public health problem. Cervical cancer is the 13th most common cancer affecting Australian women and is considered one of the most preventable through prevention measures, such as HPV vaccination and screening. It is considered a very treatable cancer when detected and managed early with appropriate treatment.
‘As nurse cervical screening providers in Victoria, we have shown that a nurse-led model for cervical screening is safe and effective at reaching unscreened and under-screened populations. To support our ongoing role in providing cervical screening, I hope that into the future, the CST MBS item includes nurse cervical screening providers, so that nurses across Victoria and Australia are able to provide CST independently and ensure we can continue to provide access for vulnerable populations.’
Michelle Cornelius, Nurse Consultant, Cancer Council Victoria
The priority areas of our National Women’s Health Strategy for 2020– 2030 include:
- increasing access to information, diagnosis, treatment and services for sexual and reproductive health • investing in targeted prevention, early detection and intervention
- tailoring health services for women and girls
- co-designing and delivering safe and accessible services.
Cancer Council data show us that during 2020 and 2021, a sharp decline in cervical cancer screening test numbers was reported as an impact of the COVID-19 lockdowns in Victoria. In 2020, Dr Jeannie Knapps informed us that ‘The traditional Medicare feefor-service for a GP attendance funding model has limited the participation of general practice nurses in cervical screening.’
Cervical screening nurses are known for providing robust screening collection and inclusion of cervical cells and for providing screening for under-screened and never-screened women. The VCS report provided strong evidence that nurses were more likely than other providers to collect CSTs from those whose last test was more than 48 months ago.
The presence of endocervical cells within a cytology test specimen is considered to be a reflection of collection quality. Of the technically satisfactory cytology tests collected by nurses from women with a cervix in 2017, 71% were reported as including an endocervical component. The proportion of cytology tests with an endocervical component for other provider types during the same time period was 66%. CSTs collected by nurses during 2017 for women aged 50 years or older was greater than those collected by other provider types (43.5% compared with 33.7%).
Almost 60% of women screened by nurses during 2017 were categorised as most disadvantaged.
‘Cancer Council Victoria acknowledges the enormous contribution nurse cervical screening providers make in the National Cervical Screening Program, particularly their ability to engage with under-screened priority groups. We acknowledge that the change to an MBS billing model is challenging for our Victorian nurses who use VCS, and we will be monitoring the impacts on priority groups most at risk of cervical cancer. We continue to provide the Victorian Certification program and professional development opportunities to support nurse-led CST, and we will continue to support efforts to advocate for a change to the MBS CST item to include nurse cervical screening providers.’
Kate Broun, Head of Cancer Screening, Early Detection and Immunisation at Cancer Council Victoria
Australian Indigenous HealthInfoNet states that ‘Cervical cancer impacts [a lot of] Aboriginal and Torres Strait Islander women. Aboriginal and Torres Strait Islander women are more commonly diagnosed with cervical cancer – and [more commonly] die from it – than non-Indigenous women. While cervical screening programs are effective for reducing cervical cancer deaths, participation tends to be low among Aboriginal and Torres Strait Islander women.’
Reducing barriers for First Nations people to access cervical screening, including improved flexible funding for nurse cervical screening providers, may encourage more Aboriginal and Torres Strait Islander women to attend local service providers, particularly in rural and remotes areas.
In APNA’s 2020 Workforce Survey, 52% of respondents expressed that they would like to undertake more complex clinical activities or extend their role in the workplace. Relating this data to sexual and reproductive health, approximately 26% of nurses surveyed indicated that they are trained in or are in the process of undertaking training in women’s health.
PHC nurses are recognised as quality controllers, change agents, and educators. They tend to be great proponents of a team approach to care, codesigning care with patients, supporting self-management and delivering evidence-based practice.
There is untapped potential for PHC nurses certified in cervical screening to support improved access to sexual and reproductive health care, including cervical screening. Provided with the opportunity, these nurses can support eligible patients to access cervical screening, the HPV vaccine, and selfcollected CSTs, with self-collection likely to be expanded over time.
Indeed, in the UK, Ruth Stubbs, cervical screening program manager for Public Health England, informs us that nurses administer most cervical cancer screening in England.
Over the past 10 years, the number of primary health nurses certified to provide cervical screening has increased significantly. Their clinical practice and nurse-led clinics have increased women’s access to cervical screening. … Certified nurses are experts in engaging with reluctant screeners and these funding changes may well impact on this important work.’
Sandy Anderson, Cancer Prevention Nurse, Ballarat and District Aboriginal Cooperative Medical Clinic
More flexible funding arrangements have been under discussion for years and many PHC nurses have indicated a desire to provide a broader range of care. At a time where preventative screening rates have fallen in some Australian states due to the advent of COVID-19, the recent decision appears to be inconsistent with equitable access to sexual and reproductive health care, including CST provision.
As essential members of the health-care team, nurses strive to work to their full scope of practice. This requires:
- reform of funding models in general practice in line with the Quadruple Aim of primary health-care reform
- interdisciplinary and patient support
- removal of regulatory barriers
- more widespread use of nurse-led and integrated models of care
- digital health capability and government policy that better enable nurses to utilise digital health platforms, such as telehealth. Recommendations to support decision-making:
- prioritise solutions to funding model barriers to support PHC nurses to work to their full scope of practice
- expand the previous Victorian nurse cervical screening model into other states to support improved access to care and improved health outcomes for patients attending for cervical screening, especially in rural and remote and/or vulnerable populations
- optimise system- and businesslevel arrangements to support equity of access to cervical screening in line with WHO recommendations and the priority areas of the National Women’s Health Strategy for 2020–2030.
National Women’s Health Strategy 2020–2030 – What women want
- ‘Guaranteed timely access for all women to comprehensive coordinated prevention and life-long care, ensuring world-class health outcomes.’
- ‘To ensure that all women in Australia are clear on what the issues are that affect their health, how they can go about getting screening, diagnosis and the relevant treatment.’
- ‘Make the health system more efficient by connecting key services – health promotion, prevention, treatment and care – so it is seamless for all women and girls.’
- ‘Address the leading causes of death and disability for women using a comprehensive life-course approach ... with a specific focus on the social determinants of health and equality for all women!’
- ‘Gender-sensitive services that treat women holistically, encompassing all aspects of herself, not just the disorder she presents with – across the life course from pre-conception to old age.’
For concerns or enquiries about the changes, please contact: • VCS Pathology, Ph (03) 9250 0300 or email NurseCoordinator@vcs.org.au or • APNA Ph 1300 303 184
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