Care factor: The real-life benefits of putting nurses in charge

By APNA PR/Corporate Affairs Advisor Nick Buchan

Source: APNA Primary Times Summer 2022-23 (Volume 22, Issue 2)

Primary health care (PHC) nurses have long chafed under the ‘doctor-first’ restrictions imposed by the Medicare Benefits Schedule (MBS) funding mode on their scope of practice. However, recent experiences from the COVID-19 and monkeypox vaccination programs have demonstrated the benefits of trusting nurse-led teams to get out into the community and provide care where it is often needed the most.

Take two nurses with similar skill sets, experience, and qualifications. The first nurse works only under strict doctor’s supervision and is often restricted to a tight range of simple procedures. The second nurse enjoys a wide scope of practice and is trusted to work independently on more complex procedures.

Why the difference? The first nurse works in general practice under the Commonwealth MBS. The second nurse works in a community health service supported by state funding.

'It's just bewildering that we're not enabling all nurses to work to their capabilities’, said Cate Grindlay, Director of Integrated Care & COVID Services (and registered nurse), at Your Community Health in Melbourne’s north. Cate understands the funding model situation better than most, with some nursing services in her organisation funded by Medicare billings and others by the Victorian Department of Health via their public health units.

Under the MBS, apart from a $12 chronic care item number, practices can’t claim payment from the government for a service provided in their clinic by a nurse unless a GP is on the premises to supervise. The GP must also contact the patient and the item must be billed under the doctor’s name. This is despite nurses being trained and legislated to provide care without doctor supervision. In contrast to this, nurses in state-funded COVID-19 and monkeypox vaccination clinics (for example) are led by nurse immunisers and have no such restrictions.

This inflexible MBS regulation not only restricts patient access to timely care but can have a real impact on workforce retention and nurse job satisfaction. APNA’s 2021 Workforce Survey found that PHC nurses have an average of 21 years’ experience working as a nurse and an average of 11 years in PHC settings. However, 34% of survey respondents (all PHC nurses) reported that they were not working to their full scope of practice. With health-care systems under incredible strain, we need to focus on smarter and better use our scarce health resources.

Cate said that she was thankful that her organisation was able to offer an MBS-funded clinic; however, the campaign to vaccinate the community for COVID-19 highlighted how restrictive MBS regulations could impact access to critical health care.

'We had one day where 2 of my nurse immunisers were providing COVID vaccinations at rooming houses and women’s refuges, and there was no issue with this service being entirely nurse-led', Cate said. 'That was the same day our general practice had to cancel a Medicare-funded vaccination clinic due to a doctor going home sick.'

‘A nurse's work must be recognised and acknowledged in the MBS on its own merits. Nurses are not just a GP value-add, they are skilled, clinical team members providing a service to the public.’ — APNA President Karen Booth

'On one hand I’m able to empower my fantastic nurses to vaccinate independently in the community, whilst on the very same day equally experienced nurses working in an MBS-funded clinic are unable to provide care because a doctor is not available to “supervise”.'

Your Community Health operates COVID-19 and monkeypox clinics across northern Melbourne through a combination of outreach, client-based and centre-based activities and co-located services. Nurse-led health teams are embedded in their local communities and prioritise outreach to disadvantaged and vulnerable people to provide care in a safe space.

'We've had nurses vaccinating in public parks, community festivals, and church halls, without a doctor, and they have been doing this safely for more than a year. The team takes basic emergency equipment with them, have great safety protocols and it's gone spectacularly well,' Cate said. 'By comparison, in an MBS-funded medical centre, where you have significant clinical infrastructure, and other team members on hand, nurses can’t be funded by the MBS to provide vaccination without a doctor’s supervision.'

One notable example of Medicare’s strict requirement for doctor supervision of nurse activities almost left an entire town without a vaccination clinic at the height of the pandemic.

When the only GP in Canowindra, in rural NSW, was notified he was a close contact of a COVID case, he almost had to cancel a pop-up vaccination clinic the day before it was set to open. At the time, all close contacts of positive cases had to isolate for 2 weeks, even if a negative test was returned.

As a solo GP and one of only 2 GP clinics in Canowindra, there was no one else to supervise the vaccination clinic, which was operating for one day only, with the goal of administering about 1,000 vaccinations. This would have left the town vulnerable to COVID-19 at a time when people were desperate for protection. The clinic was only able to go ahead after the doctor was granted special permission to be at the clinic, isolated in a separate room in protective gear.

'It could have been a public health disaster,' APNA President Karen Booth said. 'We got permission for the doctor to attend the vaccination clinic in full PPE, but hidden away in a separate room, in order to meet the obligations.'

'It highlights the ridiculous nature of the rule, and the lack of thought by those responsible for implementing the MBS item number for COVID vaccines, giving no acknowledgement or credit to the high level of skills of nurse immunisers.'

Karen said the rule needs to change, given it is about billing and not patient safety or clinician skill set.

'Just let nurses do what they are amazingly skilled at, and free the doctors up to go deal with acute care, and do house calls to see sicker patients,' she said. ‘If funding for clinics was attached to the patient service rather than the doctor billing the item, nurses would no longer need GP supervision to access funding and maintain the practice’s bottom line.’

There is precedent for authorities to change regulations when the circumstances require it. For example, at the height of the pandemic the Victorian Government changed the regulations so that student nurses could give vaccinations while supervised by a nurse practitioner or registered nurse supervisor.

Cate Grindlay said this flexible approach to regulation had a real impact on the quality, speed, and flexibility of care her team could provide. 'It became very clear that there were not enough nurses or nurse immunisers. The decision was made in Victoria “we’ve got to do this [vaccinate] and do it quickly and safely at scale”,' Cate said.

'Regulations were changed by the Victorian Department of Health to allow second- and third- year student nurses, allied health professionals, allied health and paramedic students to work under the supervision of a nurse immuniser. This authorised “surge workforce” undertook online learning modules and were supervised by a nurse immuniser to give 5 vaccinations, and were then authorised to work under nurse immuniser supervision.’

As a result, the nurse-led Your Community Health vaccination team has provided more than 250 COVID-19 vaccination sessions in community settings, supervised not by a doctor but by a nurse. Settings have included church halls, mosques, markets, family violence shelters and forensic mental health facilities. The program has been so successful it was awarded the Courageous Public Sector Team of the Year award at the recent Leadership HQ Outstanding Leadership Awards held in Brisbane.

'One day at the peak of the pandemic, 2 of my nurses took an esky and went out to vaccinate vulnerable people under an awning near some public housing because that's what needed to be done, and we were funded by the state government to be able to quickly respond to that need,' Cate said. 'This is what effective public health looks like.'

Karen Booth said that the current challenges with MBS item numbers mean that in their current format they restrict nurse practice and a nurse’s ability to provide services to patients when and where they need it most, such as in the home.

‘At no point in our history have we had more highly skilled, accredited nurse immunisers than we do today, Karen said. ‘A nurse's work must be recognised and acknowledged in the MBS on its own merits. Nurses are not just a GP value-add, they are skilled, clinical team members providing a service to the public. When it comes to MBS reform, we must acknowledge PHC nurses’ scope of practice, trust them as colleagues and as health professionals, and give them the authority to do more of what they are trained to do.'