Primary health care nurses are not just a GP value-add

By: Karen Booth, APNA President 

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

Some members of the Royal Australian College of General Practitioners (RACGP) have suggested that MBS item numbers should be changed to allow nurses in general practice to administer vaccines without a GP being present. This proposal is well intentioned; however, it does not go anywhere near far enough.  

Tinkering with MBS funding models will not solve the very real problems needlessly restricting a nurse’s scope of practice when it comes to vaccines. These arbitrary restrictions can lead to decidedly serious yet avoidable situations. Let me give just one example.  

Last year a solo doctor in rural New South Wales came within hours of cancelling clinics for nearly 1000 COVID-19 vaccinations (at the height of the pandemic, no less). This was because the GP was forced into isolation after being in close contact with a positive COVID-19 case. However, the arcane MBS billing requirement for GPs to be physically present to give ‘direct’ supervision to nurses during vaccinations almost created a near-miss public health crisis, and could have left a large swathe of the regional town either under- or unvaccinated. 

The GP team had organised the local church hall to run vaccine clinics over several days, with people travelling from around the regional area to get vaccinated. After lobbying from APNA, the Australian College of Rural and Remote Medicine and the local primary health network, special exception was gained from the local public health unit that allowed the GP to be onsite but forced into the ridiculous situation of being isolated in full PPE in the church attic, so he could – from a distance – ‘supervise’ the nurses doing the actual work. This was purely a billing requirement.  

All this happened despite the practice having highly trained accredited immuniser nurses on staff. This situation simply must change to ensure the optimal use of the skills of all health practitioners and to facilitate a team-based model of care to provide the best outcomes for patients.  

APNA completely agrees with the RACGP that the funding to run large-scale immunisation clinics via general practice is insufficient. Accredited nurse immunisers are already authorised under the National Immunisation Plan (NIP) to give vaccines, covered under NIP without a medical order. Primary health care (PHC) nurses in general practice should be enabled to administer flu vaccines without a doctor present. This would provide better access to care for patients. It would also be better for nurses and GPs, who would have more time to care for the sick and those with complex care needs. 

We must acknowledge the PHC nurse's scope of practice, trust nurses as colleagues and as health professionals, and give them the authority to do more of what they are trained to do

But this issue is about more than just getting a new MBS item number. It is also about how the item descriptors are worded, and where the fee goes. The current challenges with MBS item numbers mean that in their current format (for example ‘for and on behalf of’) they restrict nurse scope of practice and a nurse’s ability to provide services to patients when and where they need it most, such as in the home. As autonomous registered health professionals, PHC nurses rightly find this ‘hand maiden’ clause insulting. 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. The December 2020 General Practice Primary Care Committee of the MBS Review Taskforce states ‘Recommendation 11 – Modernise the terminology currently used in the MBS to describe registered and enrolled nurses and their role to reflect the important role these health professionals play as members of the practice team’.1 To this end, terminology such as ‘for and on behalf of’ and ‘direct GP supervision’ should be removed from MBS requirements for activity within a nurse’s scope of practice. This could be replaced with 'may be assisted by a nurse’. 

There is precedent for authorities to move quickly and change regulations when the circumstances require it. At the height of the pandemic the Victorian Government saw sense and changed the regulations so that student nurses could give vaccinations while supervised by a nurse practitioner or registered nurse supervisor.  

At no point in our history have we had more highly skilled, accredited nurse immunisers than we do today. However, their activity is stymied by outdated MBS requirements that reflect billing demands rather than the PHC nurse skill set and scope of practice, or the legislative framework covering nurses.  

There has also been little acknowledgement by the Commonwealth as to how the need to redirect doctors to short sharp vaccination visits to ensure item billings for flu shots has affected the bottom line for many practices, as care is directed away from complex care and preventative health checks and is blowing out waiting times in an already stressed marketplace. 

We also need to be clear on the pathway for funding transactions. Ideally it would be a population-health-style payment directly to the practice rather than an MBS item number that sees 65–75% going home with a doctor because it is billed under a GP provider number.  

When it comes to MBS reform, we must acknowledge the PHC nurse's scope of practice, trust nurses as colleagues and as health professionals, and give them the authority to do more of what they are trained to do. In APNA’s 2021 Workforce Survey, 34% of PHC nurses reported that they are not working to their full scope of practice. This situation cannot continue. With health care systems under incredible strain, we need to focus on smarter ways to use our health workforce.  

Considering the current workforce crisis with workload and staffing issues plaguing the health and aged-care sectors, untying nurses from direct supervision would create a much more flexible model that would allow practices to let their trained immuniser nurses do home visits, residential aged-care facility visits and outreach to vaccinate patients. 

The RACGP’s MBS proposal is intended to ease the burdens on GPs. That is a worthy goal – but let's not stop there. Instead, let’s fix this arrangement once and for all and give practices flexibility in service-delivery models. Let’s give PHC nurses the trust and respect they deserve as health professionals who have so much more to contribute. 

Reference 

Medicare Benefits Schedule Review Taskforce, Report on primary care, Australian Government Department of Health and Aged Care website, June 2020, accessed 2 November 2022. www.health.gov.au