Maximising primary health care nurses

It’s time to be bold 

 

Lynette Smith, Primary Times writer

Source: APNA Primary Times Winter 2024

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Primary health care nurses know what’s stopping them from working to their full scope of practice. They are the same barriers that prevent Australians from having effective primary health care. But could all this be about to change? 

Australia’s Medicare system was set up for episodic care – infections, injuries and the diagnosis of acute diseases. This may have been fit for purpose 50 years ago, but it’s not where the greatest demand is now. Chronic conditions have become the largest burden of disease. Many conditions, such as mental ill-health, have complex social causes. 

There is also a shocking lack of care in regional, rural and Indigenous communities, making decent healthcare a lottery that depends on who you are and where you live. Nurses are often the only healthcare providers in some of these communities, so enabling them to work to their full scope can help ease these workforce shortages.  

As Fran Cieslak, APNA’s Advocacy Manager, says ‘Not enabling primary health care nurses to work to their full scope of practice is wasteful of nurses as a critical healthcare resource, particularly when nurses want to do more to meet health needs and improve healthcare access for Australian communities.’ 

One of the biggest challenges in contemporary healthcare is prevention rather than treatment, which is only feasible if care is easy to access, by anyone, anywhere, whenever they need it – or even before they realise they need it. 

This issue of access is critical and, in the current system, it becomes harder and harder to address it. APNA is working to show how, despite the barriers, nurses are taking the lead by setting up clinics that are easy to access and where people feel safe to talk about more than just what brought them there. 

As Fran points out, ‘Nurses working to full scope of practice increases healthcare access for more people – particularly vulnerable people.’ 

One of the nurses we spoke to for this article, Jodie Duffy, demonstrates this with the walk-in wound clinic she set up in Port Macquarie. Jodie’s clinic is effectively diverting people from the emergency department for wound management that can be addressed by a nurse in the community. Timely and accessible treatment like this can prevent chronic and debilitating conditions from developing. This simple and low-cost intervention is making things better for patients and taking the load off the wider health system (see page 25 for more details). 

‘Primary health care is the future!’ a general practitioner once told long-time APNA member, Diane Bowden. It’s a vision that fuelled Diane’s commitment to working as a nurse in primary health care rather than a hospital, or the university she started in. 

This vision, however, is a future we haven’t yet reached. And it can’t be reached unless nurses are enabled to work to their full scope of practice. One of the barriers is the current funding model, which makes it extremely hard to offer nurse-led primary health care – no matter how urgent the demand or how qualified the nurse or other clinical staff. 

Yet, even within the current funding model, nurses and nurse practitioners continue to find ways and means. Sue McKinnon, for example, established a teen health clinic in Bega that was so effective that it has been replicated in other general practices in New South Wales (see page 26). And APNA has other examples of nurses and nurse practitioners doing extraordinary things. But what we need is a system where these kinds of initiatives are widespread.  

The funding model, already mentioned, is the biggest barrier. Others are to do with perceptions of nurses and entrenched privilege. To resolve this, all it takes is support from a GP and a nurse can be working to their full scope of practice quite easily. This is what opened the door for Kayleh Meredith, an enrolled nurse assessing the risk of cardiovascular disease in 45–49-year-olds at the Coffs Medical Centre. 

Better public understanding of where the work of primary health goes on is also needed. With so much attention on private general practice, many of us don’t think about other places of care, such as schools, prisons, pharmacies, and sexual health clinics.  

‘Nurses are invisible in the primary health care system,’ says Fran. This means that opportunities to provide true person-centred, multidisciplinary primary health care are missed. Salaries for primary health care nurses are also lower than their counterparts working in hospitals, which reflects a perception that they don’t make a valuable contribution. On top of this, the nursing curriculum rarely covers primary health care. 

If we’re not careful, we’ll not only waste the valuable human resource we have now, we’ll also harm the development of a workforce that we will critically depend on in the future. 

This is why APNA continues its advocacy. It’s advocacy on behalf of primary health care nurses who are currently being prevented by our healthcare system and culture from doing what they are trained to do. But it’s also advocacy that is driven by the same thing that drives so many registered nurses and nurse practitioners – the desire to see Australians healthy and safe from harm.  

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APNA visits Parliament House 

On 7 February 2024, APNA’s team – along with nurses Jodie Duffy and Sue MacKinnon and nurse practitioner Diane Bowden – travelled to Canberra.

Parliament House, they met the government’s health portfolio ministers: Mark Butler, Ged Kearney, Malarndirri McCarthy and Emma McBride. They also met with member for Indi, Helen Haines, and the shadow minister for health, Anne Ruston. 

The purpose of these meetings was to raise the profile of primary health care nurses to government with the announcement of our first Primary Health Care Nurses Day and to advocate for changes to funding and care models that would allow nurses to work to their full scope of practice. Diane, Jodie and Sue provided examples of how and where this is already happening in their clinics across Australia. 

A crisp morning on 20 March saw the APNA team back in Canberra for a breakfast hosted by Ged Kearney, Assistant Minister for Health and Aged Care. This time, nurse practitioner, Kerrie Duggan, and enrolled nurse, Kayley Meredith, presented their work and experience to an audience including politicians, chief nurses from around the country, representatives from the Australian Medical Association and Professor Mark Cormack, who is leading the independent Scope of Practice Review that is still underway. 

According to Fran, the ministers ‘loved hearing about the nurses’ experiences and models of care.’ For many, ‘it was a light-bulb moment,’ she adds, with some politicians hearing for the first time about a large, underutilised workforce that has the skills, knowledge and evidence-based practice that their electorates desperately need. 

Now is the time to be bold! The current government has its eye on health-system reform and APNA is at every table and consultation to make sure primary health care reforms are implemented. The recommendations of the Strengthening Medicare Taskforce, released in late 2022, were an important step in the right direction. Stakeholder meetings and consultations for the independent Scope of Practice Review are happening now, with the final report and implementation plan due in October 2024.  

‘This is one of the biggest reviews undertaken in primary health care in Australia and if most of the reforms go through – it will be a game changer!’ says Fran. 

The reforms on the table include: 

• Building primary health care capability in Australia 
• Reviewing legislation and regulations to enable greater capacity for health professionals to work to their full scope of practice 
• Changes to funding and payment policies to support innovative new models of multidisciplinary care, rather than the limited Medicare Benefits Schedule (MBS) model that dominates at present. 

APNA continues to make submissions to the Scope of Practice Review on behalf of all primary health care nurses in Australia and we encourage all nurses to read about the review, join the roundtables, listen to the discussions, and have your say too.  

The rest of our cover story focuses on the registered nurses and nurse practitioners who joined us in Canberra. They are all doing work APNA would like to see more of you doing … in a system and culture that enables and rewards you to do so. Please reach out to APNA if you want to chat about how to make this happen at your clinic/service – we would love to help and see you working to your full scope of practice too. 

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At a tipping point 

Diane Bowden is a life-long learner – always open to new ways of doing things and with a clear eye for how things can be better. Recently, after 30 years as a registered nurse, she was endorsed as a nurse practitioner.  

It’s been a rich career. She describes her time working at Bungendore Medical Centre, which at the time was Bungendore’s only practice, as ‘hard work but also rewarding.’ She encountered major emergency presentations and ‘resus on the street’, as well as patients with chronic health conditions. According to Diane, she was stretched to her full scope of practice, learning all the time in a team where everyone took responsibility. 

‘I absolutely value the learning I got from working there,’ she says. But the need to broaden her horizons meant that, after 7 years, Diane had to move on, though she misses being connected to the community.  

In Diane’s experience, people in a town like Bungendore, NSW, value the primary health care they receive, and, in particular, what nurses do for them. It was ideal for chronic disease management, she says. ‘You could monitor their health and organise a program of care. People would come back consistently … and they were thankful they were getting good healthcare.’ 

It also meant the primary health care met people’s needs – ‘because you knew how to sort out problems for people.’ 

With the urgent demand for primary health care, there should be rich prospects for nurses and nurse practitioners anywhere they would want to go in Australia. However, the barriers to them working to their full scope of practice are still there, blocking the way for Australians who urgently need their care. 

These are the barriers that APNA, through its advocacy, wants to pull down. 

Change has been hard to win, but Diane believes we are at a tipping point. With the legislative requirement for a collaborative arrangement with a GP now removed, a choke point in the current system has gone. More changes are needed to realise the opportunities for nurse-led primary health care but it’s a critical change. 

Diane thinks back to the early 2010s when nurse practitioners got access to the MBS. Before then, Medicare billing made primary health care very task-driven – Diane says she did a lot of ECGs because there was an item number associated with it. 

But she’s optimistic and, after all, with 30 years of experience in the system, Diane has seen a lot of change. Asked about her visit to Canberra with APNA, Diane says that she thought Mark Butler, Minister for Health and Aged Care, was really engaged. 

We have a window of opportunity. And, as Diane says, ‘I like change!’ 

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Here for the people 

When Jodie Duffy started a walk-in wound clinic in a Port Macquarie pharmacy, she was thinking of leaving nursing.  

‘I had started work at the pharmacy administering vaccines while I worked out what to do,’ she says.  

Instead, she stumbled across an opportunity, which, she says, ‘relit her fire.’ 

Jodie noticed that many people coming into the pharmacy had gone to emergency for basic wound care when they couldn’t get into a GP. Acute wounds, she observed, are the kind of thing where an early intervention can not only treat the wound but also prevent chronic wounds and other complications that require more complex care. 

Nurse-led care in the pharmacy seemed like such an obviously good idea that Jodie thought there would already be several examples of it. But, as far as she could see, there weren’t. It seemed that no one had tried it before in Australia.  

Some might have stopped there, but once Jodie got the go-ahead from the pharmacy owner, she took off. 

‘I had nothing!’ she says. ‘No policies, procedures, equipment, or models for how to do this.’ Funding from APNA for a nurse-led clinic was the first step. The local Primary Health Network contributed start-up funds too. Jodie got in touch with the wholesaler to get the best price on wound dressings. And a local general practice was closing, so she got all the equipment she needed at a good price.  

Jodie says she discovered that ‘you may as well just ask!’ She said that she got more than expected, which reduced the start-up costs and the cost to patients. 

The policies, procedures and documentation needed to function as a wound clinic were the next step. Finding out about how to set up clinical governance was hard. And there is currently no software suitable for administering a service like this, so she keeps paper records for all patient interactions. 

With the walk-in clinic set up, Jodie needed to build awareness. As well as radio and social media, she made a personal visit to every general practice in Port Macquarie. She went to industrial places to tell the tradies that they could come to the wound clinic rather than go to emergency. ‘I walked the industrial area, dropping in leaflets … I even went to hairdressers!’  

Some things still frustrate her. Not being able to send off a wound swab means that a patient has to go to a GP, which puts them at risk of complications – after all, difficulty accessing a GP was one of the reasons why the walk-in wound clinic was needed.  

Jodie wants to improve and scale up what she is doing with the walk-in wound clinic. But she also wants other nurses and nurse practitioners to take this model, learn from what she has done, and apply it where they see a need.  

‘There is a huge opportunity for nurses to work in pharmacies. It doesn’t have to be in wound care – it can be whatever that community needs.’ 

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So much better together  

Sue MacKinnon has a sharp eye for how things work – and what will make things work well in a general practice.  

Her clinic serves Bega, NSW, a town of about 5,000 people in a dairy-farming area, with the local cheese factory being one of the biggest employers. The town is changing demographically but has poor socio-economic outcomes for many who live there.  

Sue’s day consists of booked appointments with patients for chronic diseases, wound care, mental health, child and adult immunisation, sexual health, women’s health and many acute presentations on the day. The clinic does all the usual point-of-care testing, biometrics, ECGs, procedures, and infusions. She also does home visits, which are not funded at all, for patients who find it difficult to come in.  

The practice has also established a nurse-led clinic for teenagers two afternoons a week. Teenagers can drop in and chat to a nurse about anything from a sore throat to sexual health, mental health, domestic and family violence, or something like school-based stress. Because teenagers see a nurse rather than a doctor, it’s not funded by a Medicare rebate, so it operates as a registered charity.  

When asked about working to her full scope of practice, Sue says, ‘we’re a practice that recognises that if you can do a job, then you should just be doing it.’ In her general practice, for example, nurses cannulate and insert and remove most of the contraceptive implants.  

However, because the viability of a clinic comes down to a GP billing for item numbers, nurses must interrupt a GP’s consultation for a simple script. Breaks like that in the workflow are a burden to the whole practice – contributing to the 4–6-week wait for a GP appointment. 

‘Allowing nurses limited and well-regulated prescribing rights, following rigorous additional training, would make a massive difference in all of our working lives,’ Sue says. Other countries, such as the United Kingdom, have qualified nurse prescribers, but in Australia attitudes have been hard to budge. 

‘But it’s not so difficult to change people’s attitudes,’ says Sue. ‘Let suitably trained nurses do the work and it becomes the norm.’ 

In short, the funding model is stopping general practices from meeting the needs of patients in an efficient and effective way. It also stops the Commonwealth Government from knowing what nurses actually do because it only has data about what it funds under the MBS. 

Sue is optimistic. She knows what it is like to work in a practice that is collegial – where nurses are respected – and therefore valued in the practice, and visible in the community. 

‘I am a great fan of looking for common ground ... we work so much better together than apart.’  

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The ripple effects of kindness 

In a system where six-minute consultations are the norm, Kerrie Duggan makes time for kindness. 

The general practice she co-owns in Cygnet, Tasmania, has a minimum 15-minute consultation so that nurse practitioners like her, and the GPs she employs, can check their patient’s history, identify potential gaps in their care, and plan the consultation. 

As Kerrie says, it’s about trying to look after the whole person. She gives the example of an elderly woman in the Huon Valley who wants to die at home. ‘We’ve got care wrapped around her now and she hasn’t had to go to hospital at all. Her health has improved to the point where her life expectancy has been longer than it would have been if she had gone into hospital.’  

The ripple effects of this kind of care – on the woman, her family, the primary health care services, and the hospital – are enormous. They cascade beyond the healthcare system into the rest of the economy, but also into the lives of the people in the community. 

This keen eye for those ripple effects is why Kerrie has pursued innovative, nurse-led models of care that empower the nurses, paramedics and other practitioners who make up this underutilised workforce.  

Funding is critical for them to be financially sustainable, of course. However, rather than fighting to get items on the MBS, Kerrie argues that block funding and other funding models are the way to go. ‘This way, GPs don’t need to feel that they are losing income or status,’ she says. By sidestepping a fight about the model, ‘it’s much easier for a government to implement reform.’ 

Empowering practitioners is also critical to the success of primary health care. ‘As a nurse practitioner and a practice owner, I can drive nurse-led care and develop innovative ways to deliver it.’  

With funding from the Government of Tasmania, for example, she set up an innovative model of urgent and after-hours care that ran for 12 months alongside her general practice. Over the course of the year, she and her paramedic colleague saw 1,400 people for minor illnesses and injuries, contacting the on-call emergency doctor just 12 times – providing care effectively more than 99 per cent of the time. 

We have a window of opportunity, believes Kerrie, and she’s ready to be bold. With Ali Spicer, a paramedic, she’s developed another business, NP Assist. ‘We’ve got a business plan that delivers 100 appointments a week for $250,000 a year, diverting people from the emergency department who can be helped by a primary health care practitioner. A GP model would quadruple the cost. Everything’s ready to go, we just need the funding.’ 

For Kerrie, kindness is not an intangible – it’s not an optional extra in a hard-nosed business and funding regime. Instead, it’s crucial to primary health care ... and the only way to guarantee it is to empower nurses.