Australia’s population is aging. More than 16 per cent of the total population is now aged 65 or older, and this figure is predicted to rise to 23 per cent by 2066.
As a result, there is an increasing demand on general practitioners (GPs) to manage large numbers of patients with multiple complex chronic diseases related to ageing. Many people experience long wait times or are unable to find a regular doctor due to a shrinking GP workforce.
The viability of primary care is threatened, even with the recent announcement of extra funding to boost Australia’s universal health care system, Medicare.
However, in Australia, we have a large workforce of nurses who have the skills and experience to provide additional services that would reduce the workload on GPs, but these opportunities are limited by Medicare fee-for-service rules.
A GP told us that medical practices need “primary care nurses who can do a bit of everything”, but there are multiple barriers that prevent nurses working at their full scope of practice.
This problem is not just in Australia – primary care faces workforce challenges internationally.
The United Kingdom, USA, Canada and New Zealand have responded by introducing health service reforms that support nurses to work at an advanced level. This reduces demand on GP services, while creating opportunities for patients to access timely, low-cost care that is evidence-based and person-centred.
We are yet to take this step, but the Australian Government’s Primary Health Care 10-year plan 2022-2032 recommends that registered nurses work to the full scope of their practice and as part of multidisciplinary teams to improve access to care for people with chronic illnesses.
Nurses aren’t allowed to work to their full potential
‘Scope of practice’ describes the activities health professionals are educated for, competent in and legally allowed to perform.
In Australia, primary care nurses’ scope of practice varies dramatically; some nurses only perform task-based care under the direction of general practitioners, while others manage and deliver nurse-led services either independently or in collaboration with medical practitioners and allied health professionals.
Research shows that Nurse-led clinics are well-established and effective, with nurses conducting physical assessments, providing treatments (like immunisation and cervical screening) monitoring disease self-management, and providing lifestyle advice and health information.
In 2018, the Nursing and Midwifery Board of Australia (MBA) proposed registered nurses’ scope of practice expand to include prescribing of medicines by suitably educated and experienced registered nurses.
To progress this, NMBA have just released a consultation paper, Registration standard: Endorsement for scheduled medicines − designated registered nurse prescriber, to assess the risks and impact of different models of registered nurse prescribing.
Medicare funding requires GP-led service
Overseas, nurse prescribing has been successfully running for several years, but in Australia the GP must be actively involved in every consultation to generate a Medicare fee and prescribe medication.
This funding system limits opportunities for nurses to work independently or develop new care models and fails to alleviate the GP workload.
In addition, the government workforce incentive paid to general practices to employ nurses does not incentivise independent GPs to shift tasks to nurses as they receive no benefit if a nurse completes an episode of care without their input.
There needs to be more rewards for GPs and clinics if they are to hand over consultations to nurses.
Incentives to upskill are lacking
Nurses also need more incentive to complete further studies to increase their scope of practice or to take on extra responsibility, like gaining postgraduate qualification as a nurse practitioner.
Nurse practitioners are the only nurses who can currently bill Medicare and prescribe medication, but there are too few of them working in primary care.
Primary care nurses work under an award that pays them significantly less than hospital nurses and offers no additional benefit including study leave or qualification pay.
Education for nurses seeking to work in primary care settings remains problematic too.
Nursing students get limited exposure to primary care due to the associated workload, supervision requirements and costs to the practice associated with clinical placement.
Nurses working in primary care generally do not benefit from postgraduate scholarships like those working in the state-funded public hospital system. So, the number of nurses choosing a career in primary care remains low, resulting in few education providers electing to offer postgraduate courses in primary care.
In Australia, nurse practitioners must complete a Graduate Certificate in a relevant area of practice followed by a nurse practitioner master’s degree. In addition, they must have at least five years of clinical experience, with three years completed at an advanced level.
The proposed scholarships in the budget will undeniably help some nurses to complete university courses, but without funding to support general practices to mentor nurse practitioner candidates, their numbers are unlikely to grow. This requires urgent attention.
The following actions should be considered:
- Count practice nurse time towards long and complex consultations (Medicare Level C and above) so that nurses can provide additional input without the GP losing financially.
- Introduce primary care nurse prescribing models, supported by education scholarships to upskill nurses.
- Increase Medicare Benefits Scheme nurse item numbers to support nurses and practices to develop new models of care.
- Ensure the Workforce Incentive Program provides for the total cost of employing a nurse at a rate commensurate with hospital employment. Ensure this is paid to the nurse with study leave, contributions to continuing professional development and a qualification payment.
- Provide scholarships for enrolled primary care nurses to become registered primary care nurses, creating a career path.
- Establish a sustainable model of mentorship for Nurse Practitioner candidates and registered nurses undertaking training in diagnostics and prescribing.
- Establish a national clinical training program that supports the development of advanced practice skills for Nurse Practitioner candidates and prepares them for independent and collaborative practice in primary care and community health.
- Establish a mechanism for evaluating the impact of nurse-led initiatives in primary care on community access and patient-reported outcomes.
Until the funding and legislative barriers that prevent primary care nurses from working independently and to their full scope of practice are addressed, GPs will continue to struggle to provide the first-class health service that Australians expect.
As a nurse working in regional Victoria puts it: “The question is no longer ‘if’ nurses should increase their scope of practice to support GPs, but ‘when’?
“Nurses are very well placed to absorb some of this pressure, but they must be given adequate training, resources and incentives to provide safe care under best practice guidelines. This would enhance, not impede, the substantial and fundamental role GPs hold in the primary care space.”
