Claire Jackson: Defining the nurse practitioner role

THE nurse practitioner (NP) role has for some time been part of the hospital environment — particularly in emergency departments and hospital diabetes clinics.

But the NP is a very new player in the PBS/MBS-funded primary-care world, with changes announced last November giving NPs limited access to the PBS and the MBS.

The NP role and its optimal linkage with general practice have received broad and sometimes sensational attention in the media since then.

The RACGP has been actively working with key stakeholders, including medical colleges, medical indemnity insurers, NPs and government to ensure that this change has no impact on the optimal continuity of care and quality use of medicines for patients.

While the stakeholder focus early in 2010 was on the legislative framework for the role, this has now turned to the implementation reality in Australian primary care.

Our two major areas of member concern lie in extended duty-of-care responsibilities and medication misadventure.

GPs are concerned about the receipt of isolated pathology or radiology results ordered by NPs, which trigger duty-of-care obligations and confusion about who is following up.

One solution involves the return of the  results, in the first instance, only to the NP who ordered them.

The NP would then, in accordance with legislated principles of practice, MBS requirements and patient consent, provide the GP with a timely written summary of diagnosis, investigation results, intervention and management plans and proposed follow-up.

This approach would address concerns expressed in a number of states without increasing GP workload, fragmenting care or adding to GP risk.

The College is currently collecting member feedback on this proposal.

NP prescribing is autonomous and will not necessarily involve GP input before prescription, even in the elderly or those with complex co-morbidity, unless the NP requires clarification, or a formal collaborative arrangement exists.

Preventing fragmentation of prescribing and its attendant risks, and ensuring a quality use of medicines framework will clearly require ongoing work with all parties in 2011.

The College’s framework on non-medical prescribing will provide an excellent starting point.

The College has also invited the Australian College of Nurse Practitioners to nominate a primary care member to work with them, medical defence organisations and the AMA in developing collaborative care templates for general practice.

Current issues involving the NP role include:

•    developing a collaborative arrangement template that meets the needs of GPs, indemnity providers, nurse practitioners and patients

•    clarifying and addressing the ill-defined linkage with the patient’s GP outside these arrangements

•    clearly defining the clinical role of the “nominated medical practitioner”, raised in the legislation

•    assessing the ability of primary care NPs to deal with the vast number of ill-defined primary care presentations likely to present across the full range of age groups and clinical conditions when they have a much shorter and less intense training period than general practitioners

•    assessing risks to patients, particularly the elderly and those with multiple co-morbidities, of fragmented prescribing in non-collaborative arrangements

The College is keen to work closely with the many nursing, medical indemnity and government stakeholders involved, to ensure a safe, productive and accessible model of care with primary care nurse practitioners.

Formal collaborative arrangements providing clear definitions of roles and responsibilities, clinical handover, quality use of medicines and decision support will be essential.

Professor Claire Jackson is the president of the Royal Australian College of General Practitioners and Professor in General Practice and Primary Health Care and Head of the Academic Discipline of General Practice at the University of Queensland.

Posted 24 January 2011