ANOTHER review on “doctor versus nurse” role substitution with a brave finding that there are few differences between GPs and nurses based on very limited data.
These studies are usually based on flawed health goals, provoke turf war arguments between professionals, and stifle the very real opportunities for nursing within primary care.
Australia needs a smarter approach to workforce management to meet its health care needs.
Task or role substitution has been the darling of health workforce researchers for many years. The supposition is that similar health outcomes will be achieved for lower costs by reassigning health care services to lesser trained and lesser paid providers.
Similarly, nurses have been trained to do colonoscopies and vitreal injections, and are involved in epidural care, but does that make them gastroenterologists, ophthalmologists or anaesthetists?
Nurses have been trained to perform some primary care duties, but does this mean they can provide the comprehensive services or have the system value of the trained GP? More accurately, they are seen as nurses with a special skillset.
Australia, like other high-income countries, has introduced nurse practitioners in primary care with substantial support through Medicare.
While general practice nurse numbers have grown substantially, the use of advanced nurse practitioners is limited. One reason is that practices that do engage nurse practitioners cannot pay salaries equivalent to the public sector, and many of the general practice roles they perform can be adequately met by practices nurses.
Countries undertaking health professional task/role substitution have found implementation to be complex, requiring greater oversight and regulation, yet reduced costs are not guaranteed.
The introduction of a nurse practitioner-based walk-in clinic in Canberra attracted criticism. Although the primary goal was to ease accident and emergency workload at Canberra Hospital, paradoxically the clinics increased demand.
The Canberra clinic mostly treated minor upper respiratory tract infections and musculoskeletal conditions, but had high referral rates to GPs and other agencies, and the cost of a service averaged $196 — more than four times that of general practice.
In the private sector, nurse practitioner-led clinics are increasingly operating in pharmacies, mostly via the drug company Apotex, which recently purchased the Revive clinics, adding to its nurse workforce. Apotex claims to have nurses and nurse practitioners providing screening programs, treatments and education services including “product recommendations” at more than 800 locations.
Australia has strict laws regarding direct-to-consumer advertising and medical relationships with drug companies. So far regulators have not acted on drug companies delivering direct-to-patient clinical services via the nursing and pharmacy professions.
Nurse practitioners delivering GP services at higher cost than GPs and providing a workforce for drug companies are hardly examples of policy success.
The lesson to learn from this latest research and from our experience so far is that nurses are trained professionals who can be utilised as effective primary care agents. However, they can be more expensive and ineffectual if not actively managed and services targeted in the health system.
Task substitution between GPs and nurses in the real world has, overall, not been successful.
To overcome this Australia should instead focus on producing a more effective health system by developing role delineations and collaboration in primary health care teams. Similarly, the nursing profession should recognise the important role general practice plays in the Australian health system and strive to complement rather than replace it.
Primary care does not need nurses to duplicate or replace a GP, and does not need single-skill nurses trained in the hospital setting. Primary care needs a range of advanced nursing skills to complement the clinical skills of a GP and to help them deliver a comprehensive set of services to solve health sector priorities, such as palliative care, hospital-in-the-home programs, hospital avoidance programs, drug and alcohol services, advanced mental health skills, and telehealth-supported supervision of aged patients in their own home. These are roles where appropriately trained nurses can add value to the health system within a collaborative general practice model.
Instead of concentrating on professional competitiveness between GPs and nurses, Australia should appreciate the added benefits nursing can bring to primary care, and start resourcing the training of nurses to provide a delineated skillset that will address and solve Australia health needs.
Dr Evan Ackermann is a GP at the University Medical Centre, Southern Cross University, Gold Coast, Queensland, and the chair of the Royal Australian College of General Practitioners National Standing Committee – Quality Care.