AS Australia begins to emerge from the fog of the COVID-19 pandemic, there needs to be a clear-eyed examination of our health system.
While there is much to celebrate about system capability, there remain obvious areas for improvement. One of the most significant opportunities is in primary health care.
This is not to downplay the major contribution by GPs, nurses and other health professionals in providing continuing care to the public during the pandemic. Rather, it is to build on what we have learnt during COVID-19 and strengthen the contribution of these professions.
Policy makers now have clear evidence as to how they could unlock further potential in primary health care for the benefit of patients.
A good example of this has been the government’s extension of telehealth for services to patients with chronic diseases which are provided by nurses in general practice and nurse practitioners (here and here). This was a sensible, pragmatic decision that has improved health access for vulnerable people staying at home for fear of catching COVID-19.
It also enabled a greater role for nurses, the largest health workforce in primary health care with more than 82 000 employed in general practice, aged care and other non-hospital settings.
It is advisable, indeed critical, that this group is empowered to do more to create a healthier Australia as we return our focus to the challenges of an ageing population and rising rates of chronic disease.
Highly educated but underutilised
The annual Australian Primary Health Care Nurses Association (APNA) Workforce Survey provides a few pointers as to what needs to happen. Released for International Nurses Day on 12 May, it shows that nurses are ready, willing and able to do more. They are highly motivated, highly educated and highly experienced.
Eighty per cent of our 1678 respondents said they enjoyed their work, with patient care being their prime motivator. Most had bachelor degrees and the average time in nursing was 21 years.
Yet, 45% of primary health care nurses reported that often or most of the time their skills are not being fully used in the workplace. More than half asked if they could undertake more complex clinical activities or extend their role. That met with a mixed response, with 30% having their suggestions refused and another 40% being told their employer would think about it.
The main reasons cited for not approving a more complex role were lack of financial incentives for the business and resistance to change. It was also disappointing to learn that half the survey respondents had not had a formal performance review in 2 years to either acknowledge their efforts or identify areas for growth and development.
The underutilisation of nurse skills represents a significant lost opportunity for the Australian health system, patients and employers.
So how can we improve things?
New funding models
Much planning has already been done by governments to predict the number and type of services needed for the community. A clear issue is the way that services for chronic complex care are funded.
It is very difficult for a single practitioner to manage large numbers of people with ongoing, chronic complex care needs. And the patient load is not going away.
Not every patient needs to see a doctor every time they visit the practice. Many patients can and are managed by the nurse for chronic disease management, lifestyle and self-care support visits, immunisation, dressings and care coordination catch-up. However, under the current system, the doctor needs to tick off the exercise so that Medicare Benefits Schedule billing can occur.
Paying for episodic care dependent on face-to-face, come to the doctor when you are sick, or in crisis visits is not a sustainable model for complex care.
There needs to be predictability and assured funding that supports proactive, preventive, managed care to keep people well and supported in their community and avoiding unnecessary hospitalisations.
If Australia took up the recommendations of the Primary Health Care Advisory Group in 2015, we would remodel our system to share the load of care in a more patient-centred, team-based model. This is built around the quadruple aim for health care including a vision for better outcomes, improved cost-effectiveness, improved patient access and satisfaction, and very importantly, improved health professional sense of satisfaction.
Adequately funded bundled payments for people with chronic complex health issues would allow flexible use of team members. Such models free up GP time to see acute patients, knowing the nurse is supporting planned care activities.
The APNA Workforce Survey indicates that nurses are highly involved in care planning activities but would like to do more in relation to case management and health coaching, ongoing patient education activities, including group sessions to support self-care. Nurses are also very active in quality assurance activities that contribute to clinic accreditation and to the Practice Incentives Program Quality Improvement Incentive that attract funding to the practice.
They play a key role in cold chain management and infection control, including sterilising re-usable instruments and training other staff members. The Royal Australian College of General Practitioners recommends appointing an infection prevention control (IPC) coordinator who has the primary responsibility for overseeing a comprehensive IPC program. This is also a crucial component of accreditation. In most practices, this duty will be allocated to the nurse. While nurses play key roles organising and driving IPC activity for safety and practice accreditation, 76% of APNA survey respondents indicated they either were never or infrequently asked to have input into policy development.
Another issue identified by the APNA survey was the ageing nature of the primary health care nursing workforce. A significant number of respondents are approaching retirement age, with 35% of them being aged 50–59 years. This compares with 22% for the same age cohort in Nursing and Midwifery Board data for Australia’s entire nursing workforce.
This presents an obvious challenge for workforce planning to meet population health needs at a local level.
APNA and the Australian Institute of Health and Welfare
APNA has been collecting workforce data since 2004. In 2020, it has collaborated with the Australian Institute of Health and Welfare (AIHW) on their first statistical profile of primary health care nurses. The AIHW report is based on APNA workforce survey and membership data along with other sources.
The AIHW has been tasked with building the National Data Asset for Primary Care:
“Primary health care is a vital component of Australia’s health care system accounting for a large proportion of health care expenditure annually. It is often the first point of contact individuals have with the health system and encompasses a broad range of professions and services. Despite this, there is limited availability of primary health care system data making it difficult to assess the positive impact of this sector on the health of Australians and or identify where improvements are needed.”
Understanding the work and roles of the various team members to build that big picture is critical to meet the evolving needs of the population through strong primary health care services.
The next steps to reform
The Australian Government has recognised these challenges and has appointed the Primary Health Care Reform Steering Group to oversee the development of a National 10-Year Primary Health Care Plan and look at how we can tailor our health system to be more person-centred, integrated, efficient and equitable.
While COVID-19 has delayed this process, it will be integral that it responds to the lessons of this pandemic and takes meaningful steps to release the potential of nurses within primary care to improve the health of Australia.
Karen Booth is President of the Australian Primary Health Care Nurses Association and a member of the Australian Government’s Primary Health Reform Steering Group.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.