[ozmidwifery] Interesting article on proposed increased medicare funding for nurses

[Helen and Graham]

http://www.theaustralian.news.com.au/story/0,20876,18787989-28737,00.html   Healing hand extended Allowing nurses to perform tasks now handled by doctors would save money, but it is likely to be fiercely resisted by the medical profession, write Adam Cresswell and Patricia Karvelas April 12, 2006 AFTER 19 years as a nurse at the same medical clinic in Melbourne, Ann Salmons has immunised babies who have come back to her as 18-year-olds to be vaccinated before they go on their first overseas holiday. Faces such as Salmons's may soon become more familiar in doctors' surgeries, following news the federal Government is keen to expand their role. As The Australian reported yesterday, federal Health Minister Tony Abbott proposes to lift the limitation on what practice nurses can do under Medicare. Details about other tasks they may be allowed to perform are yet to emerge. Abbott said yesterday there "are all sorts of things which nurses could conceivably do". "They could perform more health checks for patients, they could perform more follow-up work for patients under care plans, and so on," he said. Medical and nursing organisations say likely tasks include suturing wounds (as well as dressing them, as at present), taking patient histories and measurements, administering certain tests such as for lung function, blood pressure and blood clotting ability, and providing a wide range of advice and support. The latter role may include advising new mothers about breastfeeding techniques and on how to get young babies to sleep, as well as asthma and diabetes education. Salmons, who works at the East Bentleigh Medical Group clinic in Melbourne, says she is relieved by Abbott's plan. "It is a good area to work in," she says. "You're out there in the community, but it is a lot more rewarding: you follow up with your patients and with children; you see them grow up. I've got patients that I vaccinated as babies getting vaccinated to go overseas as adults." NURSES AND DOCTORS Practice nurses Average earnings: $23 to $25 an hour (about $48,000 a year full time). No specific certification or requirements. It is up to employing GPs to satisfy themselves nurses have the required skills. Registered nurses and enrolled nurses can work as practice nurses. Most states require enrolled nurses to be supervised by registered nurses, so the former make up only 6 per cent of GP nurses. Registered nurses complete a three-year bachelor of nursing course that covers anatomy, chemistry and physics, drugs, side effects, bacteria, basic infectious diseases and prevention. The course looks at specific contexts, such as caring for children, the elderly, the mentally ill and patients with specific needs, such as those being treated for heart failure as opposed to those recovering from surgery. General practitioners Average earnings: Estimates vary but Australian Taxation Office data from 2002, released in 2004, puts average GP earnings at $212,833 before tax and practice costs (which can be up to 50 per cent). Medical students wishing to be GPs must complete a basic medical degree, which ranges from four to six years, depending on which university is chosen and whether the course is undergraduate or postgraduate. After the degree is awarded, the doctor has to spend one or two years as an intern in a public hospital before applying for one of the 650 places in the GP training scheme. GP training lasts three years for those intending to work in the city and four years for those aiming to be rural GPs (who often need to be able to give anaesthetics and deliver babies). Salmons is in the vanguard of change: for the past six years she's been conducting health assessments in the homes of people over 75. "Every day I do wound management and immunisations, I assist doctors doing surgical procedures," she says. "I also do education for asthma, diabetes and heart disease." Salmons says it is a team effort in her practice. "It is a collaboration, we work in a team. If a patient comes in with five different problems, the GP can handball things like asthma education, all vaccines, all immunisations, all wounds, to me. "Because the GP doesn't have time to do that in 15 minutes, there's a role for us." The Australian Nursing Federation's national secretary Jill Iliffe says the proposed change makes sense. "There's such a wide range of things that nurses can do to help improve the health of a community in general medical practice," she says. Iliffe also believes the expansion will improve job satisfaction for nurses: "The partnership between doctors and nurses is really important." She says nurses are capable of providing a much broader range of healthcare services if restrictions are removed, citing "routine injections and antenatal care and postnatal care, women's health care, baby health care". "It's just amazing the number of things that nurses could contribute in that setting," Iliffe says. The main doctors' groups have been supportive of the practice-nurse role, but this attitude conceals a crucial disagreement over the degree of autonomy nurses should be given. It remains to be seen whether extending the practice-nurse role will bring such differences to the fore. Some nursing advocates are pushing for nurses to be given the right to see patients on their own, to diagnose illnesses and prescribe drugs. Doctors' groups fiercely oppose these proposals, insisting nurses are not trained for such decisions; they say the GP should delegate tasks to the nurse and remain responsible for them. Abbott yesterday gave another boost to practice nurses by extending the subsidies the Government pays to doctors to help cover the cost of employing them. At the moment the subsidies - worth about $8000 per full-time GP, up to a maximum of $40,000 per practice - are available to surgeries only in rural areas and some urban areas where doctors are in short supply, usually in outer-metropolitan suburbs. Under yesterday's extension, an extra 650 general practices will qualify for the payments. "Getting more skilled nurses working in general practice is an important way of making better use of the existing health work force," Abbott says. "The work of nurses helps to free up doctors, allowing the general practice to see more patients on a daily basis." If previous experience with such subsidies is anything to go by, yesterday's extension will lead to an increase in the number of nurses working in Australia's general practices. Nurses have been working in some doctors' surgeries for many years, but until 2001-02 their numbers remained limited because there was no way of paying them other than out of the practice's profits. Medicare was and, barring a few recent exceptions, remains strictly doctor only. Employing a nurse was a luxury that many GPs, particularly those in rural and outer-metropolitan areas, could ill afford. That changed in 2001, when the federal Government first introduced the lump-sum incentive payments designed to help GPs with the cost of employing nurses. The number of practice nurses rocketed as a result, rising from a few hundred to almost 5000 in recent years. In 2003, only 93 (23 in urban and 70 in rural areas) of Australia's approximately 6000 GP surgeries claimed the practice-nurse incentives. By 2005, that number had risen to 1617 (574 urban and 1043 rural). The number of individual nurses working in those practices is much higher. Until now there have been no accurate figures on practice nurse numbers, but the Australian Divisions of General Practice - a peak body representing the 120 or so divisions or local networks of GPs - has completed a survey that is expected to be published in the next two weeks. The survey has found that about 50 per cent of practices now employ a nurse and there are about 4800 GP nurses now working, most of them in rural areas. The ADGP's estimate of practice nurse numbers more or less matches the figures of the Australian Practice Nurses Association, which has 5000 practice nurses on its books. The association's president Lynne Walker says that as the nursing profession is predominantly female and many nurses work part-time, there can be as many as 10 to 12 nurses attached to a single practice, sharing a smaller number of full-time positions. Ninety-four per cent of the association's nurses are registered nurses who earned their qualification after completing a three-year university course. Another factor encouraging GPs to hire practice nurses was the introduction in February2004 of new rebates that allowed a GP to delegate wound dressings and immunisations to a nurse, and then recoup some of the cost of employing the nurse by claiming the rebate (now worth $10.40) from Medicare. The rebates were later extended to also cover nurses who provided pap smears in certain rural areas. As Medicare now pays $31.45 if the same wound dressing, immunisation or pap smear is performed by a GP, the appeal of practice nurses to the federal Government's bean counters is obvious. And in an environment of increasing GP shortages and crowded waiting rooms, practice nurses offer a tailor-made substitute work force, especially as health planners inside and outside government increasingly agree on the need to delegate health tasks to the least-qualified health worker skilled enough to carry them out. In other words, there's no point in getting an already busy GP to do tasks that could just as easily be done by a nurse - such as giving diabetic patients advice about a healthy diet - just as it's a poor use of resources to get a cardiologist to take someone's blood pressure. Walker says the APNA does "have some reservations" about how practice nurses are working. "When you are talking about Medicare item numbers, you are usually talking about a very specific task, such as pap smears or immunisation," she says. "We are concerned about that because it encourages nurses to be task-oriented. "We would probably prefer some way of funding nurses so what they do is not restricted to tasks."