Privately practising nurse practitioners offer the best solution for vaccinated marginalised populations, but they have been excluded from access to Commonwealth emergency pandemic vaccines.
Nurse practitioners (NPs) have been established in this country for more than 21 years. The USA has been using NPs for more than 50 years. They are an accepted part of the public hospital system and are demonstrated to supplement, complement and improve existing services.
In the public sector, for example, NPs are demonstrated to prevent re-presentations to emergency departments and their expertise is drawn on significantly by the multidisciplinary teams.
In the private and community sector, they have established programs of work primarily for the underserviced and underserved.
Research evidence tells us that NPs provide quality care that patients are highly satisfied with, and that NPs have increased patient access to health services, particularly for marginalised populations in community settings, but that funding for their services continues to be an issue.
Privately Practising Nurse Practitioners (PPNPs) have had limited access to Medicare Benefits Schedule (MBS) funding since 2009, but their ability to be financially sustainable in the private and community sectors has consistently and persistently been blocked by both the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP).
One of the consequences of this exclusion is being clearly demonstrated right now.
In the middle of the COVID-19 pandemic, with Australia struggling with the delta variant and, up until recently, a shamefully sluggish vaccination roll out, PPNPs have been left out of the efforts to vaccinate all Australians.
Despite a growth in vaccination clinics across the country, the recent inclusion of pharmacists to deliver Covid vaccines, and states calling on health students to assist with vaccinations, PPNPs have not been included in these processes.
PPNPs offer the best solution for vaccination of marginalised populations across Australia. Yet PPNPs continue to be excluded from access to Commonwealth emergency pandemic vaccines and the funding to enable them to administer it. This is despite the fact that they are able to both prescribe and administer vaccines, and are already accredited to supply vaccines that are provided to them under the National Immunisation Program (NIP) to children and adults.
Examples of PPNPs in Australia and what they could do to assist
- A nurse practitioner working in remote areas of Australia is the only contact point for the community, including the Aboriginal population, for general health care needs, and particularly for women’s health, sexual health, and family planning. A GP flies in to visit for a half day every 2–3 months. The nurse practitioner has the trust and engagement of this community, covering an area of approximately 500 square kilometres. Due to vast distances, the nurse practitioner regularly travels to the remote community, as well as holding regular clinics in several locations throughout the region. As a part of their usual service provision, vaccines are given. The nurse practitioner is clearly both the best engaged with the community to maximise uptake of the vaccine, and the most trusted and available qualified health professional to deliver it. Under existing arrangements, a GP will have to be flown in, and transported around to remote clinics.
- A nurse practitioner in a large city works in their own clinic, and currently prescribes and administers vaccines under the National Immunisation Program. They also work as part of an outreach team visiting the homeless, addressing their primary health care needs, including vaccinations. Members of the outreach team are the only health professionals that visit the homeless in the city, and have established a high level of trust and engagement, with most of their clients refusing to enter clinics or hospitals due to fear or embarrassment. These people may never access a Covid vaccine.
- A nurse practitioner working in a regional area visits four residential aged care facilities (federally funded). Of these, three are visited by general practitioners (GPs), although the nurse practitioner is the only one that visits after hours, or at short notice if a resident becomes unwell. The fourth has no visiting GP service at all. Following repeated delays, and several attempts to find a service that would attend and administer Covid vaccines, the nurse practitioner was able to obtain supply of the Covid vaccine for the elderly residents of the fourth aged care home, and worked several days vaccinating them without payment for his time or expertise.
- An Aboriginal nurse practitioner in rural Australia manages both Indigenous and non-Indigenous groups suffering from end-stage renal disease, and has brought about significant and positive changes in their health. The need for this role was identified as a result of the rising number of people needing acute dialysis 24 hours a day. A retrospective study of the causes of this rise suggested that 80 per cent of the patients had risk factors that, if addressed early enough, would have prevented admission to the tertiary referral hospital for acute intervention. These risk factors were further examined and the diagnostic, clinical and referral skills required to address them were evaluated, and it was found that the scope of practice of a nurse practitioner met the requirements. The community renal nurse practitioner was able to develop and implement nursing models that integrated evidence-based clinical management with nursing advocacy for quality of life. This NP is ideally placed to provide vaccines and preventative care, for very vulnerable people, however, currently cannot.
NPs and the marginalised people who access NP care are being actively discriminated against and locked out of the ability to participate in the program due to the deliberately constraining MBS descriptors and the channelling of funds to individual GP fee for service billing items, rather than an “all hands-on deck” approach that could reach people in areas where GPs either can’t or won’t go, and communities are paying the price.
In the National Covid Vaccine Campaign Plan, Lieutenant General John Frewen identifies that the only three groups with unrestricted access to all aspects of immunisation in all jurisdictions are medical practitioners, nurse practitioners and nurse immunisers. Of these three groups, PPNPs are the sole group who do not have access to the Covid vaccine. States and territories have specifically stated, in their pandemic-related legislation changes, that NPs can be used during the pandemic (and in most cases can supervise and/or have other health professionals reporting to them).
Nurse practitioners could have been funded at a federal level to provide mobile and in-clinic services to the general public, leading teams of nurses, and ensuring disadvantaged people are not left out.
The Australian College of Nurse Practitioners (ACNP) and all the key Australian nursing organisations have been seeking access for PPNPs from government for months, but this has still not happened. There is no legitimate reason why this should be the case. We are of the view that this relates to ongoing “turf” concerns. Michelle Grattan, writing in The Conversation, asks these salient questions in relation to the late utilisation of pharmacists, and the very same questions could be asked about PPNPs:
- Why, way back when, did the government put so much weight on the doctors in delivering the early months of the rollout?
- How much did doctors’ lobbying influence the initial shape of the rollout? What clout did they have with senior health officials?
Why and how much indeed? Far more than we could even have imagined, given the developments of the past week in relation to the introduction of what seemed (at last) to be an opening to “enable” PPNP access to the Covid vaccine.
With only one day’s notice, the ACNP and other key nursing groups were invited to a webinar by the federal Health Department to learn how PPNPs were to be given access to Covid vaccines. Despite the short notice and work demands, there were about 140 attendees.
What we learnt was that instead of PPNPs being able to access the same MBS item number to administer Covid vaccines as doctors and pharmacists, they would need to make a request for tender (RFT) under a new scheme entitled VAPP — the National Vaccine Administration Partners Program panel.
The 25-page document explained that the lodgement closing date for phase one of this three-phase process would be September 24 at 2pm (so move quickly whilst working full time in your own practice) but the final phase would not be until December 3, which would effectively mean that PPNPs would not have access to the Covid vaccine (were they to be successful) until just before Christmas.
The RFT itself was released on September 14 with an enquiry cut-off date of September 17, so three days to resolve any queries.
Furthermore, the average IProvider (immunisation provider) is required to have the capacity to deliver 500 doses per day, unless exemptions were granted for rural and remote IProviders. But as the examples above demonstrate, many NPs even in the inner city have small vulnerable populations who still require vaccination.
To say that PPNPs are disappointed would be an understatement.
Many are outraged.
They have vulnerable patients who desperately need to be vaccinated against COVID-19 and they are in the perfect position to provide those vaccinations.
Yet now they have to jump through another series of hoops not required of other health care providers.
And let us be really clear. The majority of Covid vaccinations in this country are being administered by nurses, at state, territory and federal level. At state and territory level these nurses are remunerated by the state and territory governments. At federal level the remuneration goes to the doctors and the pharmacists, even if they then employ a nurse to give the vaccinations.
It seems that there is an unwritten determination at federal level that seeks to avoid giving a recognised regulated group of health care providers (who are already qualified immunisers) access to MBS as a means to enable them to care for their underserved communities.
In a previous paper in P&I, I used the word “perverse” to describe the decision of the MBS review taskforce to reject all 14 recommendations of its own nurse practitioner reference group. That perversity continues and it will be the vulnerable patients of nurse practitioners who are the victims.