Mary Chiarella. Co-payments, general practice and workforce reform.

Jan 5, 2015

If there’s a problem in primary health care then nurses are (and always have been) the solution. 

Susan Sontag wrote in 1978 “Illness is the night side of life: a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and the kingdom of the sick”. I was working in palliative care nursing when I first read this and it struck me that, continuing the metaphor, nurses were therefore like tour guides for those negotiating these health care kingdoms of both the well and the sick. We provide the translator services (“what did they say nurse?”), the coordination of meetings and events (“I need an appointment to see…”); the advice on what to do and how to do it (“I don’t know how to work this spacer thing”), and always, always, always the assistance to do whatever needs to be done when people lack “the necessary strength, will or knowledge” (Henderson, 1966) to do it themselves.

If we look to primary health care (PHC) there is clearly a need for “tour guides” in this space, whether it be to help them stay in the kingdom of the well or to assist them to travel in the kingdom of the sick. John Menadue has suggested the key is to rethink funding for general practice. I would go further. The key is to rethink who provides the bulk of PHC and then think about how to fund it.

In 2009 I compiled a compendium of nurse-led PHC models in 38 countries for the World Health Organisation (WHO, 2009).The elements of PHC identified for reporting purposes in the template were that each service, programme or project should:

  • provide essential health care based on practical, scientifically sound and socially acceptable methods and technology;
  • be universally accessible to individuals and families;
  • involve full participation of the community;
  • have a cost that the community and country can afford to maintain;
  • foster self-reliance and self-determination;
  • be an integral part of the country’s health system and overall development; and
  • have an entry level for patients located close to the heart of the community.

The main needs of the populations served were those of the chronically ill and the elderly, basic social and infrastructure needs, psychological and mental health needs, maternal and child health needs and acute care needs (particularly in war zones).

To provide a local example of what is possible, the work of an Aboriginal renal nurse practitioner in Australia with both indigenous and non-indigenous groups suffering from end-stage renal disease brought about significant health gains. 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% 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 nephrology nurse practitioner was able to develop and implement nursing models that integrated evidence-based clinical management with nursing advocacy for quality of life.

Two key areas, considered central to the success of the case studies, presented challenges for a number of contributors. These were the issues of reliable and adequate funding and resources, and challenges to narrow thinking about the capacity of staff to take on new roles. The issue of sustainable funding; access to other resources such as medication, equipment, textbooks and staff created significant challenges. Some projects were completely or predominantly funded through the charitable sector (for example Chile, Haiti, United States). For example, a US project working with a poor community in Chicago sought its primary funding from a charity, and supplemented it with grants from no less than 16 funding sources and a further 13 in-kind donation sources. The time required to undertake the fundraising, administration and reporting on so many donations takes the nurses away from much-needed care delivery.

In addition, there were a number of reports of medical and some nursing staff having difficulty in letting go of conventional and stereotypical thinking about who ought to perform which tasks. This issue has been much studied and discussed (Chiarella 2002) and has been described in relation to affirmative action as the ‘myth of the meritocracy’ – the possibility of work being taken on by another group, unless similarly qualified, is unthinkable because they are seen as incapable of meeting the challenge (Hall 1997). Yet there is ample evidence and experience to show that different personnel and community members are capable of equal, high quality participation in health care decision-making and delivery. Strong claims to maintain the status quo are often made on the grounds of safety and quality, but the evidence about the outcomes demonstrates this resistance to change is based only on protecting professional power and privilege.

There is such potential to harness the skills of nurses to provide first class primary health care in this country, yet currently we seem to move further and further away from this potential and back to outdated models of health care provision that service only those who can afford to pay.

Mary Chiarella is Professor of Nursing, Sydney Nursing School, University of Sydney.

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