It is disappointing, although hardly surprising, to see the medical organisations in July of this year trotting out their opposition to anything other than GP-led primary health care in both Queensland and the ACT; and then (again in a September media release) to see that remarkably (or maybe predictably) the RACGP is restoking its outrage about the ACT clinics.
The objections from the AMA in Queensland argued not only against nurse-led walk-in clinics, but also anything that basically isn’t owned by, dominated by, and remunerated to a GP. Their objections in the July media release included satellite hospitals and pharmacy prescribing as well. Furthermore, they seemed to oppose these clinics in the city, where they claim there are plenty of GPs, but almost suggested they should be in the country. So perhaps Queensland nurses could feel that the opposition from these medical lobby groups is not necessarily as personal as it so often sounds, with language such as “band-aid fixes,” “lower quality care” and “fragmentation of care” flowing freely from the pens of these medical critics. It seems, from the AMAQ critique, they are happy to apply such critiques to, well, anybody really, who isn’t a doctor.
The ACT urgent care centres to be opened up this year are also being opposed, so once again, the message is predictable: do not try to solve the existing problem with any new models of care, unless they are controlled by and remunerated to GPs. This latest media release on 16 September continues with the same arguments: “The ACT’s nurse-led walk-in clinics are bleeding taxpayers’ money – cost-per-service is up to five times more than to see a GP.” It goes on (and on…) “There is no substitute for the quality care you get from a GP who knows you, and your history, and cares for you over the years. And general practices have always provided urgent care and kept appointments for people with issues that need to be seen to on the same day.”
Now my complaint is not against general practice per se. I have the best GP anyone could ever have, with excellent continuity of care. But I am fortunate, as I am reasonably comfortably off. I can afford to pay my gap fee and do so willingly. But we know that this is not the case for many people today, whether they live in the inner city or in remote Australia. Access to free healthcare under alternative models is necessary and long overdue, both in the country and in the cities. For example, the Health Minister in NSW reported only this week that there was a 3.3% increase in emergency department presentation from the same time last year, and that this increase coincides with more residents struggling to access care through general practitioners. These results from the NSW Bureau of Health Information include new data showing a dramatic net decrease in the number of GP attendances per 100,000 people in NSW between 30 June 2022 and 30 June 2023 – from 754,709 to 653,802. This is the first and most significant decrease in GP attendances in over 10 years of BHI reporting. Put simply, it is not possible to fragment care that is not being delivered. People have more chance of avoiding emergency departments if they can find free and accessible health care across a range of models.
So, I do have a complaint. My complaint is about the constant denigration and distortion of the other models of care delivered by other healthcare professionals and shown to be successful, both in Australia and across the world. It is about medical lobby groups misrepresenting and distorting data for political aims and scaremongering in their criticism of other successful models of care. Other HCPs do not denigrate GPs (or indeed any other doctor) in the same way, despite the disdainful and elitist way the medical lobby groups choose to speak of other highly educated HCPs, be they pharmacists or nurse practitioners .
What is remarkable in the arguments put forward in the above media releases and articles is the selective presentation of the data, particularly around the ACT walk-in clinics, some of which have now been operational since 2010 and to which, in 2023-2024, over 125, 000 Canberrans made their way (information provided to stakeholders). The AMAQ claims in the July article cited above that, “In the ACT, each visit to a nurse-led clinic costs taxpayers almost $200 compared to $40 for a GP visit”. But the critical issue here is that these walk-in clinic visits are FREE to those very taxpayers, unlike many visits to a GP. In addition, they are much cheaper than the cost of a presentation to an emergency department, which in the ACT in 2021-2022 was $717 per person for a non-admitted emergency department presentation. So, the taxpayers are actually getting an excellent return for their taxes.
The very reason these visits are free is because the people attending them have already paid their taxes. The costing applied in the data spruiked above by the medical lobby groups would presumably relate to the infrastructure and wages of the staff inside the clinic, for which the taxpayer does not have an out-of-pocket cost. That costing is not paid by the person attending, nor is there a gap fee that goes straight to the GP business holder, be they a GP in private practice or one of the large conglomerates that manage so much general practice business today. It is highly probable that the infrastructure costs for a GP clinic would be similar, although of course, the GPs are entitled to claim from the government for the nursing staff they employ, as those staff are charged back to the government for doing work “for and on behalf of” a medical practitioner, a situation that we know is frustrating for nursing staff in general practice, who would prefer to be recognised and remunerated for their own work for and on behalf of themselves.
Perhaps to balance these arguments, let us look at some of the data the ACT Government has provided on walk-in clinics. The introduction of Walk-in Centres has been associated with a statistically significant decline in the proportion in primary care type presentations to ACT Emergency Departments. This decline averaged 1.9% per year between 2013-14 and 2020-21 (based on AIHW data), going against the national trend where those categories of presentations were increasing over the period. Previous performance reporting demonstrates that, across all the Walk-in Centres, only 5.9% of presentations were redirected to an emergency department and 81.2% were treated in full by the Walk-in Centre. However, the ACT Government themselves have stated that “the ACT’s Walk-in Centres are not intended to be a replacement for general practitioners, and they will continue to work with primary care providers in their local regions to support the community’s healthcare needs.” (information provided to stakeholders from the ACT Government).
So, if potentially 93-95% of more than 125,000 people avoided an emergency department in 2023-2024 by visiting a free, nurse-led, walk-in centre, the ACT has saved itself a significant amount. Furthermore, this same group of 93-97% of 125,000 patients was able to receive care without making a booking, and free of charge. In fact, so successful have these nurse-led clinics been, the ACT Government is now planning to extend them to introduce free nurse-led care in four secondary schools. At a press conference, the Health Minister Rachel Stephen-Smith said the centres would run on campus by Advance Practice Nurses and offer focused services, including preventive healthcare, sexual and reproductive healthcare, and mental healthcare, as well as the treatment of minor illnesses and injuries. We know that, globally, teenagers are reluctant to access healthcare, particularly for mental health issues, so making access to care easily available has been shown to improve that access.
The four free nurse-led clinics announced in Queensland will be staffed by nurse practitioners and nurses with a focus on the healthcare needs of women and girls. The Queensland Government has committed $46 million to establish the new clinics in regions of high need as part of the Queensland Women and Girls’ Health Strategy 2032. Premier Steven Miles reported that the Women and Girls Health Strategy survey had the biggest engagement of any Queensland Government survey ever. “We heard loud and clear that women and girls wanted better access to tailored healthcare services in their communities.” Women-focused healthcare will be provided, including access to contraception, maternal health, treatment for sexually transmissible infections, advice on period and menopause as well as support and referrals for women experiencing domestic, family or sexual violence. It is important to clarify what these nurse-led clinics a) are about and b) are in response to, as the AMAQ article is misleading in the way it reports this matter, when it describes Dr Nick Yim as stating “after promising to cater for areas of ‘high need’, Queensland’s Government has picked a confounding location for its first clinic: central Brisbane”. Perhaps when all the facts are laid out, it will be clear that these clinics do address an unmet area of high need.
It is not in the best interests of the community to oppose alternative models of PHC and does not encourage good multidisciplinary collaboration, regardless of who leads the team. There is no one-size fits all solution to PHC, and if there were, it certainly is not GP-only led care, as it simply does not exist for many underserved communities in this country and never has. The data clearly demonstrate that nurse-led clinics provide a free and readily available service that significantly decreases the costs associated with ED presentation.
Mary’s career spans 40 years both in the United Kingdom and Australia. Mary is Professor Emerita, Susan Wakil School of Nursing at the University of Sydney. In 2003/04 she was the Chief Nursing Officer, NSW Health Department and prior to that was the Foundation Professor of Nursing in Corrections Health, with the University of Technology, Sydney.
Mary is a Board member of Northern Sydney LHD and chairs their Health Care Quality Committee. She also serves on the Health Ethics Advisory Panel to the NSW Minister for Health and the Clinical Governance Advisory Committee to Healthdirect Australia.
Mary was awarded an AM for significant contributions to nursing and midwifery education and healthcare standards in June 2019.
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