The Strengthening Medicare Taskforce: Commonwealth must resist lobbyists and embed team-based care
Sep 21, 2022
The Strengthening Medicare Taskforce must set aside the tired, unhelpful trope that care is about choosing between a GP, or a pharmacist, or a nurse. Health care professionals are complementary to each other and provide better care working as a team.
Following the outcome of this year’s Federal Election, Health Minister Mark Butler convened the Strengthening Medicare Taskforce (SMT). The Department of Health and Ageing website identified the role of the SMT as having five aims. Somewhat confusingly, at its first meeting, the Taskforce established five focus areas to guide its recommendations to the Australian Minister of Health and Aged Care.
The second focus area of the SMT is ‘Increased access to multidisciplinary care, harnessing the full skills of nurses, pharmacists and allied health professionals.’ This is in line with the third aim of the role of the SMT set out by the Department of Health and Ageing, which is to “mak[e] primary care more affordable for patients.”
Team-based, multidisciplinary care
Healthcare is a team game, and a patient is best served when every discipline within that team is able to play their part to the fullest extent. Multidisciplinary care (MDC) has been shown time and again to provide high patient engagement and strong patient outcomes. But it also benefits the practitioners who are more likely to enjoy their work and therefore remain in healthcare.
The politics of healthcare tends to follow a tedious binary narrative -the idea that care is about “either/or”. A nurse practitioner OR a general practitioner must diagnose a patient. A pharmacist OR a nurse must immunise. A nurse OR an allied health professional must write a care plan. This tired, unhelpful trope ignores the reality of modern healthcare. Health care professionals with different areas of speciality, knowledge and expertise are complementary to each other’s work and, by working as a team, generally provide better care and better outcomes for the patient.
But health professionals haven’t traditionally been taught to work in teams. Curricula with increasing amounts of specialisation generally enforce the primacy of the profession being taught. This is then reinforced by funding systems, once training is complete. This leads us to a health system that is ill-prepared to work cohesively and often constrained from doing so.
The Commonwealth could embed better team-based care practices by:
- considering directing much of its continuing professional development funding into team-based training
- Reviewing funding models to incentivise team-based care, thus enabling all health care professionals to work to their full scope of practice.
- Building team-based care into all health care professional workforce strategies
- Updating current health care curricula to enhance team-based working in primary health care settings
Barriers to implementation of multidisciplinary care
The difficulties for the implementation of this third aim of the Strengthening Medicare taskforce are financial, structural and political. In relation to the financial problems, the funding model for general practice has not been constructed in a way to use the full skill set of all health professionals. It quite specifically excludes health professionals such as nurse practitioners and also limits the ability of many other professionals to refer for specialist treatment, diagnose and prescribe.
in relation to funding, the days when general practices were solely owned by general practitioners has long gone. Current estimates are that ~25% of general practices are owned by GPs, with the rest run by corporate entities, often backed by venture capital funding.
Accepting this, it is time to recognise that working with other funders and owners of general practice is required. Working closely with the states and territories to have government owned and run general practices is an obvious pathway. Likewise, why couldn’t the Commonwealth own and run general practices in poorly serviced communities? Exploring these options could combine the states’ and territories’ (traditionally more efficient) use of health professionals with the structures of the Commonwealth.
The Commonwealth could enable better care by:
- Enacting funding models that support the provision of care to the 20% of Australians (5.4million people!) who do not have a regular general practitioner.
- Mapping a plan to transition away from fee for service funding to a sustainable value-based funding model
- Reviewing the potential for government-owned general practice models
- Incentivising health professionals to perform to perform to their top of scope by remunerating the most competent but least expensive health professionals to perform specific health services
Lobbying efforts on behalf of general practice owners to control the flow of funds, whether the owners are commercial entities or general practitioners themselves, have been very effective. This lobbying has left the Australian public with the misguided impression that general practitioners have to be the employers and controllers of all other professions working within general. practice.
However, in reality this is not the case. Currently, ~80% of allied health professionals and ~25%-30% of the nursing workforce work in primary health care, inside and outside of general practices. For the past decade, the APNA Workforce Survey has showed that ~40% of nurses (the largest workforce in primary health care) are never or rarely used to their full scope of practice. Anecdotally, this rate is similar for allied health professionals. This is a ridiculous waste of potential and professional expertise.
With a poor track record for using nursing and allied health professionals effectively, the question that the SMT must consider is the value of the Department’s second aim for the role of the SMT. The SMT must ask “who would be advantaged by continuing a structure that enshrines the GP as the only employer in Commonwealth policies for multidisciplinary care?” This structure is failing financially and failing to attract new general practitioners whilst concomitantly underutilising nursing and allied health, the largest sections of the primary health care workforce. The Practice Nurse Incentive Payment (PNIP) was designed by the Commonwealth to enhance the use of practice nurses in general practice by providing funding to GPs to expand their scope of practice. However, a review of this this program was funded by the Commonwealth and found to be flawed on multiple levels: in fact, the review found that the PNIP structure actually constrained the practice nurses’ scope of practice. The somewhat unusual response from the Commonwealth was to expand the program to enable GPs to employ more nurses and allied health professionals, renaming it the Workforce Incentive Program (WIP), and including allied health professionals and pharmacists.
In fairness, these disappointing models of wasted skill and capacity cannot be laid purely at the feet of general practitioners and practice managers. They themselves are both structurally and politically constrained by the Medicare funding model and the outmoded item descriptors that often limit the role of nurses and allied health professionals to bit players in patient care. This is a huge, missed opportunity when these health professionals could be actively advancing the health care of a patient with all the autonomy that their education and training allows. Any and all of the other health professionals in the team could lead a multidisciplinary care team, and the criteria for team leadership might most sensibly meet the primary needs of the patient. There are multiple avenues for communication and consultation with other members of the multidisciplinary team that would minimise fragmentation of care.
The Commonwealth could ensure better utilisation of all health professionals by:
- Amending the WIP program to ensure there is accountability for government funding that is tied to full scope of practice work by nurses, pharmacists and allied health professionals.
- Amending Medicare item descriptors to remove ‘for and on behalf of’ terminology, except where supervision of a second health professional is required.
- Ensuring access to funding models that enable existing health professionals to remain in the community, meeting its health needs to the best of their ability, where there is no GP or limited GP services available to service community need.
- Actively funding nurse-led and allied health-led clinics
The first two articles in this series can be found here:
What the strengthening Medicare Taskforce: Must do to modernise the primary health care workforce
Ken Griffin is the CEO of the Australian Primary Health Care Nurses Association (APNA) and has spent more than 20 years in different parts of the healthcare sector including not-for-profit, life sciences, pharmaceutical and logistics. He has experience in marketing, communications, government affairs and governance and has recently co-authored articles on nurse-led capacity and interventions in autism and disability.
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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