If we want to improve the health of Australia, we cannot continue to under-use the largest workforce in primary health care.
There are 91,000 nurses in Primary Health Care (PHC) in Australia (including aged care) making it the largest workforce in the sector. (DoH, National Health Workforce Dataset). Australia’s use of this workforce goes largely unexamined and is poorly understood. Their daily work is not visible to policymakers because it is not captured in any of the data used by government. The annual Australian Primary Health Care Nurses Association (APNA) Workforce Survey provides a few pointers as why this workforce is critical and needs to be better utilised to meet the health challenges faced by Australia.
PHC nurses are highly motivated, highly educated and highly experienced. Thirty-two per cent have completed or are currently studying for a post-graduate qualification. On average a PHC nurse has 21 years nursing experience and 11 years’ experience in primary health care. The survey shows that nurses are ready, willing and able to do more, but are held back by the structures in the health system.
An example of this is the low utilisation of the workforce to its full scope of practice. The 2021 results show that 34% of PHC nurses were either never or rarely used to their full scope of practice during the pandemic. Typically, this utilisation only sits between 42%-46%. Even in a pandemic, with a health system under incredible strain, our system was unwilling to use nurses to their full capability. Although nurse practitioners are well utilised in the public sector, in PHC, where they could play a vital role in both support and supplementation of the medical workforce, the resistance to Nurse Practitioners(NPs) working to supplement PHC where no medical practitioner is available is still maintained by major medical groups. This opposition cannot be in the best interests of patient care, when NPs have demonstrated themselves to be excellent, safe and highly skilled practitioners in the public sector.
A range of issues impact full utilisation including: funding models; understanding of the nurse scope of practice; regulatory barriers; inadequate access to systems and infrastructure and cultural barriers. As we emerge from the pandemic and as the new Labor government begins to address the challenges facing the health system, we cannot afford to perpetuate inefficient models of care that sideline nurses, the largest health workforce.
These need to be addressed by a range of stakeholders, including federal/ state governments, employers and peak bodies, to ensure a more accessible, sustainable, efficient and effective health system. The underutilisation of nurse skills represents a significant lost opportunity for the Australian health system, patients and employers. The Survey shows that the main reasons cited for not allowing nurses to do more were lack of financial incentives for their employers and resistance to change from current fiscal stakeholders.
In primary health care it is very difficult for a single medical (or other) practitioner to manage large numbers of people with ongoing, chronic complex care needs. And the patient load is not going away. Not every patient needs to see a doctor every time they visit a primary health care setting. Many patients can and are managed by a nurse for chronic disease management, lifestyle and self-care support visits, immunisation, dressings, and care coordination. However, the system consistently undermines this. A good example is general practice where, under the current system, a doctor needs to ‘tick off’ an activity performed by a nurse, so that Medicare Benefits Schedule billing can occur, even when it is completely within the nurse professional scope of practice. On many occasions, the patient may have booked in for a dressing or immunisation, and the doctor is required to pop their head in the door to simply say hello, in order to claim an MBS payment. Even though the work was performed by the nurse, it can only be claimed if it was ‘for and on behalf of’ the medical practitioner. This is a waste of the medical practitioner’s time and an insult to the professionalism of a registered nurse (RN) working well within the RN scope of practice.
If Australia took up the recommendations of the Primary Health Care Advisory Group in 2015, we could remodel our system to share the load of care in a more patient-centred, team-based model. This is built around the quadruple aim for health care including a vision for better outcomes, improved cost-effectiveness, improved patient access and satisfaction, and equally importantly for recruitment and retention, improved health professional sense of satisfaction.
While COVID-19 has delayed a number of reforms, it is integral that Australia responds to the lessons of this pandemic and takes meaningful steps to release the potential of nurses within primary care.
If we want to improve the health of Australia, we cannot continue to under-use the largest workforce in primary health care. The health system is capable of rapid change. COVID has proven this. Let’s not bury the change that’s manifestly needed in yet another round of consultation.