A general practitioner will be required to supervise nurse practitioners as they administer the COVID-19 vaccine, a decision that was made without concerns of health and safety. This means under-resourced and at-risk communities will be slower to gain access to the vaccine,
The ABC reports that “under the federal government’s COVID-19 response, nurse practitioners can only give the coronavirus vaccination while being supervised by a general practitioner or ‘suitably qualified health professional’ while working in a private setting.” It seems remarkable that nurse practitioners, our most experienced, our most regulated and our highest educated clinical nursing personnel have been overlooked in this way.
Because by and large, despite the GPs worrying about the “business model” and the amount they are going to receive per jab it won’t be the GPs who are giving the vaccinations. It will be nurses. AMA President Omar Khorshid, speaking about the MBS item payment for COVID-19 vaccinations, pointed out back on 27 January this year that:
“This is not intended to be an item where a GP spends 15 or 20 minutes with a patient. This is a ‘for and on behalf of’ item where a practice nurse follows a fairly expeditious sort of process where consent hopefully is done in advance. Hopefully online. Essentially it will work so the patient comes in, gets their vaccine, is observed for a while and leaves. Yes, there are other tasks there, but they’re largely done by someone other than the GP”.
So who might that “someone other” be? Well, happily Geir O’Rourke fills that gap in for us on 24 February.
As expected, the suitability assessment and the administration of the vaccine can be done by a registered nurse or other suitably qualified health professional registered with AHPRA, as well as GPs. And vaccines can also be provided by an enrolled nurse, however, they have to be under the supervision of a registered nurse and they must have completed the mandatory COVID-19 vaccination training.
And of course, it is a relief to know that the registered and enrolled nurses will have undertaken the mandatory vaccination training because the Royal Australian College of General Practitioners described the very same training as a “time sink”.
The GPs employ practice nurses, who are usually paid a salary. The work the practice nurses do is reimbursed through Medicare payments as work done “for and on behalf of” the GP. So, if the work of the practice nurse is increased by the introduction of COVID vaccination clinics, it would be lovely to imagine that the salary of the practice nurse would also increase, due to their ability to undertake further work “for and on behalf of” the GP, for which the GP can claim the new item numbers and thus generate extra income. If this were not to happen, the result sounds a lot like what Marx described as “surplus labour” – The “surplus” in this context means the additional labour a worker has to do in their job, beyond earning their keep.
In New South Wales, a large proportion of the vaccinations will be given by “authorised nurse immunisers” (ANIs) – in other words, “Registered nurses and midwives …[who are] appropriately trained and accredited to deliver immunisation services and administer vaccines as an Authorised Nurse Immuniser”
These ANIs are differentiated in the Policy Directive from “registered nurses and midwives who have not completed the specified training but who may administer vaccines under the direction and authorisation of a medical officer or nurse practitioner”. It is worth noting this policy directive makes no distinction between the ability of a medical practitioner or a nurse practitioner to direct and authorise a nurse or midwife who is not an ANI. If they are an ANI (and have also completed the mandatory COVID -19 vaccination training) then they will be able to vaccinate without the direction and authorisation of a medical practitioner or a nurse practitioner.
Lest you are getting lost in all these different levels of nurses who might be involved in vaccinations generally, there are three levels. The most senior clinical nurses are nurse practitioners, endorsed separately by the Nursing and Midwifery Board of Australia and able to prescribe medications within their scope of practice (including vaccines) and oversee vaccination programs in the same way as medical practitioners.
Then there are ANIs, who are registered nurses and midwives who have undertaken a rigorous education program and are able to manage their own vaccination programs and clinics once the vaccine has been prescribed. Thirdly, there are registered (and enrolled) nurses and midwives who can give vaccines, as they would give any other medication, under the authorisation and direction of a medical practitioner or a nurse practitioner.
So why on earth, with the COVID response, should it be that “nurse practitioners can only give the coronavirus vaccination while being supervised by a general practitioner”? Because the missing piece of this jigsaw has nothing to do with authorisation, it has nothing to do with safety or quality, it has nothing to do with equity of access. The missing piece of this bizarre jigsaw is in the final piece of that first sentence “while working in a private setting”.
This is about access to the Medical Benefits Schedule (MBS) rebate as payment for privately practising nurse practitioners (PPNPs) who are unable to earn a living unless they are receiving reimbursement for the work they do. Given the response of the MBS Review Taskforce to the need for PPNPs to have greater access to MBS items, it seems inevitable that access to COVID vaccinations payments would be quashed in the same way as every other request for payment raised by the Nurse Practitioner Reference Group of the MBSRT.
What do we know about PPNPs? We know that they tend to work with underserved populations: indigenous groups, remote groups, people with chronic and complex care needs and people with chronic mental health problems.
We know that they did this hidden work critically during the COVID -19 surges last year and that several of the populations they served would not have received care at all had they not lobbied for access to PPE
We know that the safety and satisfaction record of care by NPs in general, as well as PPNPs, is second to none. That they are safe, effective and appreciated and that they provide equity of access to care.
And yet, once again, this same group of PPNPs are being subjected to the humiliation of being told that they cannot serve their clients unless they are supervised by a medical practitioner – someone who is considered in health policy documents to be their equal, not their superior.
The Federal government is at extreme risk of missing out on the opportunity to facilitate access to some of the most vulnerable groups in the country, groups who don’t have a GP and would be unlikely to make a booking for their vaccination unless it was with a trusted clinician – in this case, a PPNP. That the government has taken the advice to travel down this road of the supervision requirement seems, as I have observed before, “perverse, offensive and oppressive.
But it is worse than that. It is uncaring and thoughtless, as it pays scant regard to the needs of the groups for whom the PPNPs care.