Helping hands

IF you've been near a GP's surgery in the past few months, you may well have joined the growing band of patients who were cared for by someone like Jill Bruce.

At her surgery in outer metropolitan Adelaide, Bruce provides immunisations, helps new mothers with breastfeeding issues and other baby problems, treats and dresses wounds, takes patients' blood pressure, and does triage _ sorting out which patients need urgent attention. She's a diabetes educator, and runs a clinic one day a week helping patients with the disease to manage their condition.

Next month, she's due to start providing pap smears to check for signs of cervical cancer.

Bruce and other professionals like her are, for a small but rapidly growing number of patients, the face of general practice in Australia. But she's not a GP; she's a nurse. And she's not alone.

A report issued this week by the Australian Institute of Health and Welfare showed nursing numbers on the rise for the first time in five years. The number of employed nurses (excluding those registered but not working, or working in other jobs) rose 3.7 per cent, from 228,230 in 2001 to 236,649 in 2003.

Part of the explanation for this _ and a factor that the AIHW report barely mentioned _ was that since 2001 there has been an explosion in the numbers of general practice nurses in Australia, fuelled by federal government subsidies to encourage more GPs to take them on, and by the creation of new Medicare rebates _ traditionally reserved for doctors _ that apply to their work.

Although some (overwhelmingly rural) surgeries have employed nurses for many years, these incentives have now started to make nurses a common sight in general practices more generally, including in outer metropolitan and inner city areas.

Nurses are becoming a focus of interest for governments around the country, as health officials wrestle with the problem of doctor shortages and climbing medical workloads.

Some of the efforts have focused on tempting nurses no longer in the profession back into the workforce; in other cases, there have been renewed proposals to increasingly set nurses up as autonomous alternatives to GPs, able to diagnose, prescribe and order tests. Only last month Queensland Premier Peter Beattie called for "a robust discussion on how we can spread the load of medical care'', and advocated the greater use of such autonomous "nurse practitioners'' as well as of pharmacists, US-style "physician assistants'' and other health professionals. Queensland is already starting to roll out more nurse practitioners, which until this year were on trial in four sites.

In May, the state created seven more, all in rural areas.

These are controversial developments, especially for doctors' groups who insist nurses must remain under the supervision of doctors.

But this debate has obscured the impact of nurses working within general practices, known as practice nurses. They are not so revolutionary, but they are certainly evolutionary. And for many nurses, these roles are proving popular.

"I prefer it," says Bruce, who now works 2 days a week at the Chandlers Hill Surgery in outer-suburban Adelaide. A few years ago she only did half a day a week in the practice, but that has rapidly increased since the incentives began to apply to outer-urban areas such as hers, in November 2003.

"There's more variety (than in hospital work) - you don't know who's going to walk in the door next. There's different things you are dealing with on a daily basis."

Demand for her services is such that the practice of 12 doctors is planning to increase Bruce to full-time status in due course.

It's clear what's enabling this rapid increase in hours: hefty federal subsidies, worth up to $40,000 per practice. The latest budget in May renewed the original subsidy scheme, which applied to rural practices, at a cost of $129.7 million over four years. The extension of the scheme in November 2003 to urban areas of workforce shortage which also ranked low on the socio-economic scale cost another $78.5 million over four years.

As Medicare rebates only applied to services provided by doctors, that still meant general practices had to pay the nurses' salaries and materials, such as wound dressings, out of their profits (although the subsidies did much to ease that pressure).

But in February last year, the government also introduced Medicare rebates for practice nurses. Initially these were for wound management and immunisation, but in January this year were extended to include nurses taking Pap smears in rural and regional areas.

Accurate figures on the number of practice nurses across the country are not collected, but federal health department statistics show many more practices claiming the subsidies.

Whereas in May 2003 there were only 32 practices in urban and outer urban areas claiming the subsidies, one year later this had soared to 485, and reached 574 in May this year.

When rural and remote practice nurses are added, it means there are now at least 1600 working in surgeries Australia-wide.

Government figures also show that since the new MBS rebates for nursing services were introduced, practice nurses have provided over 3.5 million immunisation, wound management and Pap smear services – 95 per cent of them bulk-billed.

Chris Pearce, a GP involved in a research project looking into the role of nurses in general practice, conducted by the Australian National University and the peak GP body the Australian Divisions of General Practice, says about 60 per cent of practices now have a nurse – probably double the number of 10 years ago. And he says this has created a reservoir of expertise that, properly tapped, promises to improve patient care.

"It increases the range of services that general practices can offer, and the capacity of practices to deliver those services," he says.

"If you are a busy GP, you can structure the practice so the nurse can do some of the work."

The improvements should be evident in terms of better patient outcomes: Pearce says that by doctors and nurses doing what each does best in a team, practices should be better able to run efficient recall and reminder systems to chase up patients where relevant. Nurses can also spend more time with patients than doctors often can, providing a better way of looking after patients with chronic conditions, such as diabetes and heart failure.

Pearce says while this might all add up to better care, a Cochrane review published last October shows that nurses are not necessarily cheaper.

But he does believe nurses could be doing more in the GP setting – looking after heart failure patients, adjusting dosages of medications and improving monitoring to keep them out of hospital.

Some nursing bodies object to the practice nurse model, claiming it is preferred by doctors as another way of keeping nurses in a subservient role (a criticism Pearce says embodies an old-fashioned view of their respective roles.

The AMA last month issued a policy statement on practice nurses, flatly opposing the independent nurse practitioner model and calling for "clear and agreed practice protocols" to guide how practice nurses should work.

Although the proliferation of practice nurses signals less of a turf war than more independent nursing models, their arrival does pose questions for the future shape of general practice.

As Pearce puts it: "If the doctor's role is to diagnose and manage medication, and the nurse's role is to manage care – and then the nurse does the diagnosing – what does the doctor do?"

Article from www.theaustralian.news.com.au