Evidence shows ‘no benefit’ for more nurse-led clinics

Anastasia Tsirtsakis

2/10/2020 3:37:27 PM

The ACT Government’s promise to open five new walk-in health centres has drawn criticism as an expensive and inefficient model of care.

Nurse with arms folded
The average cost to taxpayers per service delivered by a nurse-led clinic is $162.21, compared to $38.22 for a standard Level B GP consultation.

While the total cost is still unclear, ACT Health Minister Rachel Stephen-Smith has said each centre is expected to cost between $2.5 million and $5 million.
ACT Chief Minister Andrew Barr has said the plan will take ‘pressure off our emergency departments’, but Shadow Minister Nicole Lawder thinks otherwise, saying the investment will do little to address the state health system’s significant problems.
‘It doesn’t help with our long elective surgery wait times, it doesn’t help with our emergency department wait times. They’re still blowing out despite the nurse-led walk-in centres we currently have,’ she said.
‘It doesn’t help with access to many, many health services, in which Canberra leads the country in poor results.’
Chair of RACGP NSW&ACT Associate Professor Charlotte Hespe agrees. She told newsGP the move represents ‘yet another silo’ of primary care delivery.
‘It doesn’t follow our whole mantra that the best possible model of primary healthcare delivery is through a GP home,’ she said.
‘Nurses are fantastic at being part and parcel of that, but not when it’s set up as a completely separate clinic that is not actually part of the general practice. Unfortunately, the model that the ACT has been doing is exactly that.’
The average cost to taxpayers per service delivered by a nurse-led clinic is $162.21, compared to $38.22 for a standard Level B GP consultation.
‘This is a very expensive model of care … and the patients very often have to just be sent back to either emergency or to a general practice,’ Associate Professor Hespe said.
‘So it introduces yet another level of inefficiency and duplication of services with very little assurance of who is actually taking responsibility for follow up of care.’
Fragmentation of care is among the concerns cited by the RACGP in its new position statement on independent nurse-led clinics. While it acknowledges nurses’ important role as part of GP-led teams, the college highlights a lack of evidence to support any long-term benefits of nurse-led clinics.
Since the model was established by ACT Health nine years ago, it has yet to be adopted or implemented elsewhere in Australia.
‘The evidence overseas and the Australian data shows no benefit in having standalone nurse-led clinics where not only is it expensive, but you then end up with duplication of services because they still then have to refer to a doctor for the next thing,’ Associate Professor Hespe said.
If Labor is re-elected in the ACT this month and the plan goes ahead, the new nurse-led clinics will be progressively rolled out from 2021, with the first to be co-located alongside the existing National Health Co-operative in Coombs.
Part of the plan is to expand the services being offered by employing more nurse practitioners.
‘Walk-in health centres will have a focus on prevention, early intervention and coordinated care for people with chronic illness,’ Minister Barr said.
‘Nurse-led multidisciplinary teams will work closely with consumers, carers and general practitioners to help keep Canberrans out of hospital and take pressure off our emergency departments.’
But that plan has been branded ‘ridiculous’ by Associate Professor Hespe, who says any chronic disease management should be done ‘under the leadership of a GP’.
‘For goodness sake, who are they doing the chronic disease management for? It makes no sense whatsoever,’ she said.
‘I don’t know who they’ve [Labor] been talking to, but certainly both the AMA and the RACGP are strongly saying this is just ridiculous.
‘If you’re keen to fund and solve the problem, let’s do that, because there’s some great opportunities to do it and do it well, using nurses.’

‘This is a very expensive model of care … and the patients very often have to just be sent back to either emergency or to a general practice,’ Chair of RACGP NSW&ACT Associate Professor Charlotte Hespe said of the clinics.

In a letter addressed to ACT Labor Secretary Melissa James, the RACGP, together with the Australian Medical Association (AMA) ACT branch, Primary Health Network ACT, and Capital Health Network, has called for a commitment to ‘open, public, and competitive tender processes’.
‘Given the potential and significant commercial benefit accruing to a general practice co-located with a new WIC [walk-in centre] … we believe a public tender process is warranted to decide the successful general practice,’ the letter states.
‘[W]e also seek your commitment that the new Molonglo WIC will be put out to tender regardless of today’s announcement. In our view, to do otherwise excludes other local, general practices from the opportunity and may not produce the optimal outcome from the expenditure of $700,000 of taxpayer funds.’
Associate Professor Hespe indicated that GPs had been blindsided by the decision to create more clinics.
‘In all of our negotiations with government to date over this, [there] has been an assurance that they would not go ahead with introducing any more because of all the concerns that we’ve raised,’ she said.
‘So not only did they not consult, they just put it in there. There was no transparency around the appointment of even the first clinic that they’re putting it in.
‘So, although from what I can see it’s co-located in a practice, the other nearby general practices weren’t even contacted to see whether they could also do a similar sort of service. But it’s still not actually a collaborative exercise – it’s still a standalone unit.’
A funding proposal that invests in nurses within general practice, Associate Professor Hespe says, would be of greater benefit to patients and makes more financial sense.
‘They can also fund some services within a general practice that then mean a general practice is more able to do bulk billing for people who can’t afford it,’ she said.
‘At the moment, the problem with most of the practices in the ACT is that obviously the overheads are so high that they can’t actually afford to do bulk billing because [it] just doesn’t cover costs.
‘If it was a partnership about provision of services that aligned with the ability to roll it out, then the GPs would be in a much better position to be able to offer bulk billing. But in a much better model of care because it would be within that whole general practice model that we’re talking about, which is about team-based care, collaboration, better communication, and ensuring that you’ve got safe hand over of care between services as well.’
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Dr Chien-Che Lin, Palliative Medicine Specialist and General Practitioner   3/10/2020 8:15:38 AM

We need to stop using Nurse Practitioners as replacement GPs, and continue to focus on Nurse Practitioners as extensions of specialist hospital services with mandatory GP participation on the front line.