News

GP resistance to nurse practitioner Medicare push


Amanda Lyons


24/05/2019 2:36:04 PM

The RACGP has flagged its opposition to a proposal that nurse practitioners be granted more autonomy in patient treatment.

Nurse practitioners.
The RACGP believes the nurse practitioner’s role in healthcare is complementary to, not interchangeable with, the GP’s.

The Nurse Practitioner Reference Group (NPRG), a sub-committee of the Medicare Benefits Schedule (MBS) Review Taskforce, released its report containing recommendations on Medicare items relating to nurse practitioners in February this year.
 
One of its key recommendations was to dismantle the Medicare requirement that nurse practitioners work in collaboration with a doctor when prescribing and providing patient care, arguing it is an ‘impediment to growth of the role in improving access to quality care for all Australians’. 
 
The report also suggested extending MBS rebates to include nurse practitioners in item descriptors for team care arrangements, health assessments, urgent after-hours home visits and aged-care services, and significantly boosting the rebates for existing nurse practitioner attendance items.
 
‘Basically, the NPRG has claimed that nurse practitioners could provide almost all the services currently provided by GPs so long as they have access to the same MBS item numbers and ability to order investigations,’ Associate Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), told newsGP.
 
‘The NPRG claims this will provide choice for patients to select nurse practitioners for their primary care needs and that they will plug current access gaps for vulnerable or remote patient-types.
 
‘The NPRG further claims that allowing open access to the same patient rebates and referral rights as GPs will reduce fragmentation.’
 
The MBS report cites research that shows ‘the net benefit of care facilitation services provided by a nurse is seen to be equal to that of a primary care provider or other allied health practitioner providing expert care’.
 
But Dr Michael Wright, Chair of the RACGP Expert Committee – Funding and Health System Reform (REC – FHSR), strongly disagrees with this finding.
 
‘Nearly 90% of patients see a GP every year, and so I don't think access to primary care services is the problem,’ he told newsGP. ‘Previous reports from the MBS Review Taskforce have suggested the stewardship role of general practice should be strengthened.
 
‘Proposals such as the NPRG’s will do the opposite, leading to fragmented siloed services, worse health outcomes, loss of important health information, and further diluting funding from front line general practice services.
 
‘What we need to be doing is linking services better, support providers to communicate safely securely and consistently, and investing in general practice.’
 
Associate Professor Morgan believes the more comprehensive training received by GPs better equips them to handle a wide range of healthcare concerns.
 
‘General practice training involves extremely competitive entry to medical school, six years’ Australian Medical Council-accredited intensive training, postgraduate training of four to five years, Fellowship examinations, continuing professional development,’ he said.
 
‘This results in a workforce able to manage undifferentiated presentations, emergencies, complex pharmacology decisions, multi-morbidity, thousands of medical conditions including rare conditions, and deal with multiple agenda items within each consultation.’
 
Associate Professor Morgan is also concerned that the adoption of the NPRG’s recommendations would lead to growing disadvantage for some parts of the Australian population.
 
‘It would be a dangerous precedent for Australia to accept a two-tier version of primary care, where comprehensive expert care is available in some areas and for some people, while allowing a lower level of autonomous care to replace GPs in other areas,’ he said.
 
RACGP earlier this week sent a submission to the MBS Review – NPRG, outlining its concerns that the report’s suggestions would result in fragmentation of patient care.
 
The RACGP makes it clear that it is not opposed to nurse practitioners in general, encouraging their role within GP-led general practice teams.
 
‘Nurse practitioners can and should continue to work within GP-led collaborative models. They have an important role working within general practices and greatly add to the primary care workforce,’ Dr Wright, who led the development of the RACGP’s submission, said.
 
‘But adding new groups of health professionals into primary care, and presuming that the complexity of general practice can be distilled into treatment of single conditions, is a mistake.’
 
In line with its Vision for general practice and sustainable healthcare system, the college would like to see increased funding to support more team-based healthcare, as part of an overall boost in general practice funding.
 
‘Rather than shifting funding to other primary care providers working in isolation, a better approach would be to increase funding for GPs and practices so they can better provide acute and preventive care, and coordinate care for patients,’ Dr Wright said.
 
‘The Medicare freeze has removed $1 billion-worth of funding from general practice services.  This funding needs to be restored and further increased to strengthen the delivery of primary care. The proposals from the NPRG group will not do this
 
‘I would be concerned that this proposal will lead to more fragmentation and more siloed care, leading to worse health outcomes and long term increases to health spending.’



MBS Review Medicare Benefits Schedule Review Nurse practitioner reference group Nurse practitioners



Dr Arshad Merchant   25/05/2019 6:28:16 AM

Nurse practitioner role should be restricted to one area eg warfarin management, emergency department, with community nursing or palliative care. Their scope beyond this is dangerous. You cannot replace a speciality trained Fellowship GP with a nurse practitioner, it's like you know how to wash a car so next I can fix the engine,


Dr. No   25/05/2019 7:01:33 AM

Insane. The education nurses receive pales in comparison to doctors - they are not interchangeable. Just look at how many nurses hold anti-science ideas compared to doctors - anti-vaccine, homeopathy, reiki and assorted other nonsense ideas. They don’t have the foundational knowledge to understand why they’re wrong.
A former friend who is an NP actually believes that if you put a ring or pendant on a necklace and hold it up, you can ask it yes/no questions and judge the answer on the way it moves. She also believes a friend with stage 4 breast cancer is still alive due to her raw diet, instead of recognising her friend is adding to her own suffering. Yeah sure, she should provide primary care - what could go wrong?


Dale van der Mescht   25/05/2019 7:14:14 AM

It seems like everyone can do a GP’s job better than a GP. I’ve said this before and I’ll say it again.... the sooner you can get out of clinical patient contact the better. We are already “just a GP” now we will be “oh, so you are like a primary care nurse, don’t you want to specialise?”


Luke Eldridge   25/05/2019 9:18:57 AM

I find elements of the comments made thus far offensive, ill informed, arrogant and fundamentally child like. Just disgraceful. I’m an NP with 8 years undergraduate and post graduate education, with over 20 years experience in my specialty. I’m pretty sure I know how to manage my patients in a safe and effective manner. I readily collaborate on a daily basis with my medical coworkers to ensure optimal patient outcomes. As health care “professionals” , taking cheap shots like those I have read here, says more about the author if anything else.


Rosanna Devlet   25/05/2019 9:30:20 AM

I couldn't believe it! It makes me think, why did I go through all these exams, to confirm that I am safe to work in this country as a GP, even if I had more than 20y experience in my country. In general I studied 15y altogether to be what I am now. And my role is leveled to a nurse specialist. I think now Australia won't have problems with shortage of doctors, nurse specialist could do the same


Nurse Yes   25/05/2019 10:16:27 AM

The real reason the doctors are against Nurse Practitioners is because they feel threatened. I know some crazy doctors out there as well. I have also stopped doctors from accidentally killing patients, yet I have never had to stop a nurse from accidentally killing a patient. Just remember guys that nurse practitioners have to complete a masters to become a nurse practitioner. It is my professional opinion that nurses should be at a certain level of experience and have qualifications to prove it before being allowed to start their masters in nurse practitioner.


Dr Nurse   25/05/2019 10:37:16 AM

There are many people like me. Nurses who have become doctors. Many of us worked in cutting edge areas requiring advanced skills and knowledge. The thought that nurses with a two year Masters degree can replace those who were able to get in and out of medicine and suffer the rigours of training before passing fellowship exams is ridiculous. And terrifying! The danger to the public is NPs not knowing what they don't know. If they really think they are equal, lets see how they go with the RACGP exams. Not NP nursing assessment. Crazy thing is, its seems to be that everybody wants to play doctor without doing medicine. Quite frankly, they are welcome to it, and the litigation that will take them down as a consequence of them thinking that they are better and more knowleagable than they are.


Omar Akram   25/05/2019 10:39:31 AM

Wow. Since when did nurses become doctors?
First it was pharmacies offering health checks and flu vaccines and now nurses providing primary care. At the end of the day it comes down to $. Patient safety and outcomes is always secondary


Lachlan Brown   25/05/2019 11:57:01 AM

I have already had the experience of two different aged care facilities calling in nurse practitioners to see patients instead of ringing me. On each occasion unnecessary prescribing decisions were taken, one of which was dangerous, which I then had to undo. Nurse prescribers do well in specialised roles, but they are not GPs. If nurses want to become GPs they should do GP training as many have already done.


TR   25/05/2019 12:57:14 PM

Primary care diagnostics is actually highly difficult, a fact which politicians and economists do not understand. I was actually misdiagnosed by a NP in the UK where nurse practitioners are common. She completely misdiagnosed pyelonephritis even though I actually told her the diagnosis, because the presentation did not fit the algorithm she was working from. I had to beg for antibiotics and even then she was reluctant, basically told me I was imagining the symptoms. Ended up in hospital a few days later on Gentamicin. Most patients will be fit a pattern but certainly not all - duplicating GPs with NPs will simply fragment and will not be any cheaper, in fact it will certainly increase the cost of the Medicare Benefits scheme. Also the large working party was entirely made up of nurses except for one person. Is this not a conflict of interest?


DR. AHAD KHAN   25/05/2019 5:30:38 PM

There is a saying : " Half a Physician is a DANGER to the Community "

If these Nurse Practitioners want to FUNCTION as a GP & be PAID like a GP, then they should undertake a Rigorous MBBS Course - follow this with Hospital Internships - & follow that with a GP Registrar Training Course.

This is a Quintessential Requirement, before a MBBS is let loose on the Community.
The SAFETY of the Populace is of paramount importance.

There is a Saying : " Half a Physician is a DANGER to the Community.

These NON-MBBSs will never know what they do not know.

There is another Saying ;
" The One who Knows that he Knows not - Teach him
The One who Knows that he Knows - follow him
The One who knows not that he Knows not - BEWARE of him.

DR. AHAD KHAN


Igor Jakubowicz   25/05/2019 6:32:36 PM

Nurses in some aged care facilities that I visit aren't even allowed to decide whether a person who's had a "fall" (can be a roll out of lolo bed onto crashmat) needs additional action or not! Protocol is for GP to review within 4-6 hours or need to be sent to hospital. My ED colleague commented that she sees about 5 of this type of presentation each shift.


A Nurse   25/05/2019 7:19:50 PM

Let’s face it, this debate is not about what’s good for the patient or for the community. It’s about money and turf wars. It’s understandable that GPs feel threatened, if they read the evidence coming from the USA where they have had NP since the 1960s, they would know that not only are patient outcomes improved when they see an NP, they prefer to be cared for by a heath practitioner who has time for them and doesn’t just reach for a prescription pad to get them out the door as ASAP. Oh, by the way, there are more and more nurses with PhD every year, and nurses are getting qualifications from medical schools too. If i was a doctor my masters qualification from an Australian medical school would give me a masters in medicine. NP don’t want to be medical doctors, if we did we know it would take less time then getting our multiple masters qualifications and NP qualifications. We also know we would earn more, but we just want to improve patients health without having our hands.


Amanda   25/05/2019 7:54:08 PM

As a NP with 3 university degrees, over 10 years of post-graduate experience, I find the cheap shots very offensive.
I have GPs begging me to see their patients because the GPs are not extensively trained in that specialty. They ask for me to diagnose, prescribe and manage their patients. If GPs were so perfect, knowledgeable and special as you feel, then why not manage all aspects of a patient. Why even refer to specialists?

All NPs specialise in a certain area. They are great in their respective fields. We had to undergo extensive training within our Masters degree, hundreds of supervision hours, be assessed in front of a panel of pharmacists, health professionals, consumers, professors etc. We are not taking away your degrees and years in training to become a GP. NPs are just saying we can help out in our respective specialty areas, but don't need hand holding with a collaborative arrangement.


Helen   26/05/2019 10:19:59 AM

Wow i cant believe the insults to specialist nurses such as NPs. They do many many years of training and assessment to achieve this. They are not just any old nurse! The country areas of australia are in dire need of them. Some of the overseas GP’sthat are sent to the country have less training than the NPs! Many GP’s-refer to these specialist nurses for their advice ,so please don’t discount their expertise!.


GM   26/05/2019 1:15:57 PM

In all health professions groups we can find sad stories of poor quality care. So drawing on individual cases does nothing to this conversation. More importantly - look to what the evidence-base says. Multiple studies have shown that nurse practitioners provide as high a level of quality in the specialty areas and are accepted by consumers as an alternative to healthcare. Sometimes, given their long experiences and large network of professional colleague, nurse practitioners have a better understanding of the nuances of their specialty area. They are also very good at understanding their scope and seeking assistance when during the diagnostic period they identify issues or markers outside their experience. This can only help patients get to their essential healthcare treatment more promptly. Ultimately, the scare tactics are refuted by quality research.


DR. AHAD KHAN   26/05/2019 3:42:29 PM

Regarding Comments by ' A NURSE ':
" Let’s face it, this debate is not about what’s good for the patient or for the community. It’s about money and turf wars. It’s understandable that GPs feel threatened, "

This Debate is most definitely not about 'Turf wars '.
This Debate is also not about GPs feeling 'Threatened '

This Debate is only about Safeguarding the innocent populace.
This Debate is only about the threat to the innocent populace, that unsupervisedNurse Practitioners will pose.

Even with a Basic MBBS Degree + Hospital Internship, the College of GPs , feels that this doctor is unsafe for the innocent populace, unless this Doctor does GP Registrar Training. Only then is the RACGP confident of letting Loose this Doctor into the Community unsupervised -
Such is the high standard of primary care that the innocent populace deserves.

Unsupervised Nurse Practitioners will be a serious threat to the Well-being of the innocent populace.

With grave Concerns,
DR. AHAD KHAN


NP   27/05/2019 12:04:41 AM

I am a Diabetes NP. I would love to provide GP's with education on how to manage a newly diagnosed person with Type 1 Diabetes in General Practice. Just last week I sent another young patient straight to ED as the GP had failed to provide correct care/ did not check ketones (BGL 26) and did not recognise the symptoms of DKA. Unfortunately this happens all too often and is very concerning. So with my 'useless nursing skills', I saved a persons life last week.... yet again.


Luke Eldridge   27/05/2019 6:56:07 AM

Wow, and the hits keep on coming. Such insightful and articulate comments from our superiorly educated medical colleagues. Again, baseless cheap shots at low hanging fruit.


jiwan jyoti   27/05/2019 11:13:31 AM

if they think they are good as FRACG or MBBS why not they go and do degree in Medicine and Fellowship in RACGP
it will solve the whole problem we do not like to fight with any one


Dr Catherine Brooker   27/05/2019 10:06:58 PM

I'm a GP and I agree with the comments of the NPs above (Amanda, GM and NP) who discuss SPECIALIST Nurse Practitioners who I agree are fabulous. I have worked alongside specialty NP's often and am quick to admit that in their area they know more than me and have, and continue to teach me a lot.
GENERALIST NPs are a completely different thing. I have left a work place because of the danger that generalist NPs have subjected my patients to. In two separate city jobs NP's have left me extremely concerned for patient wellbeing. For inappropriate choice of inx (often wasteful), for lack of micro knowledge, for inability to make a clinical diagnosis, for lack of capacity to know when to consult specialist colleagues, for medicolegal issues, and ultimately for patient safety. I understand and have seen the place for generalist NPs in remote areas (with GP oversight from afar). In the city need does not outweigh the danger and also expense of inappropriate management.


DR AHAD KHAN   28/05/2019 7:13:14 PM

Dr. Catherine Brooker, I totally agree with with your Summation Opinion.
Like you, I too have absolutely no problems with Specialist Nurse Practitioners - they have developed Skills in a Limited Area of General Practice - Diabetes or Renal Dialysis , etc.

But, the Issue is about GENERALIST Nurse Practitioners & not NPs who have developed some Skills in limited Areas of General Practice.

General Practice covers a wide Spectrum - from O & G / Orthopoedics / Cardiology /Dermatology / Neurology / Urology/ Respiratory Medicine / Endocrinology / Paediatrics / Oncology / Palliative Care, etc .

It takes years of Training Post- MBBS, to be able to muster the Confidence to deal with this VAST SPECTRUM of GENERAL PRACTICE.

It is only when the College of GPs deems a Doctor to be SAFE , that they let this Doctor loose on the Australian Populace.

I have GRAVE Concerns for the Populace , if these Generalist NPs are let loose, UNSUPERVISED.

DR. AHAD KHAN


Toni   29/05/2019 1:31:08 PM

Dr Khan,
Many of us in specialist roles are fighting for a fair Medicare rebate system. My list for seeing Diabetes patients is booked out sometimes up to 6 months- I just Accepted a university lecturer position as I can not sustain private practice employment. Fortunately I still work one day a week with an endocrinologist (who values my expertise)
So 6 months list of patients (5 days a week) are now going to clog up the already bursting at the seams acute care facility. This is why we are fighting for recognition. Many of us are specialised and we deserve recognition for the excellent work we do in primary care. There are hundreds of studies proving our valuable work. We don’t deserve insults


Anne Booms   29/05/2019 4:09:29 PM

I am a NP in Palliative Care and enjoy the collaboration I have with specialists and GPs. I am an extension to their practice. I learn and teach. I believe the GP is the patients primary care provider and should take the lead on patients management. In saying this, I provide expert consultation and care in the palliative care field. Some extra MBS item numbers would be welcome to cover my cost of travel, an hourly consult, time to refer patients, write letter to patient and GP and clinic location costs... at the moment, I have max 49.80 before tax dollars per 40 min consult to cover all this.


NP   29/05/2019 9:03:25 PM

There are valid points to both arguments without a doubt. As an NP in Wound Management I get frustrated by both my medical colleagues and fellow NP's that seem to think an NP qualification allows them to fly without wings in specialist fields I which they have no post graduate qualifications. I have spent over 25 years in my specialist field and acknowledge my limitations in this area and certainly outside of this. If the NP role is to be respected and recognised work within your scope, share your expertise and acknowledge your limitations to ensure best outcomes for your patients. The ACNP should be focusing on strengthening the value of the NP role and being more politically savvy in its approach to improve the NP workforce in Australian Healthcare. More Medicare numbers is not necessarily going to improve outcomes better acknowledgement, collaboration is a better approach.


DR AHAD KHAN   29/05/2019 9:43:25 PM

Toni,
As I have said before, I will say it again : I have no Problems with Specialist Nurse Practitioners like you, who have developed Skills in one particular Field ( may it be Diabetes / Palliative Care / Renal Dialysis etc. ) , from the very Vast Spectrum of General Practice. I have Respect & Admiration for Specialist Nurse Practitioners, & I have never meant to ' INSULT ' any Specialist Nurse Practitioners.

My CONCERN & it is a GRAVE CONCERN - I dread the very Concept of Generalist Nurse Practitioners , as I fear for the SAFETY of the Populace
I have genuine Fear for the SAFETY of the Innocent Populace.

The College of General Practitioners is endeavouring to Safeguard the Innocent Populace by making Doctors undergo Vigorous Trainings, before they will consider this Doctor to be SAFE enough to let loose on the Populace, UNSUPERVISED .

' Generalist Nurse Practitioners ' will be a SAFETY THREAT to the Innocent Populace.

with kind regards,

DR AHAD KHAN


May   30/05/2019 11:54:32 AM

Why can’t GPS utilise NPs in their clinics like is the norm in UK? I am trained in Primary Health Care and don’t for one minute believe I endanger patients lives (as raised by Dr Khan). NPs work within their scope and seek consultation for any presentation outside that. I worked with a group of GPs and was well accepted, including attending GP education sessions. Shame about some of the opinions expressed here, you are really discounting a valuable asset to your General Practice.


NP   30/05/2019 11:58:41 AM

As a Nurse Practitioner working over 30 yes in Addiction with Mental Health and Addiction masters degree I know my clients or the general public are treated with respect when seeking medical support to crease it refuce their substance use...GP unfortunately do not know how to manage this client base and refer to my practice...yet I am not paid at a professional level because nurses are not specialist...come on...Clinical psychologist are better paid with much less experience then any Nurse Practitioner from any find I have meet..
Nurse Practitioners are asking to be considered and treated as equal to Clinical Psychologist who be the wat for not prescribe medications order pathology and monitor clients through treatment.


DR. AHAD KHAN   30/05/2019 3:23:14 PM

Responding to ' May ' comments, I would like to clarify my earlier Statements.
I have full Respect for Specialist Nurse Practitioners working in only one select area - like Palliative Care / Mental Health / Diabetes / Renal Dialysis, etc

But, UNSUPERVISED GENERALIST NURSE PRACTITIONERS will pose Safety Concerns for the Populace.

DR. AHAD KHAN


doc   1/06/2019 11:32:31 AM

As NP said, as you specialise in a field, obviously you want to get recognised , as a GP I would be more than happy to refer as we do for diabetic educator or dietitian(in a specific field what you specialise ) while getting an report from you as well rather than working individually or work as a naturopath and bill private. There should not so called Generalised NP. As you all said, yes there would be GP who dont implement as knowledge fully , can you guarantee all NP would? All fields have outlines, not all lawyer fight for right not all accountant would be good on accounting . when I was still in medical school, one of the professor surgeon said, if we train a butcher to do surgery for 3 years , he would be better than any surgeon , that donest mean it would be allowed. Its all about qualification what you are supposed to do hope this helps


Dr Gillian riley   1/06/2019 11:43:49 AM

If anyone thinks more items will be added to medicare and more funding allocated to primary care, you’re mad. The government will not do anything to allow an expansion to primary health care item number use: which is precisely what this will allow.

In terms of health care outcomes for the population anyway, a two tier system of generalist nurse practitioners operating in urban areas offering parallel services to existing general practice isn’t really in the best interest of the population?

I have no doubt specialist nurse practitioners in specific fields: diabetes, mental health, palliative care, wound management I can go on - offer excellent care. If we all really want to help patients shouldn’t this be the target of the funding rather than tussling over who’s going to see the undifferentiated patient?

It’s getting tiresome.

And to the poster above who cites evidence from the US: the caveat is: there’s no robust system of general practice in that country!


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