Nurse practitioners hit back on collaboration

Calls to keep the rules governing the way GPs and NPs work together are based on fiction, according to one peak body.

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Nurse practitioners are incensed by the AMA’s calling for current “collaborative arrangements” between NPs and doctors to be retained.

Leanne Boase, president of the Australian College of Nurse Practitioners, told TMR the current arrangements are less about patient healthcare and more about maintaining turf, and were driven by an outdated view of the role of nursing.

The AMA last week raised concerns in its submission to a government review that their removal would risk patient safety and lead to fragmentation of care.

“The AMA considers that any moves to enable nurse practitioners and midwives to practise outside the current arrangements will increase the risks to patient care through the increased potential for missed or wrong diagnoses, increased fragmentation of care and greater duplication of diagnostic and other services,” the association said in the submission.

Collaborative arrangements were introduced under a government determination in 2010. NPs were given limited access to MBS and PBS items – but only if they entered into such an arrangement with a medical professional or an organisation that employs medical professionals.

Without access to MBS items via a collaborative arrangement, NPs would be forced to bill patients privately.

“The collaborative arrangements are purely financial,” Ms Boase countered, “and what they’re suggesting is that these financial restrictions should continue as a way of forcing NPs into collaboration. But if you actually read the determination, it has absolutely nothing to do with patient care and it purely relates to financial arrangements. What it’s doing is applying a financial penalty to patients who do not have a regular GP and choose to see nurse practitioner.”

AMA president Professor Steve Robson said in a statement that “improved access [to healthcare] must never come at the cost of patient safety, and collaborative arrangements provide the necessary checks and balances and support from highly trained medical practitioners”.

And the RACGP weighed in on the issue in its submission to the review earlier this year.

The college said the Nurse Practitioner Standards for Practice do not expect or require NPs “to collaborate with a patient’s usual GP or treating medical practitioner about their care”. The college argued a “formal mechanism” was therefore needed to ensure safe and efficient healthcare.

Ms Boase rejected this claim, noting that the nursing profession’s standards of practice included provisions for collaboration with GPs and others.

To be professionally endorsed, nurse practitioners need evidence that the Nursing and Midwifery Board of Australia’s (NMBA’s) NP standards for practice are being met. Among other things, the standards require NPs to:

• “collaborate and consult for care decisions to obtain optimal outcomes”;
• prescribe and implement therapeutic interventions “within a context of collaboration, mutual trust, respect and cultural safety”;
• use “effective communication strategies to inform … relevant health professionals of health assessment findings and diagnoses”; and
• “develop plans for appropriately ceasing and/or modifying treatment in consultation with the person receiving care and, when needed, other members of the healthcare team”.

The NMBA’s nursing code of conduct also requires NPs to provide safe, evidence-based care in partnership with the patient, and to promote shared decision-making and care delivery between the patient, nominated partners, family, friends and health professionals.

“Decades of international research, including local research, is available and indicates that these types of financial restrictions actually detract from collaboration,” Ms Boase said. “They actually force a wedge between nurse practitioners and medical practitioners and slow that collaborative process down rather than improving it.”

Whether nurse practitioners will achieve meaningful change via the Strengthening Medicare Taskforce remains an open question.

Two taskforce members who could potentially carry the flag for them are Karen Booth, president of the Australian Primary Health Care Nurses Association, and Annie Butler, federal secretary of the Australian Nursing and Midwifery Federation.

“I think they’re two very good voices,” Ms Boase said, “but then again, I think [the taskforce] is a poor representation of the actual health workforce in this country.

“[Nurse practitioners] do not have a seat, and we are one of the health professions where our patients do have some MBS access. However, I’m reassured by the fact that our peak nursing organisations are extraordinarily well aligned and they’ll be able to provide that representation.”

Ms Boase said maintaining the collaborative arrangements would have consequences for some specific parts of Australia.

“GPs certainly aren’t available in every part of Australia,” she said, “so if you’re going to tie nurse practitioner services only to GPs, we have a major issue. We’re not going to be able to address rural or remote health or marginalised communities.

“I think we need some acknowledgement that this is really about turf, because if you look at the evidence, the safety and quality, the actual collaboration, then what remains is for us to fight for the same goal, which is better access to great healthcare.”

Ms Boase said that while there was already genuine collaboration in the treatment room, there also needed to be collaboration around policy.

“The average GP and certainly the vast majority of medical practitioners feel quite differently from the AMA’s position around nurse practitioners, but I’m always willing to talk,” she said. “My job is to talk to people and keep communication channels open. So if the AMA or the RACGP or anybody else wants to have a reasonable conversation, I say that would be a really positive step.

“Everybody should be on the same page regarding access to healthcare. We have significant workforce problems and there’s so little tolerance now for turf protection or argument for the sake of argument. We really now need to buckle down and say, okay, we’re all working to the same goals and it’s not about whether you’re a nurse practitioner or a doctor.”