“Chief nurse makes inflammatory claim”. Even though this headline only made page two of NZ Doctor a decade ago, it was sufficiently amusing to my GP Adviser colleague at the Ministry of Health for him to blow it up large on the photocopier and stick it on the pillar between our desks!
The ‘inflammatory claim’ referred to a comment I made about nurse practitioners’ diagnostic skills at the 2008 launch of a DVD and other resources created to celebrate the first 50 nurse practitioners (NPs) in New Zealand and promote the role to potential employers.
Fortunately I wasn’t alone in being castigated by GP leaders, as the same piece included a similar shock and awe response to then Minister for Health David Cunliffe referring to NPs as being able to “independently” diagnose and prescribe.
Thankfully we have moved, by and large, away from such reactions, yet it was only this week that a Minister for Health once again nailed their colours to the mast when David Clark said he waspersonally convinced of the value of the NP workforce.
Ten years is a long time to wait for a repeat, definitive Ministerial endorsement. But it satisfying to have this testimony to the enduring hard work of all those who have sought to drive home the utility of NPs, seemingly amidst the ongoing clamour for the need to ‘train’ and deploy ever more increasing numbers of GPs. I don’t want to get all ‘inflammatory’ again though, so let’s leave it there – the Minister is on the record now and that is great news.
The reason there has been angst in the past is that NPs and their advocates have had to gain recognition through quoting studies indicating NP patient outcomes are at least as good as those of their medical colleagues – particularly in primary health care. This research ranges from the famed Brown and Grimes US meta-analysisfrom 1995 through to the Cochrane update published in July this yearthat reaffirmed these findings, and a plethora of studies in between.
Not about NPs or GPs but both
Now, while these studies are accurate and true, I am not a great fan of the ‘NPs as substitutes for GPs’ argument – particularly as it is pretty much guaranteed to raise the hackles of the latter group, who link it with the potential for their GP role to be eroded and, in some cases, financial loss.
I think it is time, with the Minister seemingly on board, that we start talking about how we can develop bothnursing and medical services to deliver high quality primary health care and meet the government commitment to lowering the cost of GP visits.
Most nurses today have completed a bachelor’s degree and to work as a practice-based nurse they will likely have several years’ experience and to have acquired specialist knowledge and skills from postgraduate education. In the case of an NP this would be a full-on clinical Masters’ degree.
GPs have also put in a decent stint at medical school, engaged in their registrar’s training and bring their own expertise to bear, hopefully in a well-oiled team that ensures ‘patient’ needs are addressed by the clinician with the appropriate skill set.
This is where the rubber hits the road… The research shows with little doubt that there are many primary health care focussed activities that an NP can acquit as well as, if not better, than a GP.
Likewise, and this is perhaps where I differ in opinion from some NP advocates, GPs are better at some things than NPs.
NPs generally excel in long term conditions management and any health care intervention that requires lifestyle changes from the people they are working with. This expertise is not necessarily the forte of many a GP, rather we need them to be deploying their diagnostic acumen in the most complex of presentations with multiple pathologies and taxing differential diagnoses.
I know some NPs will claim to be able to occupy this space too, but I am hoping we recognise that right now nurses and medical doctors are educated and have gained experience in a different paradigm. We don’t need to be shifting those discrete paradigms, rather we need to create a new one in which the talents of all are truly liberated.
Once we have agreed on such an approach we can then engage in our workforce discussion about how many NPs and GPs we actually need, and other clinician groups too for that matter. Inevitably this will bring us to a sense of whether the structure of our primary health care delivery model is fit for purpose, with a likely realisation, if not acceptance, that it really is not.
The UK Royal College of GPs, recognising the need to use GPs’ skills appropriately, moved in the early part of this century to support the notion of harnessing specialist expertise by developing the GP with Specialist Interests’ or ‘GPwSPIs’ role as a community wide resource (now known as GPs with Extended Roles or ‘GPwERs’). The aim was to create a network of GP experts to which other GPs could refer their patients with particular health needs.
Back when I was Chief Nurse I discussed the GPwSPIs idea – and of GPs dealing with the higher end of patient complexity – with our College of GPs. The response was that these notions would make life as a GP quite taxing and also lead to the possibility of patients being pinched by the practice they’d been sent to for specialist referral! My response to the former was – ‘that is what you get paid for’. Regarding the fear of your patient being pinched – well, yes, we have a system failure if that is the prevailing opinion.
As if that wasn’t tough enough, a nursing version of the GPwSPI also seemed quite a good idea to me, and the Director of Nursing for ProCare was willing to have a bash at piloting it in her territory.
It was relatively straightforward identifying the specialist skills of practice nurses across the primary health organisation’s network; diabetes, hypertension, wound care, etc. But when it came to referring patients between practices – or even an expert nurse offering advice to a colleague in another practice – it was met with the very same concerns that the medical version did. Concerns about how cross-charging for nursing services would take place. And what about patients tempted to shift practices to directly avail themselves of specialist nursing care? At least the PHO sought to grasp the concept by centrally employing nurse advisers, but I can’t help thinking an opportunity was missed.
Need for radical look at primary care model
Anyhow, this was almost a decade ago and there is little point being inflamed about it all. But right now with a Minister openly appreciating the contribution NPs can make – and the establishment of the new Primary Health Federationchaired by former health minister and nurse-aware Annette King – we have an opportunity to get this sorted out once and for all.
This will need radical action though.
If we are truly going to liberate the skills and talents of NPs, other nurses, and indeed GPs, then serious thought needs to be given to whether our current delivery model cuts the mustard.
On the face of it, we have networks of GP-led practices that, while working under the supposed oversight of PHOs, operate in relative independence with a business model likely to hinder rather than help patients needing specialist skills to access them from experts in neighbouring general practices.
Even where nurse–GP teams are working really well we can no longer afford for them to do so in the siloed ‘GP list’ type business model we have had for so long.
NPs, practice nurses and GPs, and yes patients, work well together in many places; we need to raise our gaze and make this the norm within a structure that suits more convenient and relevant access.
Yes, give everyone their ‘Health Care Home’ but find a way to let them wander over to a neighbour or the mall when the expert or focus of care they need is not available in their own front room.
Author: Dr Mark Jones was Chief Nurse at the Ministry of Health from 2005-2010 and is also a former head of Massey University’s School of Nursing.