OPINION: Judy Lumby
From: The Australian
October 30, 2010 12:00AM

IN 2005 Australian Medical Association president Bill Glasson wrote a piece on nurses.
He said that nurses "are not trained in holistic patient care. When a GP examines a particular ailment they are assessing the whole person."

Glasson went on to argue that nurses were not trained to be doctors, a point I would agree with. His initial statement, however, is untrue.

I have taught nurses for more than 30 years, and the core of the curriculum has been always thinking about the person in the patient. In other words, for the nurse to not only see and examine a body with an illness or disease but to see and consider the person feeling ill or in pain or distress and take a thorough history.

Of course, Glasson was referring to nurse practitioners in the 2005 article and was presenting a case against the appointment of such creatures, so his comments should be interpreted in this adversarial context.

Five years later, we have a different AMA president, and from November 1 we will have legislation that will enable nurse practitioners to access Medicare provider numbers, allowing Medicare to pay rebates for nurse practitioners' services for the first time.

In these intervening five years, the number of nurse practitioners has burgeoned and they occupy roles across all contexts of health care, in every state and territory and in metropolitan, rural and remote areas.

There are approximately 400 nationally, but the once-feared (by doctors) hordes waiting to be approved for these positions are non-existent. Such roles require sensitivity and diplomacy as well as high-level diagnostic and management skills in a specific area; in the early days, several nurse practitioners left their roles after a short period due to the obstacles being put in their way.

This change to our healthcare legislation means more than merely changing the way nurse practitioners are funded. It signals a new political willingness to tackle what has been a somewhat recalcitrant system in terms of cultural change, and open it up to suit the needs of those for whom the system exists: the Australian population.

As federal Health Minister Nicola Roxon has said, these "highly experienced and highly qualified nurses will now be able to use all of their skills as nurse practitioners rather than working with one hand tied behind their backs".

A changing demographic in terms of health care needs means that individuals with chronic and complex conditions often spend days consulting doctors, hospitals and pharmacies.

But it also means that there are those who neglect their multiple disease processes, either because they can't afford the increased out-of-pocket expenses or because they are in no condition to travel long distances for such consultations.

This year, in a national population survey, the Australian Institute found that 25 per cent of respondents had not attended a GP because they couldn't afford it.

This may be explained by the fact that GP bulk-billing rates fell by 3.6 percentage points in the five years to 2001, thus leaving more of the population out of pocket when accessing GP services.

And this is more so in rural and remote areas where the population has a lower income and poorer health.

One nurse practitioner I know of, John, is working in primary health care, managing and caring for people suffering with cardiac failure. A nurse practitioner with a master's degree and more than 20 years' working in his area of expertise, John keeps close contact with his patients, visiting them in their own homes and contacting them if he is concerned.

He works closely with the medical specialists in the area and has a high success rate in terms of keeping people out of hospital, as well as educating them how to manage their lives and their disease.

Another example: Jenny works as a nurse practitioner in a rural area that, tired of waiting for the healthcare system to respond appropriately to its needs, developed its own model of care through establishing partnerships across the community.

Jenny's daily practice routinely involves crisis management of clients presenting with disordered and even violent behaviour. Because of the community she serves, the people she cares for often have chronic mental health problems and many abuse drugs. This means that they need long-term management, counselling, containment and referral to specialists if they are available.

There is abundant evidence internationally and an increasing body of knowledge in Australia that is testament to the cost effectiveness and appropriateness of the nurse practitioner role in diverse contexts.

The Australian Institute's 2010 survey showed that the Australian public would be willing to use the services of nurse practitioners, if available, for a range of high-demand health services, including prescription repeats, medical certificates and referrals to specialists.

It is clear that we need greater investment in primary health care and real change in terms of shifting responsibility to consumers to take their own health care seriously.

While GPs have long been the centre of primary health care in Australia, they are now having to manage individuals with complex conditions.

The spectrum of disease and illness which they face each day demands that we re-think who else can work in the primary healthcare sector to relieve this increasing burden.

Judy Lumby is director of the Joanna Briggs Foundation, emeritus professor at the University of Technology, Sydney, and adjunct professor at the University of Sydney