Australian Doctor
28th July 2009
Dr Kerri Parnell, Editor-in-Chief

ONCE upon a time it was simple. Doctors were doctors, and nurses were, well, nurses. Doctors wore white coats, nurses wore starched uniforms, and patients knew who was who. There were no arguments about who did what.

Flash forward a few decades and we have some nurse practitioners not only claiming independent health provider status, but also calling for equal MBS payments to GPs. How did we get here and, more importantly, what does the future hold?

From the government's perspective, having nurses perform duties currently performed by doctors must be an attractive solution to the medical workforce crisis, especially in light of the ageing population.

For nurses no longer schooled in hospitals but in universities, and where nursing 101 is 'how not to be a doctor's handmaiden', assuming more challenging duties must be attractive.

Toss in a Labor government with a traditional antipathy to the medical profession, and the scene is set for Australia to follow in the steps of the UK, where suitably qualified nurses and pharmacists can prescribe any licenced medication for any medical condition, apart from controlled drugs.

Nurses are definitely in the ascendancy. Kevin Rudd's mother was a nurse and Julia Gillard's father was a mental health nurse. This year's inaugural Australian Practice Nurses Association conference had not only Nicola Roxon speak, but the Governor-General as well. Meanwhile, Ms Roxon seems incapable of saying the word "nurse" without the prefix "highly skilled".

So with prescribing rights and new MBS items to be in place by November next year, the question is not if, but how and when, nurses will play a more significant role in primary healthcare.

If the discussion and comments on the Australian Doctor website are any guide, GPs are not overjoyed at this prospect. For the most part, your comments show opposition to nurses accessing the MBS and PBS.

"Let the two-tier healthcare system begin!" wrote one GP.

"If you can't make a diagnosis, then you can't prescribe, because you don't know what you are treating," wrote another. One brave nurse who dared argue her lengthy training was sufficient to qualify her for independent practice got short shrift.

Put simply, we need more informed discussion on this issue. Soon the PBAC will be consulted on which drugs nurses can prescribe on the PBS and in which circumstances, while the health department looks at developing new item numbers. These are big decisions with long-lasting consequences, but so far the debate has not, at least publicly, been based on evidence and facts.

Maybe it's because the salient details are not all that easy to come by. Even after a poke around the web, and wading through documents such as National Competency Standards for the Nurse Practitioner, I'm not much the wiser on the exact body of knowledge nurse practitioners have. Or what clinical skills they're taught, or how they're examined. Before we can have an intelligent and informed discussion, surely we need to find out. Given that Ms Roxon tabled the relevant legislation in Parliament, you've got to hope she has these facts at her fingertips.

While limited, there's some research, and even a Cochrane collaboration, comparing the performance of doctors and nurses in primary care. According to UK researchers (Medical Journal of Australia 2006; 185:10-12), the literature suggests that "nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected patients". On the other hand, there are also unintended negative consequences when teams expand, including a lack of continuity, or fragmentation of care, the authors say.

And of course, we can't forget costs. The UK researchers say savings are rarely achieved with the introduction of nurse practitioners because savings on nurses' salaries are often offset by their lower productivity due to longer consults, higher patient recall rates and increased use of investigations.

There's no doubt we need further debate on how nurse practitioners best fit into the primary care system. As logic would dictate, let's start with the facts.