The Hon. Nicola Roxon MP Minister for Health and Ageing
"Nurse Practitioners - their role in a modern health system"
Melbourne - 28 October 2008

Thank you for inviting me here for this important conference to address the future role of nurse practitioners in Australia. After a very slow start, nurse practitioners are becoming an established part of the nursing workforce in most parts of Australia. However, significant challenges still exist for this small group - that is steadily growing in size.

Since the first nurse practitioner committee was convened in 1990, a lot has transpired. That said, almost 20 years on, we still seem to be having the same debate with some members of the health care community about the benefits nurse practitioners can provide to the community - rather than getting on with the job of determining how best to support their role in the health care system.

I can tell you all very clearly today - I am a firm believer in the vital role nurse practitioners can play in our overall health system – a health system that is in need of reform for the benefit of all Australians both now and into the future.

Current health care challenges in Australia

It is a great honour to be the Health Minister in a bold and reformist Labor Government. Good health is fundamental to the community and our economy, and just as reforming Labor Governments of the past have shaped the health system we have today, the next steps are an opportunity and a challenge I won’t let slip by.

We know there has been a lack of planning by previous Governments to provide a health system that is equipped to deal with the challenges ahead - put simply, Australia has not made the structural changes needed to cope with the health challenges that will face us, driven by an ageing population and the growing burden of chronic disease.

The nursing profession is a big part of our plans for the future. We know that Australia’s nursing workforce is the backbone of our health care system. We respect what nurses do and want policy settings that encourage nurses to stay and develop in the profession.

We have taken immediate steps to provide:
- an additional 1094 ongoing University nursing places
- incentives to attract up to 8,750 trained nurses back into the health and ageing sector workforce within five years ($6,000 each at a cost of $39.4 million)
- appointed the first ever Commonwealth Chief Nurse and Midwifery Office, Ms Rosemary Bryant, to strengthen the nursing voice in Government.

Of course, more generally our investments like our additional $1 billion into our public hospitals - the largest single-year investment in our hospitals in almost a decade – also strengthen the very places where large numbers of nurses work.

We are working on a dual track system across health - delivering immediate improvements, while at the same time developing strategies to equip our health care system for the challenges of the future.

We have several processes in train which are focused on designing the health system to tackle future challenges.

Most prominently, the COAG reform process is focused on working with the states and territories to negotiate a new healthcare agreement. This agreement will have a much
greater focus on accountability, transparency and outcomes. Through this process, there are likely to be a number of incentive-based partnerships between the Commonwealth and the states and territories, focussing on different elements of health care reform, which of course, include future workforce needs.

The National Health and Hospitals Reform Commission, whose job is to develop a long-term health reform plan, will provide us with an interim report later this year and a

final report in the middle of next. We know that greater focus on prevention is the key to a sustainable health system into the future.The Preventative Health Taskforce has been charged with developing a blueprint for tackling the growing burden of chronic disease caused by tobacco, obesity and excessive consumption of alcohol - and has just released an important discussion paper.

Focus on primary care system

This is one of my major aims - to change the focus of our system from acute care to primary care and prevention.

Most of Australia’s current nurse practitioners work in the acute system, with some currently working in thecommunity - for example in community health, mental health and aged care. Australia’s first National Primary Health Care Strategy is being developed by Government with the assistance of an expert reference group (that includes a nurse!) to ensure that our system is better able to tackle the health challenges of the 21st century, and make sure that families can get the health care they need.

The Strategy will look at how to deliver better frontline care to families across Australia, including better rewarding prevention, addressing the growing need for access to a range of health professionals, and making better use of multi-disciplinary care. A key focus of the primary health care strategy will be how to best use the talents and skills of the health workforce - including of course nurse practitioners.

The health and medical system that has evolved over many decades has done a pretty good job. But it is creating more and more barriers and divisions between the health and medical professions, and even between specialties and sub-specialties. These divisions, sometimes unnecessary and the product of historical anomaly more than logic – though not always - make it very hard for patients with complex needs to get the health care they need.

These divisions can also entrench the inequalities in access to health care services experienced by some groups in our society, including those in our rural and remote communities. Even in the major cities, they may have to travel significant distances from one appointment to another, from one health professional to another. Just getting around can be very difficult when you are frail or unwell, and then there is the problem of one health professional not knowing what the other is doing, duplication of medical
records and so on.

What we need is multidisciplinary care which enables patients to be looked after by a team which shares information. This may or may not involve co-location - but it will certainly involve better interaction between professionals.

This may mean developing new models for service provision and more flexible roles for health care workers. It’s no secret that I believe all of this will entail a redefined
and extended role for nurses - including nurse practitioners.

Looking at this afresh does not mean dropping our standards. But it does mean taking a hard look at which restrictions are appropriate and needed, and which no longer have the relevance they did in the past.

Nurse Practitioners

International experience indicates Nurse Practitioners can provide care that is safe and effective, and that they have the potential to increase the capacity of the Australian
health workforce to help meet the increasing demand for health services, particularly in primary care and rural and remote settings.

It’s been a long road to develop the nurse practitioner role in Australia. Compared to some other countries, including the USA, the UK and Canada, where nurse practitioners have been in the system for up to 40 years, Australia’s nurse practitioner workforce is relatively new. International research demonstrates that nurse practitioners provide care that is safe, effective and the satisfaction of patients with this care is very high.

We know that Australia’s nurse practitioners currently work in a diverse range of areas – but that there are challenges and barriers in expanding the profession into more community-based settings like mental health, aged care, rural and remote health and paediatric health.

These barriers include:

• a lack of access to a system that allows patients of nurse practitioners to receive pharmaceutical benefits for the scripts that they write-despite the fact that they can legally prescribe.
• a lack of access to a financing arrangement that supports the expansion of the nurse practitioner workforce into community settings
• a complex regulatory system around the country, and a small current workforce.

So here is just one example of the positive and opportunistic service that a nurse practitioner providing care in an aged care facility could provide. We know that some of our most fragile Australians, those in residential aged care facilities, do not always have good access to medical care - both on a day to day basis, or when they are suffering with a new medical complaint.

Consider an elderly resident that develops symptoms of a urinary tract infection late in the afternoon. These symptoms can often be subtle - where loss of appetite and increasing confusion may be the only signs. The aged care facility calls the local medical centre which has a nurse practitioner who is able to visit the nursing home that afternoon. The nurse practitioner makes an assessment, undertakes a urinalysis which indicates a urinary tract infection, commences antibiotic treatment along the lines of predetermined treatment protocols, and sends the urine sample off for confirmation of the infection and sensitivities of the organism to antibiotics. Finally, the nurse practitioner notifies the general practitioner and arranges a follow up visit.

This isn't to say that the patient shouldn't see a GP - or that they shouldn't follow up with a GP - but when we know it may take them several days to get in to a GP surgery, being able to see and be tended by a nurse practitioner is an invaluable opportunity that can deliver significant benefits. The timely and effective treatment has potentially avoided a deterioration, fall and lengthy stay in an acute care hospital – saving the patient pain and inconvenience, and saving labour, as well as taxpayer dollars.

While this health care service in the right circumstance could be provided skilfully and safely by a number of practitioners - including general practitioners, geriatricians and nurse practitioners - only the latter cannot prescribe the antibiotics under the PBS. Only the nurse practitioner cannot refer the urine sample for the appropriate pathology test and have the patient receive a rebate.

Registration and Accreditation of Nurse Practitioners

Different legislation and legulation that is in place in each state or territory means that for too many years there has been inconsistency across jurisdictions surrounding the definition of a nurse practitioner, what they can and can’t do and where they can work. This currently acts as a barrier to expansion of a national nurse practitioner workforce – however, many of these issues are expected to be addressed through the national registration and accreditation system, to be implemented by 1 July 2010. This is only proceeding because of our leadership and a determination to move forward after two years of delay by the Howard Government.

The national registration and accreditation system will

• ensure a consistent national approach to the nurse practitioner workforce.
• improve workforce mobility by providing consistency, so no matter where a nurse practitioner is operating their qualification and area of expertise will be recognised nationally.

Furthermore, streamlining the process for accreditation and providing clear guidelines on how nurses can become nurse practitioners will allow clarity in a sector where guidelines have often been vague.

The new nurse practitioner scholarship program There are approximately 300 registered nurse practitioners working in Australia. Workforce numbers are increasing slowly – but more nurse practitioners are needed to bring the benefits of their skills to a broader section of the community.

As noted earlier, ways to better support the role of nurse practitioners – are being explored through our policy development. As this is being explored - and the National Registration and Accreditation system is progressing - I want to ensure that the nurse practitioner workforce increases in number and is strengthened to recognise their important role in the health care system. I know this morning you heard about a 2007 survey, showing that support for education was one of the main areas identified by nurse practitioners as needing attention.

Well, I couldn’t agree more.

We know that barriers for nurses to undertake additional educational requirements to become nurse practitioners include both the uncertainty of the employment arrangements in the currently structured health care system - and the cost of the education.

As you can see, we are working on the former, and today I am going to commit to assisting some of you - the future nurse practitioner workforce - with the latter. I am pleased to announce today that the Australian Government will provide Nurse Practitioner scholarships of up to $15,000 per annum for two years to 20 potential
nurse practitioners.

Particular emphasis will be placed on rural and remote settings and other areas of high community need - including aged care, mental health, women & men’s health, drug and alcohol services. We believe this is a small but important step in building the nurse practitioner workforce that Australia needs for the future - as well as a concrete sign of the Rudd Government’s commitment to ensuring the Australian community is able to benefit from your skills.

This initiative will contribute to building the capacity of the health workforce in rural and remote Australia - and improve access to health care for Australians living in these parts of Australia.

Conclusion

To conclude, the Australian Government recognises that Australia’s nurse practitioners are highly-skilled and qualified health professionals. They, along with our registered nurses and enrolled nurses, provide a multitude of services that are essential to our health care system. You deserve more recognition and our respect.

I am pleased that nursing as a career now offers far greater diversity than was possible in the past - and the current health care reform agenda is a chance to make changes that will enhance the delivery of services to the community. Nurse practitioners are already an important part of our health care system – but they have the potential to be even more significant. Right now, there are many barriers in their way – inconsistent employment arrangements, scattershot regulation, financing barriers, the inability to prescribe on the PBS, the cost of education.

If we are to increase nurse practitioner numbers, as I believe we must, then we must look at ways to hurdle these obstacles, and move into the future. I look forward to continuing to have a positive and productive relationship with you as we move into that
future.

Editors Note

Minister Roxon gave generously of her time and stayed on an extra 20 mins to reply to questions raised from the floor from delegates at the conference. Her full speech has been included so those who were not able to attend can also be encouraged by what the department is doing on behalf of Nurse Practitioners.