The slower than hoped for take- up by nurse practitioners of the government’s initiatives to allow access to the Pharmaceutical Benefits Scheme and the Medical Benefits Schedule confirms that the road to a more cost-effective health system will take considerable time.
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The doctors may be part of the problem, but their concerns do have some validity and need to be addressed.
Nurses are also not entirely innocent, as industrial action in Victoria suggests. Like doctors, they want to be rewarded for their qualifications and preferably have those qualifications recognised with rewards nearer to those commanded by doctors. They also want to be guaranteed jobs according to patient/nurse ratios, regardless of technological or other management advances, and not be subject to enterprise-level competition or productivity gains. Again, however, their concerns are not without merit.
Two of the obstacles to building the most cost-effective health system are: the rigid boundaries between different health professionals, which limit competition and cause the system to pay more than is necessary when lower-value work is undertaken by higher-paid professionals; and the fee-for-service system, which rewards quantity of outputs, not quality of service or outcomes.
That said, both these design features have advantages. Requiring qualifications promotes expertise and safety in health service delivery. Fee-for-service rewards effort. The challenge is how to address the problems without losing the advantages.
In the hospitals sector, the move to case-mix funding will introduce a form of fee-for-service, rewarding effort but with the danger of promoting outputs, not effective or quality care. If each diagnostic group in the case-mix formula incorporates a wide range of internal hospital services, it will not promote unproductive effort but instead reward efficiency. It will also not promote professional boundaries but encourage more efficient allocation of work among the professional teams in hospitals.
Among the potential gains are those from a greater role for physician assistants, increased responsibilities for registered nurses and increased use of enrolled nurses and other caring staff. Overlaying the arrangements with a strict nurse/patient ratio could undermine these advantages, although the nurses are right to demand some assurances about quality of care as case mix, like any fee-for-service system, may encourage fast output, not quality.
In the primary health sector, the longer-term answer is probably to have some form of contract with each general practice – with the practices employing (or partnering) a number of professionals including nurses and nurse practitioners. The contract would pay the practice on the basis of the number and health status of the patients, the range of services provided and the number of particular types of services provided; for example, medical check-ups, screening tests or immunisation.
It might also include rewards for particular outcomes – for example, the proportion of relevant patients immunised or screened – and might also allow consideration of more fund-holding for the range of services chronic disease patients need.
It could also address access issues by requiring limits to co-payments, particularly for pensioners and other healthcare card holders.
Such a system would no doubt attract opposition from some doctors. Yet in time most GPs might be persuaded of the benefits to them, with rewards more focused on patient outcomes and with the ability to better co-ordinate care. The shift away from pure fee-for-service would provide them with the incentive to use nurses and nurse practitioners better, focusing their own effort on more professionally rewarding work, while the retention of some fee-for-service elements would ensure effort would also be rewarded. Successive governments have been slowly moving in this direction.
Former health minister Brian Howe’s GP strategy promoted group practices. Later health minister Michael Wooldridge built on this with increased practice grants encouraging the employment of practice nurses, and with rewards for immunisation and care planning.
Now, Health Minister Nicola Roxon is attempting to go further with nurse practitioners. The big step to contracts with individual practices will probably only come when Medicare Locals (MLs) are able to take on the task. This is not a job for the Health Department in Canberra or a state capital. It will require not only continuing to build the management capacity of MLs and increasing their discretionary budgets, but also reopening the proposal for the commonwealth to take full responsibility for primary health care. The risk of conflict of interest between MLs (with strong GP representation) and the practices with which they are to enter contracts will also need to be addressed.
The answer for nurse practitioners is not to press new fee-for-service payments separate from GP funding but to continue down the path towards broader contract funding to general practices with a mix of professional staff, and with blended whole-of-practice payments.
In localities such as rural areas where GPs are not available, by all means fund nurse practitioner-led practices, noting the more limited range of services they can provide.
The reform process might be slower than we would prefer, but there is good reason to keep the GPs onside. The public relies heavily on GPs and their professionalism. The key is to convince them that there is a better way to fund the system that will promote their professionalism and reward good patient care with maximum cost effectiveness.
