Creating a real future for primary health care nursing: although the Government's primary health care strategy has created a more positive environment for nursing, many challenges still remain to establishing effective, appropriately resourced primary health care nursing services.

The release of the Ministry of Health's Primary Health Care (PHC) Strategy signalled a change in focus for the delivery of health services in the primary health sector. (1) It was heralded as an opportunity for nursing to come to the forefront and have greater influence and visibility in health and the delivery of primary health services.

The strategy's vision of population-focused health services that improve the health of the population and reduce inequalities is admirable and is shared by many health professionals. For nurses, the strategy was welcomed, as the model outlined the approach and beliefs that nursing has long held. An holistic, wellness approach to health, working in partnership with people, their families and the community, was not new for nurses. In the strategy, they saw avenues for implementing nursing services that would lead to health improvements.

The idea of nurse-led clinics is also not new. Auckland's Well Women's Nursing Service and other nurse-led clinics such as the Nelson Independent Nursing Practice, the Takapau Health Centre and the Norsewood and Districts Health Centre have been operating successfully for many years. As well as being nurse-led, these clinics focus on meeting the needs of the community in which they function. Nurses and nursing are integral parts of PHC and although the Government has provided considerable additional funding to nurses--for nursing innovations, post-graduate nursing scholarships for both rural and urban nurses and for Maori nurses' postgraduate studies--we are still hearing that, apart from the formation of primary health organisations (PHOs) and a few specific projects, eg Services to Improve Access (SIA) and Care Plus, little has changed.

As at April 2005, the Government had allocated an additional $1.7 bit[ion in funding spread over a six-year period from 2002/2003 to implement the strategy and a total of 3.8 million New Zealanders were enrolled in PHOs. (2) Minister of Health Annette King, in her speech presented at the Primary Focus 2 conference in March this year, recounted a story of how a man, who presented at a PHO requesting to see a doctor, was first seen and interviewed by the community outreach nurse. (3) After listening to the man, the nurse established that, while he had health problems, his immediate worries were his failing eyesight, a fear of losing his ability to drive and subsequently his job, difficulties with affording rent and a family member who was in trouble with the police. The nurse organised for him to see a lawyer and, together, the nurse and the lawyer sorted out his problems.

The nurse then addressed his health concerns by attending to his foot ulcer and providing dietary advice for the man and his wife, including advice on shopping. As a result, the man's stress levels and that of his family were lowered. He lost 11 kgs, his foot ulcer healed and his blood sugar levels were lowered. When he finally did see the doctor it was suggested he be referred to a specialist, to which the man responded, "What for? I'm better now." This story highlights the nursing approach to health. The nurse did not focus solely on the man's illness but also dealt with the social aspects of his situation, all of which were significantly affecting his health and well-being.

There are success stories. The nurses who have implemented the government-funded nursing innovation programmes and other nursing initiatives are to be commended for their commitment. Some of these nurses will be presenting and reporting on their progress at the NZNO PHC Nurses' Conference in Auckland early next month.

Barriers to nursing practice

While some nurses are able to practise in this way, sadly many report that they are prevented from doing so. Why is this? What are the barriers to this type of nursing practice?

The Ministry of Health's Investing in Health report identified existing funding, contracting, employment and service models, and the fragmentation of nursing rotes as barriers to aligning nursing practice with community need. (4) Most PHC nurses are still, in an employee/employer relationship with their medical colleagues. While some education funding has been provided, it is only available to those who undertake Nursing Council-approved courses. This limits the opportunity for many nurses wishing to access other educational programmes relevant to their practice. Although the focus of the primary health strategy is on preventative measures, many funding streams and how their outcomes are measured have a disease focus.

Until PHC nursing services are directly funded and appropriately resourced, are able to be provided from a wellness rather than an illness perspective, and social and environmental issues like affordable housing and electricity, and other poverty measures are addressed, little will change.

NZNO professional nursing adviser Chris Miller 

References

(1) Ministry of Health (2001) The primary health care strategy. Ministry of Health, Wellington.

(2) Health Services Research Centre (2005) Evaluation of the implementation and intermediate outcomes of the primary health care strategy. Wellington: Victoria University.

(3) King, A. (2005) Speech to open Primary Focus 2 conference, www.beehive.govt. nz/Print/PrintDocument.aspx?DocumentID=223gg.

(4) The Expert Advisory Group on Primary Health Care Nursing (2003) Investing in health: Whakatohutia te oranga tangota. Wellington: Ministry of Health.