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Practice nurses as providers--creating a future: the Government's primary health strategy promises new opportunities for primary health care nurses, but removing the shackles of the past is not always easy, particularly for practice nurses.

THE MINISTRY of Health (MoH) states that primary health care (PHC) nurses are "crucial" to the success of the Government's primary health care strategy. (1) The guide to establishing primary health organisations (PHOs) also states that PHC nurses, including nurse practitioners, will be key players. (2)

Practice nurses (PNs) are the largest group of PHC nurses in the sector and are recognised in the legislation as providers. Despite the rhetoric, there appears to be a misunderstanding of the true nature of practice nursing services and the inherent barriers to expanding roles and services within the current general practice environment.

This article is based on the assumption that:

* Nursing is a profession, with its own body of knowledge, language, research and legislature.

* PNs are largely employed by GPs to provide ill-defined nursing services that are not nationally consistent and therefore not easily understood or measured by other health professionals, managers or government.

* PNs have a generic job description, education standards policy and career framework that they themselves have formulated.

* The underpinning document is the PHC strategy. (1)

Funding through capitation

The Ministry's PHO Futures document states: "The flexibility afforded by capitation does not guarantee funding will actually be used flexibly, at least not in these early stages." (3) This is currently true. "Flexibility" is perhaps a misnomer as it implies capitation may be used for various services other than by GPs in their businesses of providing health services.

Capitation as it is, is still as it was, ie the subsidy that pays for GPs to see patients. Calling it by any other name or purpose will not change that reality. Being paid through the PHO has not in any way changed where it goes--to the GP with an enrolled population. PNs see no more opportunity from capitation funding now than they did prior to PHOs, particularly those whose practices have already been capitated.

As the PHO Futures document states, the potential for nurse involvement in Care Plus delivery is significant. This might include running clinics for Care Plus patients with chronic illnesses such as diabetes and cardiovascular disease; acting as care managers of co-ordinators; or conducting regular quarterly health checks and initiating any follow-up. Chief executive of HealthWest PHO, Alan Greenslade, in a recent MoH guest editorial, emphasises opportunities for nurses: "Nursing is one of the most exciting areas of PHO development under capitation and with new programmes like Care Plus, I would like to see PHO-employed practice nurses, district nurses, nurse specialists and nurse practitioners attached to the primary health care centres." (4)

Care Plus has been promoted as:

* focused on high-need patients, the majority of whom could benefit from nurse or pharmacist consultations, in addition to seeing their GP;

* having significant new money attached and creating a one-off opportunity to provide incentives for teamwork. (3)

These services under the current funding arrangements, ie PNs as employees of privately-run general practices, may be very difficult to implement. There are two major reasons for this. Firstly, there will be little or no perceived incentive by the PN, as funding will go directly to the GP that the enrolled service user (ESU) is enrolled with and PNs are already working to capacity. Secondly, the GP in a PHO maybe disinclined to participate, as the current high user card system is providing a better income, thus denying the PN an opportunity to provide nursing services that assist the PHO in achieving improved health outcomes for a population.

Funding streams into PHC at present disadvantage nursing services in general practice. For example, ACC has a layered level of payment, focusing on the provider rather than the services provided. This appears to assume that the service the GP provides is worth more than that of the PN, as the rate is higher, despite the fact that often the PN assesses and manages care, eg wound or plaster care, with minimal GP input. This funding arrangement encourages professional disempowerment of nurses, as GPs often insist on seeing all clients every time to gain the higher lee from ACC, regardless of the actual need.

Practice nurses are invisible in the funding and billing formulas. The charges for services are billed to and from the PHO, through the GP. This makes practice nursing services essentially invisible. Even services such as smear taking and immunisations are billed under individual GPs as providers. It is very difficult, if not impossible, to measure (and therefore audit) practice nursing services at a PHO level. Some general practices have evolved other means of measuring this income, but this is not reflected in national funding arrangements.

Practice nurses have been running nurse clinics for a long time, eg the government-funded diabetes Get Checked programme or asthma clinics, but the funding is still paid back to the GP with whom that ESU is enrolled. This creates a disincentive for PNs to become involved in expanded nursing services and GPs may see little financial gain for their private businesses, as the outcomes are not easily fiscally visible.

Training needs

It is acknowledged that general practices are private businesses and thus carry significant risk in this new PHC environment. (3) PNs have been employees of GPs for many years and it may be difficult for many GPs and nurses to separate the employee/employer status from the professional status. For PNs wishing to expand their current nursing services to improve PHO access opportunities and requirements, this is a very real issue.

Because of the ad hoc way PNs have had to arrange continuing nurse education through lack of time and funding, nurses may not feel well prepared to provide an extended nursing service without significant extra training. There will be questions of who pays for this training, who will replace the PN in the general practice during the training period and how any extra skills will be recognised financially by the employer.

Despite the availability of accreditation as a professional development tool, many PNs have not completed this or other formal education. Thus their knowledge base and skills are inconsistent nationally.

Some GPs believe--erroneously--that they are liable for nurses' professional practice. They are only responsible vicariously. (5) This belief causes anxiety among GPs, that, if not managed well, could create another barrier to expanding nursing services.

The Ministry strongly opposes tagging components of PHO funding to different professional groups. It regards capitation payments, services to improve access (SIA) and health promotion (HP) funding as "flexible" funding for the PHO to deliver the best possible services to the enrolled population. (3)

GP attitudes are well entrenched in the "ownership" of the capitation money and the population it pays for, as it has been and still is paid through the population enrolled with particular GPs. The flexibility of capitation money depends entirely on the GP involved. The SIA and HP funding accord some degree of opportunity for PNs but only that which is achievable within the confines of the general practice workplace, rather than as an extra expanded nursing service.

Expanding nurse roles

Are practice nurses considered providers? PNs are already a key part of the primary health team and the potential for them to expand their role, especially in managing chronic illness, as well as working with other nurses in the community, is well recognised. However, this is not well supported financially, locally or nationally.

Although PNs and GPs may consider PNs to be "providers', it is not often reflected either in the financial or auditing frameworks of general practice, or in PN and GP attitudes. Despite nursing being a profession, it is difficult for GP employers to reconcile their private business interests with the need to reimburse PNs appropriately for their nursing services.

An extra funding stream for GPs is related to performance against specific indicators, eg cervical smears and immunisation rates. Part of the PHO income is based on providing a measurable quality of care, with specific auditable indicators being targeted. PNs provide health promotion and screening services and are often responsible for maintaining the recall registers for some of these services, eg cervical smears, immunisations, annual diabetes checks and respiratory programmes, but their efforts are not visible in the outcomes, nor paid for directly from these quality programmes.

Finding solutions

I believe there needs to be, above all else, a separate funding stream directed specifically at PHC nursing services, professional support and related education within the PHO funding allocations. Although SIA projects have an element of education and nursing support factored into their budgets, this is not consistent nationally and, in part, is increasing the fragmentation of PHC nursing services.

I support some of the recommendations made by MidCentral District Health Board professor of nursing Jenny Carryer. (6) Carryer stresses that the funding structure and the fees policy should:

1) provide for salaried positions for nurses and nurse practitioners in PHOs;

2) support direct nursing access to ACC reimbursement rather than channeling that money to GP employers; and

3) support funding incentives to encourage the creation of NP roles as a criteria of the access formula.

These changes would ensure nurses are empowered to expand their nursing services as providers, without disadvantaging the GPs' private business model. They would also maintain PNs' collaborative relationship with GPs and minimise fragmentation of care created by separate nursing services outside general practice.

* Should GPs maintain the control of revenue for nursing services' with the extra burden that the PHC strategy implementation appears to be creating for general practice? Wouldn't it make more sense for the PHO to assume responsibility and accountability, and thus manage risk and maintain quality standards more consistently over the PHO health provider services? This would remove financial risk to the GP business model and allow nurses to drive nursing services to better serve the general practice population, adding value to general practice and maintaining continuity of care alongside GP colleagues.

* The issues around using the general practice business facilities for PHC nursing services would need to be addressed through the PHO. For example, who would pay the rent for using the room and equipment? Would the PN be responsible or should it be billed to the PHO as the ultimate employer of the PN providing the service?

* The attitudes of GP "ownership" of patients would also need to be addressed. This would involve building and maintaining professional trust and respect between the PHC nurses and GPs, so the services provided would be mutually complementary, not competitive.

* General practice services need to be auditable against the provider of that service--not the GP the ESU is enrolled with. This would allow a visible and accurate measurement of nursing services, eg cervical smears, immunisation and diabetes annual checks.

* Using a quality plan as a change management tool has already proved successful for independent practice associations and this may be a means of changing current attitudes. Quality payments should be directed to the provider of the service, recognising that in some cases this would be the PN. This would in turn entitle a PHO to have some control over the quality of nursing care provided, eg clinical education attended, accreditation as a requirement. This would involve some information technology (IT) issues, as these services are presently captured by the GP as provider for funding.

* Professional development recognition programmes (PDRPs) are a mechanism to recognise the clinical expertise of nurses and to retain professional autonomy and development.

PDRPs are frameworks that:

* ensure nursing expertise is visible, valued and understood

* enable differentiation between the different levels of practice

* value and reward clinical practice

* identify expert nurse/role models

* encourage reflection on practice

* encourage evidence-based practice

* provide a structure for ongoing education and training

* assist nurses to meet the requirements for competence-based practising certificates

* assist in the retention of nurses.

The PHO could recognise and support the College of Practice [Nurses'.sup.NZNO] accreditation programme as the accepted beginning point on a PDRP for practice. It could also support post-graduate education as part of the ongoing PN education pathway, as recommended in the college's Education Policy, Standards and Career Development. (7)

In conclusion, government and nursing groups have already identified many opportunities for PHC nursing services in the implementation of the PHC strategy. However, the inherent barriers for PNs in particular have not been recognised and well managed to allow the largest group of PHC nurses in PHO service provision to participate fully.

Funding, or the lack of such, appears to be the main barrier to overcome in order for nursing to be visible and viable as a complementary service within the general practice team. Doctors' and nurses' attitudes will need to change to allow effective implementation of PHC nursing services that support PHO incentives to provide health services to high-need populations.

Strategies such as those described above will allow more accurate representation and data collection of PHC nursing services within the PHO. It will also encourage the development of practice nursing services in collaboration with GPs that align more closely with PHO objectives and community need. Addressing these issues now will allow a PHO time to resolve issues prior to other PHC nursing groups being included in the PHO as providers.

These strategies will need to be undertaken over time, to allow for effective change management to be implemented. This will reduce anxiety and confusion among providers and allow IT and funding issues to be negotiated successfully at both national and local levels. These strategies need to be implemented now to ensure PHC nurses are able to practise as effective providers as the PHC strategy continues to be implemented.


(1) King A. (2001) The primary health care strategy. Wellington: Ministry of Health.

(2) Ministry of Health (2002) A guide for establishing primary health organisations. Wellington: Ministry of Health.

(3) Ministry of Health (2003) PHO Futures. Wellington: Ministry of Health.

(4) Greenslade, A. (2003) Primarily 8. Retrieved March 18 2004.

(5) Carryer, J. & Boyd, M. (2003) The myth of medical liability for nursing practice. Nursing Praxis in New Zealand; 19: 3, 4-12.

(6) Carryer, J. (2003) Position paper on current PHO development. Retrieved May 15 2003.

(7) New Zealand Nurses Organisation (2003) The New Zealand College of Practice Nurses, NZNO Education polio, standards and career development. Wellington: NZNO.

--Rosemary Minto, RGON, postgrad cert advanced nrsg practice, is chair of the New Zealand College of Practice [Nurses.sup.NZNO]. She works as a practice nurse at Tauranga's Fifth Avenue Family Practice.

--This article is also published in this month "s issue of The Practice Nurse, the College of Practice Nurses' official journal.
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Title Annotation:viewpoint
Author:Minto, Rosemary
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jul 1, 2004
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