Opening the PBS door

The GP landscape changed this week with the introduction of nurse practitioner prescribing legislation. Pamela Wilson examines the fallout.

AFTER much debate and fanfare this week the Federal Government took a significant step in its quest to elevate the status of allied health professionals.

On 1 November, it handed down new legislation – the Health Insurance (Midwife and Nurse Practitioner) Determination 2010 – that entitles some nurse practitioners and midwives to specified PBS subsidies and Medicare rebates for services they provide.

Although nurse practitioners and midwives already had prescribing rights under some state and territory laws, this latest move facilitates Federal Health Minister Nicola Roxon’s plan to promote these professions and foster their growth so they can be used to complement the services offered by GPs.

The road Ms Roxon chose was anything but smooth, with  multiple stakeholders raising concerns about the legislation.

Of primary concern among doctors’ groups was the level of autonomy under which nurse practitioners could practise, their potential scope of practice, and the long-held view that extending prescribing rights to allied health workers could compromise patient safety.

After much consultation and a few amendments to the original draft, the legislation made it over the line, with amendments. 

GP as gateway

A vital feature of these new laws, according to doctors’ groups, are the collaborative arrangements, as these uphold the core principle that in Australia the GP is the gateway to the rest of the health system.

It is a statutory requirement that nurse practitioners and midwives enter into collaborative arrangements with medical practitioners. These are defined as one of the following: 

- They have an individual collaborative arrangement with a medical practitioner(s) for a patient, detailed evidence of which is kept in the patient’s clinical notes – including evidence of the consent of the collaborating practitioner(s).

- The midwife or nurse practitioner is engaged or employed by a medical practice;

- A patient is referred to the midwife or nurse practitioner by a medical practitioner;

- They have a written collaborative agreement with a medical practitioner(s) covering one or more patients; or

The AMA, in particular, saw it as a win when these arrangements were finally included in the legislation, because Ms Roxon didn’t mention this type of cohesive working relationship when she first flagged MBS and PBS access to nurse practitioners and midwives in 2008.

“We have a position in Australia that is different to the rest of the world,” says AMA vice-president Dr Steve Hambleton. 

“We didn’t adopt the American model of a separate pathway of entry into the health system.

“We believe we are in a position of leading the world in the way doctors and nurses cooperate, so we are pretty happy with the way things turned out.”

But he warns the collaborative arrangements must involve ongoing professional relationships and communication, largely because nurse practitioners will be limited by their scope of practice.

Dr Hambleton believes the public won’t be able to identify what is within a particular nurse practitioner’s scope of practice, which will lead to many interactions that are potentially outside this scope.

Australian Practice Nurses Association CEO Belinda Caldwell says that a barrier some nurse practitioners may face will be doctors not trusting that they know their limits. 

But she says it is no different to GPs self-evaluating what is beyond their own scope.

“Why doesn’t a GP do brain surgery? Because they make a call as a health professional that they are not safe to do that,” she says.

“Nurse practitioners take that professional obligation for patient safety very seriously... and know to say when something is outside their scope of practice.”

Ms Caldwell also points out that the collaborative nature of these new working arrangements doesn’t mean doctors have to carry the legal burden for nurse practitioners.

“If the GPs interpret that as them [carrying] the can if the nurse practitioner does something wrong, that is going to be a barrier to getting these collaborative arrangements up,” she says.

Nurse practitioners and midwives must also be endorsed as an eligible midwife or nurse practitioner, as determined by registration standards, competency standards and guidelines issued by the Nursing and Midwifery Board of Australia (NMBA). 

Eligible midwives must also have an endorsement for scheduled medicines.

It’s also encumbent on nurse practitioners to prescribe and practise within their scope of practice or face disciplinary action by the NMBA.

The scope of their prescribing authority, and that of eligible midwives, is also determined by the requirements of the relevant state or territory drugs and poisons legislation.

These requirements can range from a blanket authority within the scope of practice to prescribing rights based on a formulary or relevant to a specific context of practice.

However, the NMBA says it is “outside its jurisdiction to specify a distinct formulary of medicines for each area of specialty of nurse practitioners, because the prescribing requirements are properly related to a nurse practitioner’s employment conditions and the relevant legislation relating to medications within each jurisdiction”.

Welcoming these requirements, the nursing profession is understandably excited about its new role. 

“This is just the start of the process and hopefully it will keep developing and allow nurse practitioners to do what they have been trained to do,” says Helen Gosby, national president of the Australian College of Nurse Practitioners.

“With these new government legislation changes, we are hoping they will encourage more people to choose this career path.”

There are only about 370 nurse practitioners in Australia, with fewer than 10 currently employed in general practice.

But Ms Caldwell sees enormous potential for nurse practitioners to complement services provided by general practices.

While for the most part midwife prescribing medications are limited to antibiotics, anti-inflammatories, analgesics, antinauseants and hormonal preparations, nurse practitioner access is far wider (restrictions include anti-androgens, chemotherapy drugs, and items available under special arrangements).

“There are key areas of the role that I see growing; chronic disease management is an obvious area, and women’s health,” she says.

“A lot of them are doing primary care type roles, but they are attached to a hospital because they haven’t had access to the MBS and PBS.” 

Ms Caldwell believes the changes will increase the exposure of nurse practitioners to GPs and with that will come wider acceptance.

“In the end, they have to trust the nurse practitioners in the same way they have to trust the physio or the dentist or anyone else they refer on to,” she says.

But who’s liable?

One key concern related to the new collaborative arrangements is around legal liability. Andrew Took, national manager of medico-legal advisory services for medical defence organisation Avant, explains that once a practitioner has prescribing rights, they wear the responsibility for the decisions they make regarding medicines, including informing patients and gaining consent.

In some cases where the nurse practitioner has directly consulted with a doctor, there may be shared responsibility.

“It does get a little complex with vicarious liability [when the nurse is an employee of the medical practitioner], but the overriding red light for general practitioners is to ensure that when you are entering into a collaborative with a nurse practitioner, the appropriate professional indemnity insurance is in place,” he says.

Mr Took adds that the nature of collaborative arrangements, and the onus on shared care, means doctors and nurse practitioners must also be vigilant about communication.

He recommends appropriate role delineation between doctors and nurse practitioners, inter-professional training, shared recall systems and care plans, out-of-hours communication systems and policy guidelines governing the working relationships.

So, it would seem the foundations Federal Government’s plans for the health landscape have been laid. Perhaps if the doctors build the infrastructure, the nurse practitioners will come.

That is certainly the hope of the policymakers, but only time will tell if their plan works.

Entitlements – Medicare rebates

Nurse practitioners

Short and straightforward consult – $9.20

Short consult less than 20 minutes – $20.15

Long consult more than 20 minutes – $38.25

Long consult more than 40 minutes – $56.30


Midwives

Short antenatal consult up to 40 minutes – $31.10

Long antenatal consult longer than 40 minutes – $51.35

Long consult, with maternity care plan up to 90 minutes – $306.90

Extended antenatal services in hospital up to 12 hours, and delivery – $724.75

Short postnatal consult up to 40 minutes – $51.35

Long postnatal consult more than 40 minutes – $75.55