Nurses are losing income and jobs, as a result of a problematic primary health care funding model whose flaws are being amplified during the COVID-19 pandemic, according to Karen Booth, President of the Australian Primary Health Care Nurses Association (APNA).
Karen Booth writes:
It has been a wild few weeks since the Federal Government announced community lockdown measures to stem the spread of COVID-19. The pandemic containment response, while successful, has uncovered shortfalls in our health system.
These cracks started appearing when many patients stopped going to the doctor, scared that they would get sick in the waiting room or that clinics were closed. With less foot traffic, a significant number of general practices began cutting staff and clinic hours.
Hundreds of frontline primary health care nurses have borne the brunt. More than 1,000 nurses responded to a recent poll about the impact of COVID-19 on their employment.
Our APNA PulseCheck survey found that:
- 31 percent have had paid hours reduced
- 7 percent have had employment terminated
- 27 percent indicated that their employer had discussed potential (or further) loss of paid hours or job termination with them.
Incredibly, this is happening in the middle of a health crisis when you would think nurses are needed more than ever.
Our survey results also indicate a huge loss of clinical care, further limiting access for patients with complex conditions whose care is supported and coordinated by nurses.
APNA is working closely with the Federal Department of Health on ways of increasing cashflow to general practices to support continued nurse activity. New MBS items to fund telehealth for chronic disease services by general practice nurses should help.
The new chronic disease management telehealth items were the result of intensive lobbying and have been welcomed by nurses, GPs, consumers and practices. We are yet to see what difference they will make to workforce retention and better utilisation of nurses in this crisis.
The telehealth items should allow nurses and Aboriginal Health Practitioners to safely reach into the homes of our most susceptible patients and provide support to keep up their managed care treatments and identify when they really do need to come in for a physical review with their doctor.
This would be a win for patients, many of whom are feeling lost and at risk without that regular contact with their care team.
Better funding models needed
It is a perverse outcome of the current funding model in general practice that nurses are having their hours reduced and employment terminated during a pandemic.
This shows the weakness of the current system in addressing the big picture of complex care management which has fostered a reliance in some quarters on episodic MBS funding.
How do we fix this? The patient load is not going away. Much work has been done to look at population needs and planning to predict the number and type of services needed for the community. The big issue is funding.
Paying for episodic care dependent on face-to-face, come-to-the-doctor-when-you-are-sick or in-crisis visits, is not a sustainable model for complex care.
We need predictability and assured funding that supports proactive, preventive, managed care to keep people well and supported in their community and avoiding unnecessary hospitalisations.
If there was widespread use of adequately funded bundled payments for treatment of people with chronic complex health issues – allowing flexible use of health team members – we may not have seen the recent roller coaster of lobbying and funding adjustments.
It would mean that the workload for chronic care remained predictable, the funding for practices would be predictable with resources and staff allocated in a predictable fashion, not the boom or bust of the past few weeks. We could all get on with doing what we do best as part of a care team.
Nurses deserve better, too
So what does this tell us about how nurses are valued?
The community certainly respects our profession, consistently rating it the most trusted in Australia. Yet that is no consolation to the nurses losing work in the frontline of primary health care.
Coming out of COVID-19, there needs to be a better appreciation of the role of nurses and more nimble ways of funding nurse activity as described above.
In general practice, nurses provide considerable support in partnership with GPs to help patients keep on track with care.
In 2018-19, there were 2,800,368 nurse visits Item number by service for 10987 and 10997 MBS 2018-2019 claimed by primary health care services such as general practices and Aboriginal Health Services. That is a significant amount of support for our most vulnerable members of the community.
The raw value of these items is $37,298,773 and this amount could increase by at least half again when bulk-billing incentive items are added. This is not an insignificant contribution to patient care and the bottom line of practices.
Approximately 14,500 nurses work in general practice. Practice billings are an underestimate of both the qualitative and quantitative contribution of these nurses, most of whom are highly qualified and very experienced. The slippage of billings by practices and GPs forgetting to bill nurse item numbers, despite the work being done by the nurse, is a well-known issue.
Practices also attract a significant contribution from the Federal Government’s Workforce Incentive Program when they employ a nurse, up to $125,000 depending on the size of the practice. Nurse activity contributes significantly to other quality improvements and population health activities that attract additional government incentive payments (QI PIP).
Nurses further contribute to the bottom line of practices through managed care planning, interviewing, educating and coaching patients and doing much of the prep work (MBS items 721, 723, 732).
According to MBS data from 2018-19, these items generated $959,883,522.
Despite these contributions, practice nurses are paid as much as 25 percent less than their hospital nurse counterparts and often have to work casually with low levels of job security.
In our annual APNA Workforce Survey, nurses report they love their job but 45 percent feel that their skill set is underutilised and despite offering to make a more complex contribution to patient care, this is often knocked back by their employer.
Mix this with short notice and reactive staff cutbacks, it is no wonder some of these highly qualified nurses are looking to leave primary health care altogether.
And that, ultimately, would be a terrible loss for Australia.
• APNA is the peak professional body for the 82,000 nurses who work outside the hospital system. This includes nurses in general practice, aged care, Aboriginal health, correctional facilities and other community settings. Find out more at www.apna.asn.au