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Putting nurses back in the picture

Wednesday, 25 June 2008

Professor Mary Chiarella writes:

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A new World Health Organisation report, which I’ve helped prepare, shows that in countries such as the US, Canada, the UK, South Korea and the Cook Islands, nurse practitioners are providing front-line care that is recognised to be as safe and effective as that delivered by doctors. Sometimes patients report being more satisfied with the care provided by nurses.

The WHO report also shows that in many countries, midwives deliver the bulk of maternity services and do so safely, appropriately and without the excessive intervention that can occur in Australian obstetric servicing.

So it’s extremely heartening that Australia is finally taking steps to modernise its health care practices and to enable nurses and midwives to work to their full potential.

The Federal Government’s recent appointment of a Chief Nursing and Midwifery Officer is long overdue.

It’s embarrassing, however, that elements of the medical profession seem to wish to take us -- not even back to the future, but forward to the past.

Rosanna Capolingua’s recent address to the National Press Club and subsequent press statements are more reminiscent of Dr Findlay’s casebook than a modern health care service. The perfect medical world that she paints is far from the reality for the majority of health care consumers.

While Dr Capolingua stresses the importance of doctors being the gatekeepers of the health system for ensuring continuity of care, I wonder who looks after her patients on the days outside her Monday surgery?

How do you think the role of nurses in the health system should change? Are the AMA out of touch on this?

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Gary Sauer-Thompson Thursday, 26 June 2008 10:42:32 AM: Are we finally going to see a reformist Rudd government find the political courage to tackle the historical convention of the GP as the gatekeeper to the health system? The multiple pressures of health workforce shortages, a national shortage of GP’s, and the difficulty of Australians in accessing primary health care highlight the need to address this convention. Is the Rudd Government serious in easing the GP gatekeeper role so that health consumers can directly access nurses and or allied health professionals, (physiotherapists, psychologists, dieticians, chiropractors and other nonmedical professionals); and allow these professionals to both access Medicare funding and the Pharmaceutical Benefits Scheme and refer their patients to specialists in some circumstances without having to go back to the GP for referral?
The AMA’s position is crystal clear. They argue that GP’s are the most effective gatekeeper in the primary health care, patient care would be compromised if anyone without the all-round expertise of GP’s were made the first point of contact in the health system, and that only GP’s have the comprehensive training to treat the patient holistically. In her National Press Club speech (http://www.ama.com.au/web.nsf/doc/WEEN-7FQ34V) Rosanna Capolingua, the AMA President, called the ALP’s proposal for a "one-stop shop" health centres a "myth", and said that this would result in the fragmentation of care. She spoke of a scenario where a patient has a brain tumour undiagnosed after going to a super clinic with a weight problem and being referred to a dietician and psychologist. The AMA is not going to compromise. The response by Nicola Roxon, the Federal Minister of Health, is equally direct. In a speech (not yet online) launching a report by the Australian Institute of Health and Welfare the minister asks, why do we need gatekeepers when families struggle to see their GP and people end up at their local hospital because they cannot get frontline care from their local GP?. GP’s, she argues, should facilitate access to health care, not stand in the doorway keeping people out. So a core issue in health reform has been identified and placed on the political agenda. We can now have a public debate about whether the phrase ’gatekeeper’ is a historical convention from the 20th century style health care, and how we can make the primary health care system more innovatively responsive to shifting consumer demands for better health care . In an earlier post on this blog Professor Mary Chiarella says that the AMA’s position is not quality of care, nor patient safety as it claims. It is turf, its money. I would add that it is also, to use an older language, about medical dominance. On the other side of the debate to the AMA we have the editorial in the Australian Financial Review (Wednesday 25th June) saying that the”health workforce needs to be expanded but it also needs to work more flexibly and efficiently. That implies general practitioners will lose their “gatekeeper“ role…It makes sense for GP’s to relax their hold on routine services that other professionals can handle in order to concentrate on the patients who most need their care.”
Maybe we will have a serious policy debate about what our health system will, and should, look like in 2020 Australia, rather than polemics from entrenched positions as we have had in the past.
Jennifer Doggett Friday, 27 June 2008 9:47:20 AM: Perhaps instead of doctors, nurses and other health professionals engaging in an unproductive turf war about who does what, we should give consumers more of a say in who they want as their gatekeeper? After all, consumers are the ones who (one way or another) fund the health system and it should be their needs which are paramount, not the professional sensitivities of doctors. If consumers had the information they require to make an informed decision (eg some of the data Mary refers to above from the WHO report on maternity services) they could decide which health professional they would prefer as their primary care provider. Obviously this may differ from person to person and situation to situation but the main issue is that consumer needs should be driving these changes, not the concerns of health professionals about their future identify and role within the health system. If the AMA is so convinced that GPs are the best possible gatekeepers for the health system then they should have the courage of their convictions and support a more flexible system. That way, if consumers are in agreement with them and consistently choose a GP as their primary provider, their case will be vindicated and they can offer some substantial evidence for their views. This would be a welcome change from their current attempts at scare campaigns and empty rhetoric about "patient care being compromised".
john Monday, 30 June 2008 7:46:05 AM: I am building my new home. There is a shortage of electricians at the moment. Should I hire a plumber to do wiring instead? I wouldn't, although I'm sure some plumbers or even handymen could do the job safely.

Both Gary Sauer-Thompson and Jennifer Doggett argued that nurses and other health professionals were as safe as GPs. How could this happen? Nurses and other health professionals are NOT trained as medical doctors, just like plumbers are not trained as electricians.

Here I have some cases that show how safe the non-doctor health professionals are:

(1) a physiotherapist treated a patient with acute cholecystitis as ribcage pain;

(2) a nurse told a patient with typical symptoms of angina that she had reflux;

(3) a nurse told a patient with obvious sings of acute arterial blockage in his leg that he had hip fracture.

But anyway, if a nurse wants to work as a doctor then he/she should do a medical course. Nursing is not a alternative pathway to medicine.
Professor Desley Hegney Monday, 30 June 2008 1:51:22 PM: I totally agree with Mary's comments. What is not being said is that there are several trials of registered nurses (as nurse practitioners or as just plain registered nurses) leading care in Australia. They are working in partnership with doctors and the doctors are very supportive of this new role in Australia. We cannot continue with the primary care model as it exists at present in Australia. Not only do AMWAC (2005) data and recommendations suggest the current model is unsustainable in its current form, you just have to be a consumer and try to see a GP within a week to know that things are not good. The ED attendance data also confirm that primary care has become inaccessible for many Australians who seek to see a GP for an acute illness. Turf wars are harmful. They are most harmful to the Australians who need to have health care (both preventative and treatment). They are harmful to the medical profession as consumers are not stupid and they do begin to question what this is all about. They do not see that all doctor delivered care is safe particularly in Queensland where consumers remember Dr. Patel and his alleged malpractice and that it was a nurse who blew the whistle on this in the interests of the patients (not the administrators or the other doctors). They are harmful also to relationships between nurses and doctors, and relationships are very important for safe care as well as retention of the workforce. There is more than enough work for all professionals to take up. Other models work internationally and will (and are) also working very well in Australia. Let's see the AMA and other medical associations call for a way to solve the medical workforce crisis that involves using the skills of other health professionals. Skills that make them equal partners rather than subjugated disciplines. That way the consumer of health care will benefit. I don't believe the AMA speaks for all doctors - certainly not the doctors I research with who are very committed to improving care and to work with other nursing models.
john Monday, 30 June 2008 8:29:39 PM: Health workforce shortage is cause by poor health policies and mismanagement by the Howard government. It's very clear that both AMA and RACGP were behind these policies (We all know that Howard's first health minister Dr Dr Michael Wooldridge had a close tie with the RACGP). It's worth noting that there was over-supply of doctors (especially GPs). However, within 5 years after before Mr Howard took office in 1997, Australia became so desperate, it had to import doctors from Africa. What went wrong with Australian health policies? Ms Nicola Roxon has been shadow health minister and health minister for more than a year. She never addressed this question. She never had a good look at Howard government's health policies. So, how can she have a clue as to how to fix the problem while she doesn't know the cause? She and Mr Rudd are driving Australian health system into another dilemma.
Robyn Williams, Menzies School of Health Research Wednesday, 16 July 2008 1:43:32 PM: What we need in order to provide a sustainable and effective health system is one with a redesigned primary health care focus. This will require collaboration, co-ordination and a multidisciplinary approach including nurses, allied health professionals, nurse practitioners, GPs and specialists using holistic approaches.
The process of developing this integrated and multidisciplinary health workforce must be combined with an increased focus on health promotion, community support and disease prevention, which of course must be adequately resourced.
Overall there is a need to put the theory and rhetoric of community partnerships for health into action. There is global recognition that the health and well being of individuals, communities and nations is influenced by social determinants of health (education, housing, transport, employment, economic stability, and basic amenities such as safe drinking water and sanitation).
What we don’t need is a continuation of the hierarchical biomedical model where it is increasingly impossible for even the best, most effective and dedicated medical practitioners to provide the best possible and most appropriate care for the culturally and geographically diverse country that is Australia.
Justine Caines Friday, 18 July 2008 9:04:14 PM: Alleluia Mary Chiarella!

John your assessment is not appropriate for at least one area of health. Midwifery. Midwives are educated and registered to provide the entire care of women with healthy pregnancies (around 80%) and yet they are prevented from working anywhere near their capacity. There is no Medicare access for midwives, they have been refused the $500 Million indemnity package affored to medicos.

All the while consumers like me are put in danger (especially in rural areas) of either no local service or facing the reality of harm created by the unnecessary interventions of 'scheduling birth'. Women in metropolitan areas face a sausage factory mentality that is current maternity service provision.

As a society we are paying a high price for the medicalisation of childbirth.
Childbirth accounts for the greatest number of hospital bed stays. In NSW the soaring caesarean surgery rate is actually preventing serious cardiac surgery from taking place (due to insufficient theatre space).

The Medicare Safety Net, a supposed mechanism to assist consumers has been rorted most significantly by Obstetricians. In the 4 years since it was created, payments to obstetricians have increased by 269%. This is no doubt hurting other areas of health.

Consumers, the women raising our countries future, are denied any real choice in their care. They also suffer any real support (with a system based on medical care with little or any social/emotional support).

Despite 37 enquiries into maternity services Australia-wide providing compelling evidence regarding the safety, cost effectiveness and consumer demand for midwifery care, little has changed. Why? Because of Governments lack of willingness to tackle the considerable power of vested interest.

In rural areas there is a preference for no service whatsoever, than a primary midwifery unit. Doctor's groups cite their concern over quality and safety and yet place 100% of women in danger with no service when 70-80% of them could be cared for very safely in local (or much closer to home) midwifery units.

Nicola Roxon has made some promising noises, but she now faces what no-one else has been prepared to take on, the might of medical interest. The 2020 Summit and the Health and Hospitals Reform Commission seem symbolic. Ms Roxon has the chance to take action. To right the gigantic imbalance, to place consumers at the centre of health service delivery and to use health professionals according to need, not greed.
Joy Johnston Saturday, 19 July 2008 11:16:53 AM: Thanks Mary Chiarella for putting midwives back in the picture. Thanks Crikey for telling us what 'they' won't. Thanks Justine Caines for highlighting midwives in this issue.
I am one of the midwives who practise in Australia's ridiculously restrictive health system which tries to keep me as an invisible obstetric assistant, passing the instruments, rather than as a primary health care provider whose duty of care includes the 'promotion of normal birth' (from the ICM Definition of the midwife).
About 15 years ago I took the big step out of paid employment as a hospital midwife, and set up my own midwifery practice. As a self-employed midwife I (and any other midwives who choose to) can take full professional responsibility for pregnant women and their babies. BUT I can't get any professional indemnity insurance.
I provide and sign all the forms that are required for registering tthe birth of a baby, claiming the 'Baby Bonus' and family payments through Centerlink, linking the new baby to the mother's Medicare card, and all the other requirements for bringing a baby into this society. I am recognised in every way as a provider of a valid and important professional service, BUT there is no public funding for what I do. There is no equal pay for equal work - when a woman has a prenatal checkup with her GP she pays a minimal fee on top of Medicare rebate; when she comes to me she pays me $90.
Most of the women in my care give birth at home. There are no drugs offered to relieve their pain. I use rugs known as oxytocics to treat excess postnatal bleeding, but that is being done outside the law. The doctor who writes the prescription for the oxytocics has no involvement in whether they are used or when. I, the midwife take full responsibility for the diagnosis of post partum haemorrhage, and the administration of the drug. It's just standard midwifery practice.
In other countries standard midwifery practice is embraced. In Australia the anti-competitive monopoly called Medicare, that protects medical practitioners as the providers of maternity care, and excludes midwives as providers of maternity care needs to be dismantled. Midwives can make a difference. There is more at http://midwivesvictoria.blogspot.com/

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Putting nurses back in the picture

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