Undertaken by the Australian Primary Health Care Research Institute

ACT ANF RESPONSE SUBMISSION
27 SEPTEMBER 2011

Introduction

The Australian Nursing Federation (ANF) was established in 1924. The ANF is the largest industrial and professional organisation representing nurses, midwives and assistants in nursing (however titled) in Australia, with branches in each state and territory. The core business of the ANF is the representation of the professional and industrial interests of its members, and the professions of nursing and midwifery. The ANF participates in the development of policy relating to nursing and midwifery practice, professionalism, regulation, education, training, workforce, and socio-economic welfare, health and aged care, community services, veterans’ affairs, occupational health and safety, industrial relations, social justice, human rights, immigration, foreign affairs and law reform.

Preamble

As the ACT ANF represents the majority of nurses, midwives and assistants in nursing currently working in the ACT, and specifically a number of the nurses currently working at the Nurse-led Walk-in-Centre (WiC) located on the campus of the Canberra Hospital (TCH), the ACT ANF appreciates the opportunity to provide comment on the evaluation report prepared by the Australian Primary Health Care Research Institute.

As stated in the ACT ANF February 2009 submission, made in respect of the original WiC proposal, the ACT ANF remains supportive of primary health care initiatives that recognise the inherent attributes of nurses and the science of nursing, and more fully utilises this valuable health care resource. Nurses are highly educated and possess a range of skills and abilities. In the 2009 submission, the ACT ANF considered that the establishment of nurse-led WiCs was an innovative application of this resource in an environment where the ACT faced an increasing demand for services, by a population that was both growing and rapidly ageing, whilst at the same time facing increasing health workforce challenges. It is therefore pleasing to note that the report demonstrates that in its first year of operation the Nurse-led WiC has proven to be a safe and popular health care option delivering quality health care outcomes to the ACT community.

Submission

While welcoming the report’s findings that show that the WiC provides a safe and effective health care service option and that it is supported and valued by many members of the ACT Community, the ACT ANF also notes that some of the restrictions placed on the service and its employees has had an adverse effect on its ability to fully meet its potential and been the subject of negative comment. This is particularly so in respect of its co-location on the acute care campus of the Canberra Hospital (TCH)and the inability of its skilled nurses, particularly Nurses Practitioners, to work within the full scope of their skills and abilities. This restriction, in terms of scope of practice has been further exacerbated by the constraints imposed in meeting the rigid protocols and Standard Operating Procedures approved for the WiC.

While the report indicates that consumers were satisfied with the current location and access times, the report has also indicated that the co-location of the WiC on the TCH campus has had an adverse effect on the workload of the Emergency Department (ED) at TCH, with a 5% increase in presentations to ED. The report indicates that this increase may be due to a combination of factors:

1. direct Inbound patient referrals, particularly in respect of weekend and after hours diagnostic imaging and as a result of the very restrictive pharmacology options imposed on WiC clinicians;
2. a combination of WiC-referred Outbound referrals and Outbound self-referrals, because the clients do not meet WiC protocols; and
3. the proximity of the ED to the WiC.

However, there is no suggestion within the evaluation report that the WiC referrals to ED, Inbound or Outbound, were considered inappropriate referrals and may be considered a testament to the calibre of the assessment skills demonstrated by the nurses working within the WiC. As stated within the evaluation report, it is not possible to appropriately measure patient self referrals to ED, whether Inbound or Outbound, but it is likely that the proximity of the WiC to the TCH ED has resulted in an increased number of ED presentations, particularly “triage category 4 and 5 … [while] … during the same period the triage category 4 and 5 services at the Calvary Hospital ED were either stable or declined” (p14).

As indicated during verbal consultations and in writing within the ACT ANF February 2009 submission on the original WiC proposal; and in responses to the draft Models of Care (MOC) developed for the WiC in February and April 2010, the ACT ANF expressed concern as to the co-location of the WiC on a tertiary campus, particularly in respect of the Primary Health Care focus of the WiC. It would appear from the report, that some of those concerns were justified. The ACT ANF maintains that consideration should be given to the establishment of WiCs in true community environments, particularly in those communities currently under resourced in terms of GP and community health centre access. Given the apparent popularity of the current location from a consumer perspective, it may not be feasible, or indeed economically viable, to move the current WiC to an alternative location. However, the ACT ANF strongly considers that a future

WiC could well be established in a north side area of growth, such as Gungahlin, possibly as part of a community health centre. In so doing it would meet a community need, in a community setting designed to deliver primary health care without the confusion of being co-located with the major tertiary health care centre for the ACT and surrounding region.

In maintaining the current WiC on its current site and considering alternative community sites for the establishment of future WiCs, the ACT would reflect the UK experience on which the model is based. Within the UK these centres are primarily nurse-led and protocol driven. Some are stand-alone ‘shopfronts’, or run as community health centres, often utilising the services of a medical practitioner or other health care professionals; while others are co-located on hospital grounds either within or separate from the hospital’s Emergency Department (ED).

The evaluation report at page 98 acknowledges that the MOC currently utilised within the WiC is not the MOC originally intended, which would have seen the full implementation of both the advanced practice nurse and nurse practitioner roles. “The lack of implementation of the nurse practitioner role was a source of dissatisfaction … [and] considered a lost opportunity. … The implementation of this role and inclusion of it in future ACT Walk-in Centres needs to be considered in terms of the capacity nurse practitioners have in the provision of primary care services and the scope of primary care services to be provided at Walk-in Centres” (p98). These are sentiments that the ACT ANF and its members very much support.

The ACT ANF considers that alternative MOC proposals for future WiCs need to be considered. As outlined in the ACT ANF February 2009 submission, the ACT ANF would be open to a mixed nursing classification structure, comprising Nurse Practitioners at Registered Nurse (RN) level 4.2 and supported by skilled nursing clinicians at RN levels 2 and 3. In keeping with the UK experience, and as suggested as an alternative MOC within the report at page 99, the ACT ANF would also be open to suggestions in relation to WiCs being established along collaborative lines utilising a GP-assisted model or an allied health professional collaborative model. Within the evaluation report, this alternative suggestion is made in response to the advanced practice nurses’ perceived “limited scope of practice” (p99). This suggestion has merit in recognising that “the presence of an additional medical source of ongoing education, collaboration and training … [could be] … an important factor in implementing nurse practitioner roles” [and without the need to have a doctor] physically present within the Walk-in Centre to achieve this” (p99).

As concerns in respect of the provision of ongoing educational opportunities for WiC employees was raised within the evaluation report, collaborative MOCs could also be utilised in addressing this identified need. In addition, as primary and preventative
health care provision is strongly supported within the National Health and Hospital Reform Commission’s (NHHRC) recommendations for national health reform, and is a strong motivator in respect of the establishment of a Local Hospital Network, particularly in relation to Primary Health Care Organisations/Medicare Locals, the establishment of robust nurse-led WiCs would appear to fit well with the national health care agenda and its focus on the delivery of primary and preventive health care

services within the community. It would therefore appear that the establishment of nurse-led WICs within the ACT could complement other primary care services.

In expanding this MOC and thereby increasing the career opportunities available to nurses within the ACT, a collegial support system is likely to flourish, further educational opportunities are more likely to be available and a greater diversity of nurses, skills and classifications could be available to support the model and each other. This is particularly relevant given some of the comments expressed within the evaluation report in terms of the ability to readily backfill positions to facilitate the utilistation of personal and annual leave, but also in terms of study leave and opportunities for professional development.

It would appear from the evaluation report that frustrations have been expressed not only by the WiC employees in relation to follow-up and outcomes, but also in respect of other health care providers. The Clinical Decision Support Software (CDSS) was identified as being problematic because of the restrictive nature of the algorithms required to be utilised by the WiC employees as well as its inability “to interface with other systems or generate particular report” (p85). “The protocols utilised by the Walk-in Centre nurses are perceived by stakeholders to be both a source of support and limitation for the nurses working at the Walk-in Centre. Closely related to this is the number and nature of referrals generated as a result of the protocols. Whilst they are a valuable, supportive risk management strategy, they are perceived to limit the capacity of the nurses to utilise clinical decision skills, which would provide an increased scope of practice, ultimately improving access to primary care for those attending the Walk-in Centre. … Additionally, well integrated systems can enhance patient safety through sending electronic prescriptions to pharmacies and providing automated medial record and medication history checks” (p99). Therefore, the ACT ANF considers that it is imperative that appropriate technological support and communications systems be established to facilitate close collaborative links with GPs, Allied Health and other health service providers within the ACT.

Further, if WiCs are to be successfully implemented within the ACT, Nurse Practitioners working within WiCs must be facilitated to prescribe Pharmaceutical Benefits Schedule (PBS) subsidised medications to the full scope of their agreed formulary and order appropriate Medicare funded diagnostic tests through the Medical Benefits Schedule. By so doing, Nurse Practitioners working within the WiC could work to the full scope of their knowledge and expertise and further enhance the value of the services provided within the WiC. The ACT ANF therefore considers that a re-evaluation of the scope of practice and role of all nursing classifications employed within the WiC should be undertaken.

In respect of the estimated costs associated with each episode of care provided within the WiC, the ACT ANF notes the wide range of estimated costs, between $101 and $175 per service (p 15, 112, 125), which meant that the WiC costs were estimated to be somewhere between costs incurred through an ED visit and those associated with an GP consultation. The ACT ANF also notes that as WiC presentations continue to grow as it becomes more widely known, established and accepted within the ACT community, episode costs are likely to decrease. The ACT ANF further notes that over the past 3-4

months presentation rates have increased and referral rates have decreased with over 77% of total presentations being able to be treated at the WiC with no need for further referral. As the evaluation report also outlines, it is not possible to estimate cost saving or expenditure in terms of clinical outcomes or quality of life associated with early treatment, education or referral or the lack thereof, if the WiC had not been utilised.

Conclusion

The ACT ANF welcomes the findings provided within the evaluation report prepared by the Australian Primary Health Care Research Institute.

The ACT ANF notes that the WiC has provided a safe and effective service which is supported and valued by the ACT Community, with 84% of patients suggesting that they would recommend the WiC to family and friends and 82% indicating that they would use the service again.

The ACT ANF also notes that 63% of clients were treated by the WiC staff, 21% were referred to GPs and only 5% of clients were referred to the ED during the 12 months of the study, with recent statistics indicating that currently 77% of total presentations are being treated at the WiC and referral rates are decreasing.

The WiC provides ACT health consumers with a safe alternative health care option, particularly given the ACT’s acute shortage of GPs, especially bulk billing GPs.

The ACT ANF recommends that further consideration be given to the appropriate location of Nurse-led WICs and that this model of care would be more appropriately located within a community care setting in keeping with its philosophy and vision in respect of delivering primary health care services.

The ACT ANF further recommends that nurses employed within the WiC, particularly Nurse Practitioners, be supported to work within their full scope of practice and role and consideration be given to alternative models of care such as future WiCs being established along collaborative lines utilising a GP-assisted model or an allied health professional collaborative model.

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