New anti-competitive barrier being created for NPs?

1 May 2014

PROFESSOR JENNY CARRYER is alarmed that after 10 years of battling barriers hindering nurse practitioners, a new contract currently being negotiated for primary health providers could create yet another barrier.

The College of Nurses is distressed to learn that it is proposed that a new definition of a general practice team will become embedded in agreements between PHOs and contracted providers.

That definition will assert that a full team contains both nurses and medical practitioners and exceptions will need to be negotiated individually with the relevant district health board.

Those of us who have spent more than 10 years now battling the tedious barriers to NP practice see this as a potential additional barrier, as once again we waste precious energy arguing for an exception to a rule and eventually arguing for removal of ‘the rule’.

This is so contrary to notions of flexibility, responsiveness, and sheer pragmatism. It also ignores considerable long-standing evidence that nurse practitioners are able to deliver safe and effective care in a highly cost effective manner.

This situation may have arisen on the basis of the proposed payment of GMS (general medical schedule) payments to all members of the primary health care team as opposed to just GPs. The situation involves apparent attempts to redefine the definition of primary care team as a component of this work.

The proposal to pay GMS to NPs, nurses, and pharmacists was approved by Health Minister Tony Ryall and announced on his behalf last year by Dr Jane O’Malley at the College of Primary Health Care NZNO nurses conference in Wellington. Following the announcement workshops were held to address implementation issues (Background: GMS is an additional payment directed to general practice as reimbursement from the Ministry of Health. It covers a small but important component of the 60 per cent government funding that sustains general practice services).

College members Kim Carter and Sharon Hansen reported that the GMS implementation meetings went smoothly, with the group working together to resolve technical and other issues related to the proposed change. It was agreed that those claiming GMS would be general practice-based and that technical changes were required in the ministry processes to facilitate a wider range of claimants. While there were understandable concerns about the potential for cost blowouts, it seemed that issues were resolved satisfactorily.

Early on, the college expressed concern that the ability to claim GMS should not be linked to the presence, or otherwise, of a GP in the claiming organisation. We did this because of our concern for the viability of rural services and services delivering care to homeless and vulnerable clients, which are increasingly nurse-led. The actual and predicted scarcity of GPs leads us to believe that sustainability of services will require NPs and nurses to have greater independence.

Philosophically nursing has no argument with the advantages and value of a collaborative and multidisciplinary primary health care team. Pragmatically however, we know that it is not always possible and may quickly become less so. Based on the college’s vision of 100 per cent access and zero disparities we believe that all agreements, contracts, and policy decisions must be future proofed towards the greatest degree of flexibility and responsiveness to community and patient need.

It is perhaps ironic that this should be happening under the auspices of a National-led Government, which by its very nature, promotes competition in support of market forces. A recent US policy paper debating this very topic warns legislators to be cautious about proposals that limit the scope of practice of advanced practice nurses. Limiting the range of services nurses can provide and the extent to which they can practice independently, is likely to have a number of anti-competitive effects. The paper goes on to say that:

Competition in health care markets benefits consumers by helping to control costs and prices, improve quality of care, promote innovative products, services, and service delivery models, and expand access to health care services and goods. While state legislators and policymakers addressing health care issues are rightly concerned with patient health and safety, an important goal of competition law and policy is to foster quality competition, which also furthers health and safety objectives. Likewise, to ignore competitive concerns in health policy can impede quality competition, raise prices, or diminish access to health care – all of which carry their own health and safety risks.

The new team definition has murky origins, no obvious evidence base and would seem highly counter to all asserted goals about maintaining services in the face of escalating need. So why is it needed? Whose interests are to be served by embedding such a definition?

Reference: Federal Trade Commission. (2014, March). Policy perspectives: Competition and the regulation of advanced practice nurses. Retrieved from

Professor Jenny Carryer is Professor of Nursing at Massey University and executive director of the College of Nurses.