TAKAPAU HEALTH CENTRE One of the early visions for nurse practitioners was improving rural New Zealanders’ access to healthcare as country GPs became scarce. After a slow beginning with getting a critical mass of nurses over the NP registration hurdle, there are now more than 30 primary health care NPs practising in New Zealand. FIONA CASSIE looks at two significant rural models - first up Takapau Health Centre
Two decades on from its tentative launch with a single nurse working 10 hours a week, the nurse-led Takapau Health Centre now has two NPs, four nurses and around 2000 patients on its books.
At first it was a steady trickle, but once word got round that Takapau Health Centre had not one but two prescribing nurse practitioners, the floodgates opened.
The central Hawke’s Bay centre has always been busy, but primary health care NPs Ingrid Cheer and Leanne Hutt say demand in the past 12 months for them and the four part-time nurses is now verging on unsustainable.
This is a strong endorsement for the NP-led service, but the community trust-run centre has always battled for funding in a primary health care funding system where nursing doesn’t fit neatly.
The centre opened its doors in 1992 with a part-time nurse after the rural community rallied around and bought the former post office that houses the centre. An outreach clinic was opened in Norsewood in 1996.
The closest GPs to Takapau are in neighbouring towns (Waipukurau, about 20 minutes drive north, or Dannevirke about 30 minutes drive south). Now, as always, the GPs are busy, and with GP books often closed to new enrolments, the nurse-led centre has filled a niche for the rural community. A complex mix of funding contracts keeps it afloat.
Ingrid Cheer joined the centre as rural health nurse manager in 1995 and rural health nurse Leanne Hutt came on board in late 2005. Both were on their nurse practitioner pathway, and in 2007 were successful in winning Ministry of Health rural nurse scholarships, allowing them to take a year off to complete their masters degrees.
In the winter of 2010 they both became prescribing primary health care nurse practitioners.
After readying themselves to provide an NP service, the centre was relaunched in late October 2010. Initially, there was a slow and steady increase in consultations.
“The floodgates opened about March of last year,” says Cheer. Word of mouth about what NPs could provide led to a staggering 1000 additional NP and nurse consultations – a 33 per cent increase – in the past 12 months.
The number of patients registered at the centre has grown from about 1200 in 2001 to 1800 midway through last year and now it would be around 2100.
Becoming NPs means the pair can step up the services on offer, but this has only had limited impact on the funding that an NGO (non-governmental organisation) provider like the trust can receive.
About 60 per cent of their current funding comes from a Hawke’s Bay District Health Board contract to deliver primary health care services across the lifespan. A further 25 per cent comes from ACC and the remaining nearly 15 per cent from six other small contracts for things like B4 school checks, cervical screening and healthy lifestyle clinics.
“It’s a tenuous funding arrangement and it always has been,” says Cheer. Constantly negotiating and reporting on the various contracts is very time-consuming for Cheer in the dual role of NP and nurse manager. Hutt splits her time as an NP between two days working as an NP for the Takapau centre and two days at a general practice in Waipawa, along with being a mother of two young children.
“The DHB has been very supportive and they acknowledge that if (the growth) continues than it’s obviously not (financially) sustainable,” says Cheer. The immediate response has been one-off targeted funding to redesign Cheer’s nurse manager role and devolve some of the administrative burden to a practice manager so she can do more clinical hours.
Cheer says the ideal situation would be to have two nurses on duty at any one time at the Takapau centre – a nurse and an NP – rather than the current model of a free drop-in nurse clinic in the morning and an appointment-only NP clinic in the afternoons.
“Obviously it would be a perfect environment for nurturing NPs, having two NPs in a small centre like ourselves, so you could have an RN working alongside an NP, to motivate and encourage them to take the same pathway,” says Cheer.
It would also be ideal if funding for the service was not an ongoing struggle. A significant proportion of the contracts stipulate no co-payment, and the drop-in nurse clinics are financed purely on a ‘koha’ basis.
During the afternoon NP clinics, however, the NPs now charge $25 (or $20 for community service card holders) for services that only NPs can legally provide, such as prescriptions, ordering diagnostic tests, or renewal of sickness benefit certificates.
Cheer says probably 40 to 50 per cent of the appointments during her NP clinics are now charged-for NP consultant work, along with people wanting a longer consultation, immunisation, and cervical screening.
Hutt does both the drop-in clinic and the NP clinic and says she sees everyone from babies to octogenarians within a typical working day, including children with ear infections, managing chronic conditions, ACC work for people with everything from cuts to concussion, case management work, smoking cessation, and preventative health.
They were also successful last year in winning rural innovation funding for 12 months from the Ministry of Health to allow them to develop a case management service, involving Flinders self-management tools, for high-priority patients and families, including under-two-year-olds, MÄori and Pacific patients, patients with diabetes or cardiovascular disease, and tobacco users.
It took more than receiving their NP registrations in the post to kick-start offering a NP service. The centre invested in the Medtech patient management system used by many general practices, installed EFTPOS, set up links with diagnostic and DHB services, and visited all the local pharmacies to introduce themselves as new prescribers. As novice NPs, they are still bedding down their new role and building the referral networks to support their wide-ranging patients.
The majority of their centre patients are enrolled with a local GP, though in the case of some new residents, the GPs are spread across the district, some because they haven’t been able to register with a local GP. Others have chosen to stay with their original GP, who might be an hour’s drive away in Hastings, or as far away as Rotorua or Dunedin.
The pair say that as RNs they probably referred about 10 per cent of their patients on to GPs, but as NPs they would refer around two per cent, as they could liaise with the GP and keep them in the loop.
The pair work collaboratively rather than competitively with their local GPs, and are keen to keep it that way. “I think it is important for people to maintain their GP in our situation so that we can work collaboratively, and hopefully our role is to support GPs,” says Hutt. Ideally, they are keen on a primary health capitation funding stream that would allow for an interdisciplinary arrangement between NPs and GPs, and broader patient enrolment options with primary health organisations.
The centre is part of still evolving discussions for an Integrated Family Health Service for central Hawke’s Bay. The two NPs can see the day coming when shared electronic patient records will “unlock doors” to integrated patient care across health disciplines. Meanwhile, they are just busy dealing with the flood of people keen to use their service.
An NP and GP professor ‘job sharing’: the times are a changing…
For the first two years after registration, rural nurse practitioner Anne Fitzwater wasn’t paid as an NP. Now she is ‘job-sharing’ with an emeritus professor of general practice. FIONA CASSIE finds out more.
Anne Fitzwater has come full circle and is now practising as an NP in the building she was born in.
That was long enough ago now for her to be thinking of retirement. But for the past two years she has been happily working part-time for the East Otago Health general practice based in the old Palmerston Cottage Hospital.
She is one of three practitioners in the practice, and since late last year her part-time colleague has been the Dunedin School of Medicine’s emeritus professor of general practice, Campbell Murdoch.
Fitzwater laughs when recalling how Murdoch, a “delightful and humble man to work with”, cheerfully told everybody at a recent conference that they job share. “Which basically, we are. He works the days I don’t… a few years ago that would have been seen as a bit crazy.”
It is a long way from when she started as a rural NP in the beautiful but isolated and damp Fox Glacier as the sole health practitioner on 24-hour call for 10 days at a stretch.
Fitzwater was a rural nurse specialist on the Coast from 2003 to the end of 2009 – an area she first fell in love with as a relieving rural nurse specialist despite her dislike of mosquitoes and rain. She became a NP in 2007, and a prescribing NP in 2009, but it took nearly two years until it was agreed to pay her as an NP and backdate it to the day she became registered.
But that wasn’t the reason she left the Coast. “I think nearly seven years of doing 10 days on 24-hour call was catching up. And I’m not young.” She and her husband decided to return to the area she grew up in, and bought a retirement home south of Oamaru.
Fitzwater then sent out a letter to the different rural practices in the region, seeking part-time work as an NP. “Some replied and some didn’t. There were mostly negative replies. After a few months, I took a deep breath and wrote to them all again, and the East Otago practice wrote back saying it was a ‘very exciting proposal’.”
The practice already had a nurse working in an advanced role doing on-call work at the weekend, so there was a good understanding about what advanced practice could offer.
“I’ve been terribly, terribly lucky I think, because the GPs have been extremely supportive and so have the nurses. I was a wee bit worried that the nurses might be a bit resentful but they’ve just been delightful, very supportive and it is a great team to work with.”
Since 2010, she has had a contract working two-and-a-half days a week alongside the East Otago practice’s two GPs (including Murdoch who practices on the days she is off). Each has an appointment book and charges patients the same rates, but Fitzwater has 20-minute appointments compared to the GP’s 10 minutes.
Fitzwater says her contract is funded out of the primary health organisation’s capitation-based funding. She says the only funding difficulty they have is trying to claim back costs from another PHO if she sees an out-of-town patient.
Initially she was very conscious of having basically been an autonomous, solo practitioner for seven years. “I had to keep reminding myself I was part of a team,” she says. But she has found it great to be able to ask for advice ‘on the spot’ from her colleagues. And she doesn’t miss the after-hours and weekend call-outs.
“Also, the work is different – the community at Fox Glacier was a young community with lots of young families and a lot of young single people coming to work in the tourist industry.
“We have an ageing population here and see many more older people,” she says. While one or two patients made it clear they didn’t think an NP was “good enough”, she found to her surprise that she is particularly popular with older women, who, instead of being thrown by seeing a ‘nurse’, are very happy to be able to talk to a woman, as Fitzwater’s GP colleagues are both male. As the only female practitioner, she also sees a lot of the women patients and the children, plus she does all the diabetes checks.
The rural practice, that covers a wide geographic area, also still does emergency work by necessity. “Someone came in on Monday and collapsed in the carpark.” And Palmerston is 40 minutes away from an ambulance coming from either Dunedin or Oamaru.
Five years on from becoming an NP, Fitzwater says while some barriers to practice have been removed, for instance now she is able to sign ACC forms and sickness benefit forms, plus she can apply for special authorities for restricted medications, others still frustratingly remain.
The 2011 Medicines Act amendment Bill, currently before parliament, should help remove some of the remaining barriers by making NPs authorised prescribers. This will, for example, change the limit on how many days’ morphine a primary health NP can prescribe to a home-based terminal cancer patient.
Another proposed omnibus bill removing legislative barriers should change some of the other “silly little things”, such as not being able to sign off everyday sick leave when NPs can sign off an ACC or beneficiary certificate. Or, despite being the practitioner called out to a sudden death, not being able to sign an ‘extinction of life’ certificate, required by the police before they can remove a body, so the police have to also call in an advanced paramedic who can complete the certificate. “On the West Coast, we got around it with permission from the coroner, but here (and most places in New Zealand), we can’t sign that.”
On the positive side, unlike some NPs, she has not had difficulties gaining the okay for ordering radiology and laboratory tests, and initial problems with referring patients to Dunedin Hospital were overcome with the help of the district health board’s director of nursing.
Fitzwater was one of the first winners of the “excellent” rural health postgraduate diploma offered by Jean Ross and Martin London from the Christchurch School of Medicine to go on and get her master’s degree and become a rural NP.
Even now, there is only a handful of rural primary health NPs in the South Island, out of the 30-plus primary health NPs country-wide.
Fitzwater, having herself been on a couple of NP panels, believes the Nursing Council registration process has improved, with more guidelines and support for candidates and panelists than in the early days.
She says more than a decade on from the first nurse practitioner, many people still don’t know what an NP is and it will take even more NPs for the public to become fully aware of the role. Meanwhile, east Otago patients have the rare opportunity to get the best of both worlds with their job-sharing NP and GP professor.
New physician assistant trial in PHC to include NP
A decade on from the nurse practitioner role being launched, more pilots of the physician assistant* model of care are planned – this time in primary healthcare.
A pilot could be under way by November, with at least three US-trained physician assistants (PAs) working under the supervision of GPs in the Midlands Health Network (MHN) region, including at least one rural general practice.
At least one of those PAs will also be working alongside a nurse practitioner, following discussions between the New Zealand Nurses Organisation (NZNO), MHN, and Health Workforce New Zealand (HWNZ), following the announcement of the trial. HWNZ director Brenda Wraight told Nursing Review that her organisation hoped to “identify one or two other communities” to demonstrate the PA role before the end of the year.
The Counties Manukau District Health Board pilot in 2010-11 saw two US-trained PAs working in senior clinician roles, under physician supervision, to support elective surgery services. The pair was unable to prescribe, as there is no New Zealand registration or education process for PAs.
The announcement of the follow-up PA pilot in primary health was initially condemned by the NZNO. Susanne Trim, NZNO professional services manager, says the NZNO argued for the Counties Manukau DHB trial to be a wider pilot involving NPs, and had argued again for the planned primary healthcare pilot to include NPs, so the outcomes could be measured and compared.
She says NZNO continued to have “significant concerns” that the costs of setting up an education programme for a new role like the PA, or whether such a role was sustainable, had not been examined. “Any evaluation needs to take that into account.”
Trim says her personal opinion is that NPs are a much more flexible option for the New Zealand health system than the PA model.
Wraight, prior to the decision to include an NP in the trial, told Nursing Review it was expected that the pilot PA salaries would be “on par” with the NP salary structure, and the pilot employer would “bear a significant portion” of the salary costs during the demonstration.
She says PAs have been shown to free up GP time by assisting with activities such as completing documentation, screening, patient education, performing examinations and responding to patient emails, so GPs can respond to more complex care needs,.
Wraight pointed out that both the PA and NP model were established in the US and had been shown to be “complementary”. “In New Zealand, NPs will continue to have an important role and there continues to be a need for more than one solution to ensure workforce sustainability and flexibility,” says Wraight. “It is very likely that the New Zealand health sector would need both roles, and the exact skill mix will depend on local circumstances and need.”
When health minister Tony Ryall was asked what role he envisaged PAs playing in the future he replied that “physician assistants could be another part of the multi-disciplinary team and we are trialing the role in other settings”.
Wraight says it is possible that prescribing under standing orders may be extended to the primary health PAs, “if the physician deems it appropriate”. Also, the Health Practitioners Competence Assurance Act is being reviewed this year and could examine the “ability of professionals to work to their full scope of practice”.
It is understood that the primary health PA pilot will include at least one rural general practice and that more than a dozen practices had expressed interest in taking part.
Midland Health Network chief executive John Macaskill-Smith declined to comment when approached by Nursing Review, saying the network was waiting for “a discussion to be completed between a number of parties”, and he could not comment until the details were settled.
Wraight said once a formal pilot proposal was received, a “robust” recruitment process was put in place and an “intensive orientation” programme completed, the earliest that the pilot PAs could be expected to start would be around November this year.
The formal evaluation of the Counties Manukau DHB pilot has recently been released (see For the Record).
*US-trained physician assistants* usually do a two-year postgraduate qualification and about half come from a nursing background, with the other half from various health professions. It is a medical model of care, and PAs work under physicians, whereas NPs can practise and prescribe autonomously within their scope.*
