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Independent nurse-led clinics in primary care


1. Position

The RACGP:

  • supports a collaborative model between patients, their general practitioner (GP) and other healthcare providers
  • does not support any model that results in fragmentation of care by increasing the number of community-based health service providers providing initial access, assessment, triage and diagnosis, and reducing the coordination of care
  • highlights that there is insufficient evidence to draw conclusions about the benefits of independent nurse-led clinics and their potential impact on healthcare services
  • sees that combining, rather than duplicating, facilities is a more cost-effective way to increase accessibility of care, ensuring optimal and equitable use of limited health resources
  • considers that independent nurse-led clinics must be part of an integrated general practice model, and supports nurses working to their full scope of practice as part of a GP-led team
  • supports nurse-led clinics working in partnership with other healthcare providers in communities of need. However, such models of care are not seen by the RACGP as a long-term solution to health workforce issues; all patients should have access to culturally responsive, GP-led primary healthcare.

2. Definition

Independent nurse-led clinic: Refers to a facility that is led by nurses and operates in the community external to a general practice setting. Nurses in these clinics have their own patient caseload and deliver treatment (within their scope of practice) for illnesses and injuries. Sometimes, these clinics have extended operating hours and do not require an appointment or referral.

3. Background

General practice is at the centre of primary healthcare in Australia and is the most common point of entry to the health system, with nine in 10 Australians seeing a GP each year.Due to their extensive medical training and a focus on comprehensive, patient-centred care, GPs are best positioned to be the clinical leaders of multidisciplinary care teams responsible for patient care coordination.

Like many developed nations, Australia is faced with the challenge of providing comprehensive and timely healthcare services to an ageing population with high levels of chronic disease. In addition to this challenge, Australia also faces issues with the distribution of healthcare professionals across the country and increasing sub-specialisation of the health workforce.2

In response, governments and the nursing profession have sought to implement new models of nurse-led primary care. They have also worked to expand nurses’ scope of practice to include independent practice and prescribing, and transition from specialist to generalist roles.3 4 Such proposals aim to promote independent decision-making and clinical leadership, with the implied intent to position nurse-led care as an alternative to GP-led care within the primary healthcare sector.

3.1 The role of nurses as part of GP-led teams

As the hub for the promotion and management of health and wellbeing in the community, general practices aim to use an integrated approach that meets increased care demands.

The RACGP supports the involvement of nurses in GP-led multidisciplinary care teams, such as in the general practice setting. The general practice sector is the largest employer of practice nurses in Australia, with over 12,000 nurses employed in general practices.5 The RACGP’s 2019 General Practice: Health of the Nation survey indicates that up to 92% of general practices employ at least one practice nurse.6 The RACGP has supported the Workforce Incentive Program Practice Stream (formerly the Practice Nurse Incentive Program) to encourage more general practices to employ nurses as part of a GP-led multidisciplinary care team.

General practice nursing care improves efficiency and capacity in general practices by:

  • assisting patients with chronic disease management or providing clinics and education for diabetes, cardiovascular and respiratory diseases
  • illness prevention, immunisation and wound care
  • managing practice quality systems and processes
  • providing outreach services to high-risk patients
  • providing health promotion, focussing on wellness and promoting heathy living, health education and self-management
  • supporting general practice to integrate the acute and rehabilitative phases of care, keeping individuals in their community for as long as possible.7

Patients and primary healthcare providers have benefited significantly from the contribution that nurses make to general practice. The integration of nursing professionals into general practice has been shown to contribute to healthier communities and more positive health outcomes, by proactively engaging members of the community with general practice initiatives.8

3.2 The role of advanced practice nurses in communities of need

In communities of need, advanced practice nurses play an important role in providing culturally competent healthcare, working in partnership with other healthcare providers, and often fulfilling a generalist scope of practise.9 Communities of need include where there are GP workforce shortages in rural and remote locations, and Aboriginal Community Controlled Health Services; or Refugee Health Services where the patient population is not able to access Medicare subsidised services, and therefore cost is a barrier to seeking care from a general practice.

However, such models of care are not seen by the RACGP as a long-term solution to general practitioner workforce distribution issues, and ensuring affordable access to comprehensive and expert care for vulnerable populations. All patients should have access to culturally responsive, GP-led primary healthcare.

4. Issues

4.1 A lack of evidence to support efficiency or effectiveness

The evidence to support the long-term benefits of independent nurse-led clinics is unclear.10 11  There is no clear evidence that nurse-doctor substitution saves money or reduces the workload of GPs.12 There is no controlled trial evidence of the quality of care provided by walk-in clinics, nor the efficacy of their management of chronic disease.13 Efficiency gains have not been observable due to a high level of task duplication, particularly when individuals present to clinics (or walk-in centres) and subsequently general practice with the same problem.14

The ACT Health Walk-in Centre model of care has not been adopted or implemented elsewhere in Australia in the nine years since its establishment.

International experience reflects this ambiguity. Between 2010 and 2013, 20 UK-based nurse-led walk in centres were closed, and prior to 2010, many nurse-led clinics were replaced by GP-led clinics. Commonly cited reasons for closures were:

  • a failure to reduce emergency department attendances
  • duplication of GP services
  • walk-in centres artificially create demand – that is, their convenience means they mostly cater to those who would otherwise self-manage
  • a lack of clarity amongst members of the public about the purpose of the walk-in centres, leading to fragmented care.15

4.2 Quality and safety of care

Nurses do not have the breadth of training required to practice in an open access environment where patients present with a broad range of undifferentiated health problems. Nurse-led care may result in unusual (and sometimes serious) conditions not being recognised and managed because they are beyond the level of training and expertise of the nurse. The majority of medical training focusses on distinguishing diagnoses which cannot be taught as a standalone course or module.

Nurses are also not trained to independently manage patients with multiple co-morbidities and complex care priorities, particularly where the patient has been prescribed multiple medications. Mismanagement could result in potentially harmful drug interactions if new medications are prescribed, or missed opportunities to review medications and consider de-prescribing.

This is particularly concerning in the face of increasing antimicrobial resistance.16 Prescribing fewer antibiotics is of paramount importance, and expanding the number of prescribers is counter to these efforts.

4.3 Equity of access to care

Although intended to improve access to healthcare, independent nurse-led clinics are likely to accentuate health inequalities by creating a two-tiered health system. Nurse-led walk-in centres in Australia are primarily located in the Australian Capital Territory (ACT), where GP bulk billing rates are the lowest in the country, and the number of GPs per 100,000 population are lower than the national average.1

Nurse-led clinics are also more likely to exist in communities of need or areas of social disadvantage, as described in section 3.2.

This may result in disadvantaged population groups being offered nurse-led care as a ‘more affordable’ or ‘more accessible’ alternative to care provided by a GP.17 Patients in all locations around Australia should have access to the same standard of medical care.

4.4 Fragmentation of care

General practice training, defined by the provision of patient-centred care, enables GPs to interpret information received from physical, psychological and social perspectives. GPs manage comorbidities and identify health issues that present in an undifferentiated way, and when urgent intervention is required.

A key role of general practice is to guide patients through the complexities of the healthcare system, and prevent unnecessary screening, testing and treatment. Creating additional entry points to the health system and introducing more independent healthcare providers will fragment care.

Evaluation of the ACT Health nurse-led walk-in centre showed that patients did not have an ongoing relationship with centre staff. Key stakeholders in the health system had not been contacted by staff since the centre had opened.18 The evaluation also indicated that the nurse-led model of care is a ‘silo’ approach to healthcare18 which undermines the core principles of patient-centred healthcare and continuity of care.19

4.5 Unnecessary referrals and increased health expenditure

Health systems underpinned by strong primary healthcare with general practice at the centre lead to better outcomes, lower costs and improved population health.19 The Australian Government has recognised general practice as the most appropriate setting in which to provide person-centred, continuous and coordinated care to the community.20

The average cost to taxpayers per service provided by the walk-in centre is $162,21 while the taxpayer cost of a standard Level B GP consultation is $38.22

Dependant on experience, nurses rely on decision-making algorithms in their practice, which may result in high levels of referrals to specialists, high rates of diagnostic testing and prescribing.23 24 By comparison, a GP could make an expert clinical judgement not to refer or prescribe, and instead treat and manage the patient within the general practice setting.

A Cochrane review of non-medical prescribing for acute and chronic disease management in primary and secondary care found that non-medical prescribers prescribed more drugs, intensified drug doses and used a greater variety of drugs compared to usual care medical prescribers.25

5. Related resources

  1. Department of Health. Annual Medicare statistics – Financial year 1984–85 to 2018–19. Canberra: DoH, 2019.
  2. Australian Government Department of Health. National Medical Workforce Strategy Scoping Framework. July 2019.
  3. Australian Government Department of Health and Ageing. Primary healthcare reform in Australia: report to support Australia’s first National Primary Healthcare Strategy. Canberra: Commonwealth of Australia; 2009.
  4. Australian Government Preventive Health Taskforce. Australia: the healthiest country by 2020. National preventative health strategy – the roadmap for action. Canberra: Commonwealth of Australia; 2009.
  5. Australian Government Health Workforce Data tool, 2017. Available at hwd.health.gov.au
  6. The Royal Australian College of General Practitioners. General Practice: Health of the Nation 2019. East Melbourne, Vic: RACGP, 2019.
  7. Nursing in General Practice: A guide for the general practice team published by Australian College of Nursing, Canberra, 2015
  8. Finlayson, M P., Raymont A. Teamwork – general practitioners and practice nurses working together in New Zealand. J PRIM HEALTH CARE 2012;4(2):150–155.
  9. Department of Health, Cost Benefit Analysis of Nurse Practitioner Models of Care, prepared by KPMG for the Department of Health, November 2018
  10. Desborough J., Forrest L., Parker R. (2011). Nurse-led primary healthcare walk-in centres: an integrative literature review. Australian Journal of Advanced Nursing 68(2): 248-263.
  11. Salisbury, C, Munro, J. (2003). Walk-in centres in primary care: a review of the international literature. British Journal of General Practice, 53(486): 53-59.
  12. Anthony, B. Surgey, et. al. General medical services by non-medical health professionals: as systematic quantitative review of economic evaluations in primary care. British Journal of General Practice, May 2019, United Kingdom.
  13. Chen CE, Chen CT, Hu J, Mehrotra A. Walk-in clinics versus physician offices and emergency rooms for urgent care and chronic disease management. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD011774. DOI:10.1002/14651858.CD011774.pub2.
  14. Salisbury, C., Manku-Scott, T., Moore, L., Chalder, M., Sharp, D. (2002). Questionnaire survey of users of NHS walk-in centres: observational study. British Journal of General Practice ;52:554-60.
  15. Monitor. Walk-in centre review: final report and recommendations. February 2014. UK.
  16. World Health Organisation Fact Sheet: antimicrobial resistance, 20 February 2020.
  17. Hatchett, R. (Ed.) Nurse-led clinics: practice issues. Routledge, 2013. United Kingdom.
  18. Parker, R., Forrest, L., Desborough, J., McRae, I., Boyland, T. (2011). Independent evaluation of the nurse-led ACT Health Walk-in Centre. Canberra: Australian Primary Health Care Research Institute.
  19. The Royal Australian College of General Practitioners. Vision for general practice and a sustainable healthcare system. East Melbourne, Vic: RACGP, 2019.
  20. BEACH team. A decade of Australian general practice activity 2004-05 to 2013-14. General practice series no.37. Sydney.
  21. ACT Legislative Assembly Inquiry into referred 2017-18 Annual and Financial Reports, Answer to Question on Notice QON No. 147
  22. Department of Health, MBS Online.
  23. Hughes DR, Jiang M, Duszak R. A Comparison of Diagnostic Imaging Ordering Patterns Between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits. JAMA Intern Med. 2015;175(1):101–107. doi:10.1001/jamainternmed.2014.6349
  24. Aledhaim A, Walker A, Vesselinov R, Hirshon JM, Pimentel L. Resource Utilization in Non-Academic Emergency Departments with Advanced Practice Providers. West J Emerg Med. 2019 Jul;20(4):541-548. doi: 10.5811/westjem.2019.5.42465. Epub 2019 Jul 1.
  25. Weeks G, George J, Maclure K, Stewart D, Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care (Review) The Cochrane Collaboration 2016.

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