Nurses and midwives’ rightful place is at the centre of primary health care
We need to challenge the prejudice against nurses and midwives using the full extent of their knowledge and abilities, Mary Chiarella told the NSWNMA Annual Conference.
Efficient and effective primary health care “is the only way our health system in the future is going to be sustainable,” said Chiarella, a former chief nursing and midwifery officer in the New South Wales Department of Health, and a professor emeritus at University of Sydney’s Faculty of Medicine and Health.
Expanding nurses and midwives’ scope of practice can deliver an accessible and responsive primary healthcare system that reduces “health inequity and improves quality of life”, Chiarella said.
“We have to remember that only 17 per cent of the primary healthcare workforce are actually GPs, and the other 83 per cent are made up of nurses, midwives, nurse practitioners, Aboriginal and Torres Strait Islander health practitioners, and allied health practitioners. And these experienced clinicians are delivering excellent integrated care, often to disadvantaged groups, which augments, rather than fragments, the patient’s healthcare management.”
Unfortunately, vested interests are opposed to expanding the role of nurses and midwives in primary health care, she said.
“In Australia, the politics of primary health care are tied up with the funding of primary health care. The medical professional groups – the AMA and the RACGP, in particular – oppose any moves on behalf of nurses and midwives to move legitimately into primary health care in their own right.
‘My view is we are Amazons, not victims. You are going to have to become stronger, more passionate, more persuasive, and persevere more.’
— Mary Chiarella, former chief nursing and midwifery officer, NSW Department of Health and professor emeritus at University of Sydney’s Faculty of Medicine and Health
“But this would suggest that GPs are everywhere, doing everything in primary health care, which is demonstrably not the case.”
Chiarella cited Ross Gittins, economics editor of the Sydney Morning Herald, who recently pointed out that other countries with good health care “make sure that GPs can’t insist on doing things that could be done by other health workers, nurses, nurse practitioners, pharmacists and physios”.
In Australia, however, “the existing funding system brings considerable financial rewards to the medical profession, in terms of controls and or monopolies on certain practices, such as prescribing treatments and referrals.”
Chiarella urged the audience to resist the current system where “the nurse or the nurse practitioner or a midwife is earning money for and on behalf of a GP.”
While organised medicine has previously sanctioned nurses and midwives carrying out many tasks that were not of themselves revenue raising, such as dialysis, “it has actively resisted the transference of others that are income related”.
Chiarella noted: “There is still a belief that doctors are in charge of the healthcare system and the patients. All other staff are subordinate to them and controlled by them.”
Nurses need to build coalitions
Chiarella observed that many nurses and midwives are highly skilled and qualified, often more so than junior doctors.
Legislation to approve the introduction of nurse practitioners was introduced in New South Wales in 1998, and as of December 2022, there were 2492 endorsed nurse practitioners in Australia.
But Chiarella said that while the role is now recognised and protected, more work is needed to persuade interest groups and the wider public of the legitimate role of nurse practitioners, as well as nurses and midwives more broadly. Particularly in the face of opposition from groups such as the AMA and RACGP, who want to restrict the role of nurse practitioners and limit the MBS services they can deliver.
After much lobbying and consultation, the 2023–2024 federal budget at first appeared to offer some hope when the federal government announced Medicare rebates for care provided by nurse practitioners would increase by 30 per cent.
Budget papers also allowed for nurse practitioners “to participate in Medicare-subsidised multidisciplinary team case conferences, offering better support to people with chronic conditions”, Chiarella said. A new $50-million scholarship program to encourage nurses and midwives to undertake postgraduate study and support registered nurses to become nurse practitioners was also announced.
But hidden in the fine print was the news that these changes would not commence until July 2024, she said.
Chiarella called for strong, disciplined coalition-building between nursing professional groups, strategic political lobbying, and campaigns to raise public awareness.
Citing the number of former nurses and midwives in powerful leadership roles today – including Ged Kearney and Helen Haines in federal parliament; Trish Davidson, Vice-Chancellor at the University of Wollongong; and Susan Pearce, Secretary, New South Wales Ministry for Health – Chiarella said now is the moment to fight for nurses and midwives’ rightful place at the centre of primary health care.
“My view is we are Amazons, not victims. You are going to have to become stronger, more passionate, more persuasive, and persevere more, if necessary, because the evidence is already out there that we do make a difference.
“We cannot allow archaic systems to continue. We need to continue to speak up and lobby for best practices in health care. And we need to provide evidence that nursing and midwifery primary health care is the answer to the overcrowding in our hospitals.”