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Brief analytical summaries or syntheses #2

Practice nurse cost benefit analysis: Report to the Ministry of Health in New Zealand

Summary

This study looks at the financial impact of transferring tasks from GPs to nurses and GPs in primary health care in New Zealand (NZ).  It describes a model developed to estimate this impact based on 2,000 consultations in nine New Zealand primary care practices and summarizes findings from a literature search.  It is clear that practice nurses can, and in some practices in NZ, do provide a broad set of primary care services. The study focuses on the financial contribution practice nurses make to primary care practices and does not address issues of quality of care, utilization of care, workforce availability or the managerial work required to distribute tasks between doctors and nurses.

Background

The study is part of the ‘New Zealand Primary Health Care Strategy 2001,’ which articulates a new vision of primary care built around a team-based approach.

The strategy, which involves a move to capitation-based funding, has created both risks and opportunities for primary health care practice nurses. It allows these nurses to be used to their full potential in primary care, but may also have a negative impact on the quality of care.

The transfer of certain tasks from doctors to nurses in order to reduce costs or improve access to care is a significant challenge. These tasks may include, for example, meeting with patients to explain lab results that are out of the ordinary or providing follow-up to patients with chronic diseases.

Analysis and results


The study clearly shows that nurses can, and in some practices in NZ, already do provide a broad set of primary care services. Data collected in two primary care clinics shows that nurses provide between 40% and 50% of total clinical consultations. Actual nursing roles in primary care can vary markedly between practices, as is evident both in the proportion of nurse consults and in the nature of the care they provide. This study does not provide information on the relative quality of nurse versus GP consultations, but the most recent Cochrane review indicates equivalent or superior outcomes for nurse consults in primary care.

Barriers to a broader scope of practice

The barriers to a broader scope of practice include insufficient facility space, insufficient nurses, nursing experience/skills and interest, and consumer expectations. The expectations and assumptions of the GPs in the practice are also likely to play a significant role.

Financial impact

The financial impact for a practice owner of substituting more nursing time for GP time is highly dependent on the following variables:

  1. nurse cost per minute relative to GP cost minute
  2. nurse consult duration relative to GP consult duration
  3. nurse consult revenue relative to GP consult revenue
  4. percent of nurse consults requiring GP time

For some practices, increasing the proportion of nurse consults and reducing GP consults without changing other parameters would result in significantly reduced profitability. For others the opposite applies.

1. Implementation of new models
The literature review undertaken as part of this study indicates that practice nurses can, at least for some consultations, provide care of equivalent quality to that provided by GPs. However, task substitution is strongly influenced by consumer acceptance and the interests of different professional groups. Resistance among professionals can be partially offset by the use of financial incentives and recognition of professional autonomy.

2. Nursing roles in care
The case studies show considerable diversity in nursing roles. However, in most clinics, nurses are generally responsible for immunizations, are leading the delivery of proactive care for people with long-term conditions, and have an emergent role in managing acute walk-in patients.

Conclusion

The modeling developed in this study indicates that task substitution will almost always be financially advantageous in very-low-cost-access practices.

Implications and recommendations

  • Impact on the financing of care
    Service funding arrangements that involve the same remuneration for the same task regardless of who provides the service are most likely to result in greater use of practice nurses.  This can be seen in:
  1. immunizations
  2. chronic disease management
  3. telephone calls, recalls, lab results calls
  4. acute consults in very-low-cost-access practices

Increased awareness of the financial contribution of nursing might also be useful in changing perceptions and assumptions. The study reveals that in some practices where payment for a service is similar regardless of which professional provides it, nurses make a greater contribution to practice activity-based revenue than GPs.

  • Implications for practice owners
    Practice owners face many constraints, including the availability and skills of the local workforce, and difficulties in changing long established business processes.  Nonetheless, practice owners stand to benefit by considering new ways of providing clinical services that make best use of, and extend, advanced practice nursing skills.  In many cases, an appropriate payment regime will make the transfer of a wide range of clinical tasks from GPs to nurses cost effective.

Source

Practice nurse cost benefit analysis: report to the Ministry of Health. Fichier PDF.