Nurses needed more now than ever in general practice
By Peter Larter, health economist and Director of Larter Consulting
As a small business owner, I understand that many general practices are grappling with remaining viable during COVID-19. Practice managers have told me that some patients are staying away and that mandatory bulk billing for telehealth/phone consultations is affecting the bottom line.
However, it is surprising and concerning to me that some nurses in general practice have lost their jobs or seen their hours significantly reduced. Now more than ever, general practice nurses have key roles to play in keeping Australians healthy.
There are compelling reasons why it is in a practice’s interest to do everything it can to retain nurses:
- Continuity of care. We know that nurses take time to develop relationships with patients, and we also know that patients sometimes talk more freely to nurses things about their lives, telling them important information because they don’t want to “bother” the GP. Nurses often also maintain important organisational aspects of patient care such as recall systems and follow up of specialist appointments. A nurse leaving employment takes all of this patient and business knowledge away with them, disrupting continuity of care.
- Turnover cost. The average cost of replacing a nurse in an Australian general practice is unknown, but in a hospital setting ranges from $17,000 to $105,000!
50% of this is for (a) termination processes (b) orientation of the new nurse and (c) decreased productivity as they learn their role and the culture of their new employer.
44% is the cost of getting a locum nurse to fill the gap, if this happens.
Only 6% is for advertising, interviewing and external training.
- Quality of care. Nurses can help identify and then telephone ‘at risk’ patients who may be staying at home and not coming into general practice at this time, for a chat and if warranted, connection to a GP, or for a care plan/review. For example, we know that people with heart disease are at higher risk of severe COVID-19 complications which may change care plan priorities. Other ‘at risk’ people may include people with existing mental illness that may be exacerbated through isolation and anxiety; pregnant women; refugees; and Aboriginal and Torres Strait Islander people. Nurses play many other important roles including accreditation preparation and managing the cold chain etc.
- Maintain revenue streams. General practice nurses can still assist GPs in undertaking care plans and reviews, and ATSI health checks, on the phone or via telehealth. Also, the Workforce Incentive Program (WIP) Practice Stream (formally called the PNIP – Practice Nurse Incentive Payment) provides up to $125,000 a year for the employment of up to 1.66 EFT nurses and/or allied health. If EFT is reduced, these payments may be reduced. Nurses may also be contributing to generating Practice Incentive Program (PIP) payments such as the Quality Improvement (QI) incentive which provides up to $50,000 a year (increased to $75,000 in calendar year 2020 through the COVID-19 National Health Plan for practices that remain open for face-to-face services at least four hours a day).
Thinking about the bottom line – what funding is available to retain nurses?
- WIP practice stream. The Australian Government will fund $75,301 for each 1.0 EFT of nurses (or allied health professionals) for eligible practices. This covers the full cost of a registered nurse on an approximate average base salary of $37.67 an hour, plus 15% on costs. Up to 1.66 EFT staff can be funded in this way.
- Chronic illness care planning. Skilled nurses can still substantially contribute toward the completion of chronic illness care plans, and care plan reviews. For example, a nurse could videoconference with the patient to collect information to inform the care plan or review, and then it could be completed with the GP on videoconference. Note that the phone should only be used when videoconference is unavailable. The items are:
GPMP #721 ($146.55 bulk billed) (videoconference #92024, phone #92068)
TCA #723 ($116.15 bulk billed) (videoconference #92025, phone #92069)
Review #732 ($73.20 bulk billed) (videoconference #92028, phone #92072)
Contribution to a residential aged care facility care plan, or review #731 ($71.55 bulk billed) (videoconference #92027, phone #92071)
- Monitoring and support for a person with a chronic illness. The following items provide $12.20 bulk-billed for a nurse (or Aboriginal and Torres Strait Islander health practitioner) to follow up with a patient on a care plan, claimed by a medical practitioner:
#93201 (telehealth) *NEW*
#93203 (telephone) *NEW*
- Aboriginal and Torres Strait Islander Health Assessments. A nurse can contribute toward health assessments for people of Aboriginal or Torres Strait Islander descent, with final completion by a GP on videoconference or the telephone (where videoconferencing is not available). There are items that pay $24.20 bulk billed for a nurse (or Aboriginal and Torres Strait Islander health practitioner) to follow up after the health assessment:
#93200 (telehealth) *NEW*
#93202 (telephone) *NEW*
- JobKeeper payment. As last resort, for general practices that have seen a significant recent loss of business and can demonstrate a 30% fall in turnover for a period in 2020 in comparison to 2019 (15% for charities). The Federal Government will pay $1,500 before tax per fortnight per employee to directly subsidise staff wages, including general practice nurses. A registered nurse being paid $37.67 an hour base salary plus 15% on costs will attract $3,292 a fortnight from the employer, so the Federal Government is essentially offering to fund over 45% of the wage cost of nurses for struggling practices.
What I’m hearing and reading is that many vulnerable people, including people with chronic illness, are delaying routine care and staying at home. Some general practices are seeing this, and one hospital representative described to me a very significant reduction in low acuity presentations.
I’m not a clinician but there may be a strong case for more proactive general practice care with nurses or GPs phoning patients to check on them at home, reminding them of the importance of regular check-ups and providing ongoing coaching for self-management of existing conditions, where it can be clinically justified.
In my opinion it is not over-servicing to proactively ring a vulnerable person at home who is due for a check-up, and this may then generate medically necessary follow-up care including GP consultations.
I hope this helps in thinking through how practices can retain a nursing workforce in this rapidly changing environment.
 Christine B Phillips, Christopher Pearce, Sally Hall, Marjan Kljakovic, Bonnie Sibbald, Kathryn Dwan, Julie Porritt and Rachel Yates. Med J Aust 2009; 191 (2): 92-97. www.mja.com.au/journal/2009/191/2/enhancing-care-improving-quality-six-roles-general-practice-nurse
 Roche, M. A., Duffield, C., Homer, C., Buchan, J., & Dimitrelis, S. 2014. The rate and cost of nurse turnover in Australia. Collegian. doi: 10.1016/j.colegn.2014.05.002 https://opus.lib.uts.edu.au/bitstream/10453/36331/1/TRN_Costs_AUS_Final.pdf
 Zaman, Sarah et al. 2020. Cardiovascular disease and COVID-19: Australian/New Zealand consensus statement. MJA. https://www.mja.com.au/journal/2020/cardiovascular-disease-and-covid-19-australiannew-zealand-consensus-statement