As ‘Unleashing the potential of our health workforce’ enters its final phase, it’s time to accept the inevitable and make it work.
The phrase of the week has been “scope of practice”, and in fact it might well turn out to be the phrase of the year.
We all know the federal government’s Scope of Practice Review is entering a crucial phase. Issue Papers 1 and 2 are out there, and starting from Monday lead reviewer Professor Mark Cormack and his team will start drafting their final report and implementation plan, to be delivered in October.
Professor Cormack is a calm and measured individual, if his appearance at a Medicare online forum on Tuesday night was any guide. He flagged there was a strong mood for change when it comes to broadening the scope of health practitioners, and he pointed out that he wouldn’t be wasting his time if he didn’t think it was (a) important and (b) doable.
It would be good if the rest of the sector could stay as calm as Professor Cormack, to be honest.
I wear two hats, which on the downside, gives me a headache, but on the upside gives me an interesting perspective on this debate.
As editor of HSD, I see and hear from the health professions that are desperate to work to the top of their scope and training – nurses, allied health folk like physiotherapists and midwives, and yes, the pharmacists.
As editor of our sister publication The Medical Republic, I see and hear from GPs who are, understandably, worried about consequences for patients, as well as for their own profession.
Just last week I had my first encounter with a physician’s assistant. Not quite true —back in 2001 I was treated by a physician’s assistant in Madison, Wisconsin in the US when I contracted a Mycoplasma pneumoniae infection. That cost me a small fortune for a packet of antibiotics but was otherwise unremarkable.
Last Friday, I had the dubious pleasure of being stuck in my regional town’s public ED with my poor old mum who had had a fall and was awaiting an x-ray to check her hips. (Truthfully, we weren’t in ED at all. We were in the ramping bay, along with eight other patients, 14 paramedics, three doctors staring at screens, no nurses, my mum and me. But that’s a whole other article.)
My mum has dementia and after a couple of hours was beginning to get very agitated, which in this case was vaguely beneficial because it facilitated getting her some care before a bed in the ED came up.
Someone in scrubs who, I admit, I assumed was a nurse, approached and started asking the right questions and explained that he could get some processes started – putting in a cannula, ordering x-rays and – once he’d taken a look at her file – a CT head scan.
“She’s on apixoban and she’s had an unwitnessed fall,” he said. “I have to go by the protocols and therefore I have to order a CT head scan.”
No worries, I said, just grateful that we were jumping the queue somewhat.
While he was putting in a cannula – something my mother objected strenuously to – and drawing some blood for tests to make sure Mum didn’t have an infection, we chatted and it turned out Dave was a PA – one of the first in the country, according to him. He’d spent 20 years as a paramedic, before doing his PA training in the US.
Another hour puttered by with no further input from Dave, or anyone else, until a young emergency doctor turned up to do a pretty thorough exam of Mum.
“Let’s just get an x-ray,” she said. And off we went.
The good news is, no fresh fractures for Mum, but before she was discharged the emergency doctor came to me and said, “Look, your Mum’s 85, she has severe dementia, she’s not showing any signs of a head injury, and besides even if she was, there’s an order for no invasive procedures for her, and nobody in neurology would want to operate on her anyway. Do you mind if we cancel the bloods and the CT head scan?”
Nope, I said.
Now, the PA, bless him, knew all of those things because it’s all in Mum’s file, and we discussed it. But he was obliged by the protocols to do the blood tests and order the CT scan.
So in the end, my mother had a cannula put in that she didn’t need and yelled blue murder about. And the imaging department had to find room for her, and then got a cancellation.
Thankfully the doctor intervened before the CT head scan was done, saving the hospital, and me I suspect, cost and time and resources.
The PA did nothing wrong. He did what he was allowed to do, and he did what was proscribed by the algorithms, protocols and guidelines that govern a PA’s work.
Was it all a waste of the PA’s time? Probably. Did it make things better for the patient? Not in the end. Did it make me feel better as a carer wanting to get my mum through the system a bit faster? Yes, but in the end, it was the doctor’s decisions that got things moving.
Did he do anything a nurse couldn’t? No, except he was able to initiate things off his own bat, and more importantly, he was the one who was available to do something.
What does all that tell us about scope of practice?
It tells us that someone needs to fill the gap when GPs aren’t available, when ED doctors are busy saving a life, when nurses are helping them do that, but your increasingly agitated mother needs an x-ray.
When GPs stick their heads above the parapets, like Dr Louise Stone has today over at TMR, other professions tend to accuse them of “gate-keeping” or “turf wars”, when most of the time, all they want is (a) their concerns to be heard, and (b) some good, solid, quality evidence that broadening the scope of practice of other professions will positively impact patient outcomes.
When other professions cry out for more scope – as the physiotherapists did this week – GPs tend to fret loudly about “fragmentation of care” and “continuity” and yes, there are some outliers who don’t want to give up power and control. But the professions who want to stretch their wings, for the most part, want (a) to be heard, (b) to be able to do everything they have been trained to do, and (c) positively impact patient outcomes.
See the commonalities there?
The facts are:
- There are not enough GPs. The reasons for that are complex, political, and financial, but the bottom line is there are not enough GPs in the right places at the right time.
- Other professions can, even if just partially, fill those gaps.
- Broadening scope of practice is coming, like it or not.
Everyone needs to step back and relax a little. Recognise the common goal – healthier patients – and then find ways to make it happen.
Because it’s going to happen.