While the numbers of general practitioners in Australia are falling, over the last five years there has been a minor boom in general practice nursing . Between 2005 and 2007 practice nurse numbers increased from 4924 to 7824, with nearly 60% of general practices now employing at least one nurse . The increased movement of nurses into Australian general practice follows similar moves in the United Kingdom and New Zealand [3, 4] where the benefits of adding nurses to the staffing configuration, ranging from improved patient satisfaction to potential cost savings, have been well described .
Funding structures have an impact on nurses, both in roles and numbers. The UK has traditionally had a well established system of nurses provided to general practice, initially funded through direct subsidies. The introduction of the Quality Outcomes Framework (QOF) in the United Kingdom in 2004 accelerated a trend first initiated by the General Medical Services contract of 1990 to change this landscape. QOF funds general practice according to defined outcomes. There are 80 indicators in 19 clinical domains, and 36 indicators in 5 organisational domains, and many of these indicators are reached with the support of the practice nurse. The QOF has altered both the roles and the self perceptions of nurses [6, 7], as they take on more specific tasks, leaving the GP to 'manage' the overall condition.
The US, with its reliance on fee-for service and insurance backed, private care, represents a different set of challenges. The complex system of insurance agencies in North America creates barriers to the employment of nurses in certain roles , while leading to a proliferation of defined positions along a continuum from physicians assistant to nurse practitioner. The numbers of all these groups have been increasing [9, 10], leading to tensions between the professional groups .
In Ontario, Canada, the Family Health Teams and related models of cares - all of which use collaborative models of practice for teams of nurses, doctors, nurse practitioners and other health workers . These models are pioneering a range of reimbursement models for primary care practitioners, including capitation.
Nurses in Australia have been reported to enhance quality through supporting systematised approaches to health care delivery (eg improving infection control, or patient recall systems) and improving clinician-patient communication [13, 14]. There is as yet uncertainty about the most effective way to fund practice nurses to achieve these quality health outcomes. General practice funding mechanisms in Australia provide a number of levers that may be used to achieve this purpose, in addition to professional and organisational development or regulatory approaches. This paper explores the impact of current funding mechanisms on the employment and work practices of nurses in general practice in Australia.
The paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate. We then detail the evidence from the Australian General Practice Nurses Study, a three year multi-site, multidisciplinary study of practice nursing in Australia, that may help guide decision-making.
General practice financing in Australia
General practice in Australia is delivered largely through fee-for-service private practice, underwritten by a government insurer. An amendment added to Section 51 of the Commonwealth Constitution in 1945 empowered the Commonwealth Parliament to make laws relating to medical and dental services, but not in such a way as would constitute civil conscription. In practice, this has meant that doctors are free to arrange their own fee schedules. There are provisions in group practices for GPs to have a common fee-structure without being charged with anti-competitive behaviour. In the traditional, and most prevalent, organisational model, practice nurses are salaried employees of small-business-owner general practitioners.
This traditional model is changing, however. A variety of models of corporate practice now exist in Australia, ranging from large publicly listed companies to practices owned by some GPs who employ others. In some parts of the country, employed GPs are now in the majority. In the Melbourne East GP Network, for example, 60% of GPs are employees, and in such cases, parties removed from the clinical consultation set fees.
In 1975, the Australian Government introduced Medibank (subsequently revised as Medicare in 1984) a universal health insurance program, that set a fixed rebate for consultations and procedures. Medicare in effect provides a funding stream direct to GPs, as in 73% of consultations  they forego any fee on top of the government-determined reimbursement for the service, and bill the government directly. When non-medical services such as those provided by practice nurses are included, this figure rises to 78%. For this reason, and because there is a mandatory contribution of 1.5% of taxable income, many patients would not describe Medicare as a system of patient insurance, but rather as a means of funding health care directly. With 85% of Australians visiting general practice annually and over $278.7 M outlays in rebates in the last calendar year , government has now become the largest funder of general practice.
As general practice remains private practice, one option for government to influence behaviour is by adjusting the funding stream and focus. It has done so in a variety of ways. Fee-for-service (FFS) remains the most significant activity, but the Medicare benefits schedule has undergone numerous revisions. Items now exist not just for general consultations but also for specific activities - pap smears and immunisations for instance. A range of incentives for complex fee-for-service activities have been introduced from 2004 under the Enhanced Primary Care Program, including items for care planning for chronic disease management, team care arrangements, and comprehensive health assessments for vulnerable subpopulations.
In addition to direct investment in FFS through item numbers, government has increased funding by broadening the funding base to create a blended payment system. There are two arms to this system: Service Incentive Payments (SIP) and Practice Incentive Payments (PIP), both of which function as pay-for-performance incentives. A SIP is a top-up payment for achieving a goal, usually a cycle of care for asthma or diabetes. A PIP is a practice-based payment for meeting specific, practice targets (e.g. providing after-hours care, teaching medical students, and having a quality computerised record system), which can be even further removed from direct patient care. PIP also provides capitation payments to improve practice infrastructure. In rural areas, for example, practices can access a PIP to a maximum of $40,000 to assist with the employment of a nurse .
Funding practice nurses in Australia
Until 2004, only activities by doctors and optometrists were eligible for Medicare benefits. Under the Enhanced Primary Care Program, item numbers were made available for services delivered by nurses working in general practice, either through the performance of a health assessment or chronic disease management plan in collaboration with a doctor, or through the direct provision of wound care, immunisation or a Pap smear, each of which attracts a nurse-specific FFS rebate under Medicare. The incorporation of nurses into this funding stream has made employment of a nurse less financially prohibitive for practice owners.
Dilemmas for policy-makers
Policy makers face three dilemmas in trying to identify and respond to the relationship between funding of nurses and general practice outcomes.
Dilemma #1 is the poor evidence base to support the notion that any of the incentive measures improve outcomes. A recent systematic review of the literature on funding incentives and multidisciplinary team care found only two published studies that used experimental or quasi-experimental design, with the remainder being descriptive studies; the authors were unable to find firm evidence on whether or not financial incentives of themselves improve health outcomes .
Dilemma #2 is the need to ensure that policy initiatives achieve their purpose and enhance productive interdisciplinary working in general practices, while not generating detrimental effects or unacceptable opportunity costs. There is little evidence exploring such effects although the potential for them to occur has been acknowledged [18, 19]. They may include an unhelpful concentration on funded activities at the expense of other valuable but less defined activities, or damage to previously productive relationships. In the UK, nurses appear to be central to pay-for-performance outcomes, where the Quality Outcomes Framework led to a range of incentives being tied to demonstrated outcomes. However, some rupture of internal practice goodwill has been documented with the sense that nurses are working hard to produce quality outcomes for the practice which financially benefit GPs, but where the bulk of the burden in achieving these is borne by nursing staff .
Dilemma # 3 is the question of whether to focus on nurses as a means of supplementing a dwindling medical workforce, or as a way of enhancing the comprehensiveness of health care. These two policy foci are not, of course, mutually exclusive; however they require different emphases. If the former is the primary focus of policy makers, they will need to focus on questions of substitution and task transfer, and fund nurses to take on work currently performed by doctors. If improving complementarity, and thereby quality, is the primary focus then policy-makers will need to focus on new models of care delivery and collaborative practice, and on ways of ensuring that health care is monitored and accountable, and that productive teamwork occurs.