When the Scope of Practice review was published last year, dissenting views were heard loud and clear – some groups were keen to expand their scope while doctors had some reservations.
We take a closer look at the ever-changing landscape of scope of practice.
By Suzanne Harrison
Everyone agrees that collaboration, communication and integration are imperative to sustaining the healthcare workforce and system.
But at the time of its release last October, a review led by Professor Mark Cormack – Unleashing the Potential of our Health Workforce – resulted in more disagreement rather than consensus.
The year-long independent review examined the system changes needed to support health practitioners to work to their full scope of practice. It found that almost all health professions in Australia faceD restrictions and barriers to their work.
Among its 18 recommendations to address this was the implementation of new direct referral pathways to improve access to some non-GP specialists.
It also called for changes to some prescribing powers and the establishment of a primary care workforce development program to support the retention of skilled staff.
Both the AMA and RACGP urged the government to tread with caution when considering the recommendations. They warned that they could result in a costlier health system, more delays to care, and higher out-of-pocket costs for patients.
The RACGP said the review did little to allay their long-held concerns around task substitution, and had a lack of risk assessment, costing and evaluation of direct referrals.
RELATED: GPs on edge over direct referrals
Conversely, nurses and pharmacy groups were welcoming of the report having campaigned to expand their scope of practice.
Now some months and a Federal election later, what has been the impact of the review and is it time to redefine different practitioners’ scope of practice?
Collaboration is key
One of the biggest concerns GPs had was around direct referral pathways. Under the recommendation, non-GP specialists would be able to refer patients needing further treatment, for example a physiotherapist could refer to an orthopaedic surgeon, or a dietitian could refer to gastroenterologist.
GPs raised concerns about this creating inappropriate referrals, fragmenting care and increasing out-of-pocket costs for patients.
RACGP Vice President and WA Chair Dr Ramya Raman said working collaboratively across different professions underpins general practice, but any changes to scope of practice must ensure quality and safety of care.
“The one thing we always have to remember is that accessibility is really important, and the quality and safety of care is really important,” she told Medical Forum.
“Our approach is to always ensure patient safety, and patient care is foremost, so that’s one of the reasons we say there is no substitute for the quality of care provided by a GP.
“A GP-led multidisciplinary team approach would ensure that care is well coordinated and there is a good communication pathway.”
Dr Raman said the less fragmentation there was across primary care, the better that was for the patient.
“The less fragmentation of care and less work for the patient trying to navigate through the system means that we can keep people out of hospital.
“When there is better continuous co-ordinated care from a GP, it means a reduced cost for both State and Federal health and, ultimately, the patient.”
Professor of General Practice and Co-Lead Doctor of Medicine at Bond University Dr Mark Morgan also warned of the risk of fragmenting care and instead suggested more funding was part of the solution.
“Funding longer GP consults, supported by a complementary multidisciplinary team, seems the only way to efficiently support the health of Australians,” he said.
“Rather than creating systems of competition, it seems much more reasonable to recognise complementary skill sets. Working under the same roof, with the same medical record, allows patients to get the best mix of advice and allows the clinical team to learn continuously about each other and from each other.”
Multidisciplinary care, not expanded practice
This ‘under one roof’ approach has been received more positively and has brought about change since the review was published.
In May this year, the RACGP and Pharmaceutical Society of Australia (PSA) joined forces to call for funding of general practice-based pharmacists to work with specialist GPs to support high-quality prescribing.
Funding for more non-dispensing pharmacists, nurses, psychologists, and other health professionals in practice teams is part of the RACGP plan for accessible and affordable care released earlier this year.
Multidisciplinary care is already underway in some general practice teams, but it needs secure funding and strong relationships with GPs to leverage the full benefits, according to the PSA.
Non-dispensing pharmacists in general practice answer queries, monitor prescribing, and conduct medicine reviews. They are also on hand to help patients understand their medicines, any changes to those medicines, and to ensure safe and effective medicine use.
RACGP President Dr Michael Wright said the move would enable general practices to expand their teams to have “immediate and long-term benefits” for patients and the healthcare system.
“People with chronic illness get the best care when their specialist GP works with pharmacists and other health professionals in multidisciplinary care teams,” he said.
“Most practices provide multidisciplinary care, and most GPs want to grow their teams to better serve our patients.”
Dr Raman agreed that increased funding for a multidisciplinary approach was needed, especially for chronic disease.
“Chronic disease is the most prevalent and, given the changing demographics in our population, that automatically increases the risk of hospitalisation,” she said.
“Targeting funding towards a multidisciplinary team approach that is GP-led will ultimately mean there is a collaborative approach that will work for better outcomes for the patient.”
Expansions to pharmacy
Despite concerns about fragmentation of care, pharmacists are already operating under an expanded scope of practice in various places across the country – a move that has caused some controversy among doctors but proved popular with patients.
In WA late last year the State Government announced expanded roles for community pharmacists. The expansion allowed pharmacists to provide care for a range of conditions including mild to moderate shingles, acne, dermatitis, musculoskeletal pain and inflammation, nausea and vomiting, urinary tract infections and wound management.
In Queensland, the government has announced its pharmacy pilot program will be made permanent – allowing registered pharmacists the ability to diagnose and prescribe medication for a variety of health issues.
While in Victoria a 2023 pharmacy prescribing pilot was made permanent in last month’s State budget, with pharmacists also handed greater powers to prescribe medications for a range of complex conditions including high blood pressure without the need for a specialist GP consultation.
It prompted warnings from the RACGP that patient care would be compromised.
Pilot programs around Australia will inform the next steps for WA.
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GP concerns have focused on the risk of misdiagnosis and that it could result in a less connected doctor-patient model – within the same vein as direct referral pathways.
WA GP and founder of the Perth Weight Clinic Dr Mark Mellor said there was clearly a need to expand scope of practice in some areas – especially as GP shortages continue – but there were some instances where it would not be appropriate.
“There are pockets where it looks like it’s going a little bit too far, a good example would be whether pharmacists will be able to prescribe weight loss medication,” he told Medical Forum.
“That could be really dangerous. At the same time you’ve got telemedicine providers that are staffed by medical practitioners and nurse practitioners that are dishing these drugs out… it’s a bit of a wild west and we always have to have patient safety as the focus here.”
Dr Mellor gives another example of pharmacists being able to prescribe for UTIs.
“A person could turn up to a pharmacy thinking they’ve got a UTI and the pharmacist does some screening that determines it’s a UTI and it needs antibiotics.
“But do you know how often a GP sees a patient that thinks they’ve got a UTI and it’s actually something very different, so I’m a bit concerned about that patient falling through the cracks.
“Are pharmacists’ experts in providing prescriptions? Or experts in medicine and medication? That’s where the concern from doctors comes from. It’s not about being divisive and against each other.”
Dr Mellor said some health practitioners could do a bit more to work beyond their current scope, but any decision needed to ensure safe healthcare was at the forefront.
The role of nurses
Perhaps the most closely linked with GPs are nurses, who were largely welcoming of Professor Cormack’s review.
The Australian College of Nursing (ACN) urged the government to accept the recommendations.
ACN Chief Executive Professor Kathryn Zeitz said the review acknowledged the restrictions, barriers, and inconsistencies that prevent nurses, nurse practitioners, and midwives from working to their full capability.
Soon after, in December 2024, the Federal Government approved a new registration standard, paving the way for qualified RNs to prescribe certain medicines in partnership with an authorised health practitioner. This change will take effect mid-2025.
Ken Griffin, chief executive of the Australian Primary Health Care Nurses Association (APNA), told Medical Forum that progress since the Cormack review was delayed by the recent Federal election, but the Labor Government had been clear it intends to pursue scope of practice reform.
“Not allowing nurses to work to their full scope of practice is a significant waste of the skills, experience and capability of the largest workforce in primary health care.”
But the devil lies in the detail. Some groups remain concerned about the impact any changes will have on various practitioners.
RELATED: Nurses want to expand their practice, but GPs have reservations
In the lead up to the Federal election nine of Australia’s peak nursing and midwifery groups called for reforms to allow nurses and midwives to provide specialist referrals, prescribe medicines and order diagnostic testing.
They said this reflects the recommendations of the Scope of Practice Review, adding that patients and communities – especially those in rural and regional areas – would benefit when they can work to their full scope.
But it was met with concern from the RACGP, which took the stance that care is best delivered when GPs and nurses work together rather than if nurses were able to make some standalone care decisions.
The College has reiterated that nursing colleagues complement GP-led care based on a relationship of trust and collaboration.
Its latest Health of the Nation report found 88% of responding GPs agreed practice nurses benefit patient health when embedded in general practice teams.
The big picture
As it stands, health practitioners remain divided on the best way forward for expanding scope of practice and improving access to care.
Understandably, doctors are concerned about any impact changes may have on patient care, but other professions want to help more.
It begs the question – do we need to accept that change amidst a healthcare system that is showing signs of struggling to keep up with patient demand?
If not, what is the best way to alleviate current workforce problems and ensure the best outcome for all primary care and allied health workers?
“I think we all appreciate that the current model of healthcare in Australia isn’t working,” Dr Mellor said.
“We do need to expand the workforce and therefore the government is looking to introduce top of scope practice for pharmacists and nurses. That’s all understandable, but it looks like it’s out of scope from a GP perspective.”
To that end, Dr Mellor added: “We need more GPs and to incentivise junior doctors to go into general practice.”
For Dr Raman, the bottom line is patient care and increased GP funding.
“As a GP who’s in the community, I work with allied health staff and pharmacists and the only thing we have in our mind is the outcome for the patient,” Dr Raman said.
“These allied practitioners are all touch points, but you also have to look at the concept of keeping general practice central.
“Many countries look to Australia for the strength in primary care that we have. It’s about recognising that and enhancing funding for general practice.”
However, Mr Griffin adds that a system based on GPs being the primary point of call for care may not work in some areas.
“We need to realise that our health system is designed around the assumption that people have a GP or a hospital which provides them access to the best of the health workforce,” he said.
“We know this is not always the case. We need to utilise the workforce that is in place to provide in-scope care when a hospital or GP are not accessible.”
One thing we can say for certain is that the healthcare system is changing. There’s increased patient demand coupled with workforce shortages, higher prevalence of chronic disease and an ageing population.
New ways are needed to ensure the best possible patient care and a safe workplace for GPs and other practitioners, so we will need to find an agreed path to move forward.
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