We did not need an unseemly spat: NPs rightly took umbrage at college’s stance on their role

The recent unseemly spat between nursing and GP leaders about the role of nurse practitioners in primary care diminishes us all.

While general practice sinks beneath the waves, we watch as the leaders of both professions involved play musical chairs on deck.

The College of Nurses Aotearoa and Nurse Practitioners New Zealand took umbrage at the RNZCGP’s position statement on the NP role, and rightly so.

In an attempt to “clarify” (or distinguish) the role of an NP versus a GP working in primary care, the RNZCGP appears to have succeeded only in insulting our nursing colleagues. This will have the effect of further fracturing the primary care workforce, which now more than ever must present a united front if real reform is the goal.

As RNZCGP president Samantha Murton pointed out, the idea was not to release a joint statement. However, seeking collaborative input prior to developing and releasing the college document publicly would have been polite, at the very least.

I can imagine how GPs would feel if any of the professional specialty colleges spoke up to imply that GPs should know their place, leaving the “real” medicine to properly qualified doctors.

Like two bald men fighting over a comb, this ridiculous bout of posturing fisticuffs misses the point

The college’s initial position statement on NPs’ contribution has been described as paternalism, when in fact the issue is one of patch protection – on both sides. Like two bald men fighting over a comb, this ridiculous bout of posturing fisticuffs misses the point.

We know there is more than enough work to go around.GPs throughout the country are closing enrolments to new patients. Our colleagues are burning out, citing lack of support in managing increasingly complex caseloads, ever-increasing amounts of unpaid paperwork and a magic porridge pot of patient demand.

If we are to address the tsunami of chronic ill health that threatens to drown us, GPs need upskilled nursing colleagues working alongside us and helping us shoulder the burden as valued members of the primary care team.

The problem is, there is, as yet, no whole-of-system strategy for primary care.

How this was overlooked in the creation of a brand-new health system is unclear.

We should be aiming to redistribute workload and address the convoluted funding streams in the community. Roles need to be redefined so that all – not just NPs – are working at top of scope.

There will be no possibility of implementing pae ora, achieving equitable access to care in a timely manner, without such an approach.

How can secondary and primary care integrate when there is a ghost workforce where the interface should be? This requires all of us to lift our game.

New Zealand’s primary care leaders have been reluctant to support this model. “Diluting the brand” has been one objection raised by GP leaders. They say general practice is for generalists. Apparently, we should be content to be viewed as the “wheely bin of health”.

Another objection has been the decreasing numbers of GPs: “Who will do the work?”

If you are talking about hours of unpaid paperwork and issuing antihypertensives to patients whose medication has not needed to change in 15 years, that is not work I’m interested in after 20 years as a GP.

Both general practice and primary care nursing must be made more attractive, with scope for career advancement. It is interesting that, as I write, the job advertisements on the RNZCGP bulletin board include three that specifically seek GPs with additional skills, in breast medicine, sports medicine and skin cancer medicine.

Cognitive dissonance on the part of the college?

While moonlighting, doing remote consultations, I was struck by how vulnerable many small rural practices are. Where they lack doctors, they are being held together by incredible nursing teams working largely on their own. My added value from several hundred kilometres away was in the diagnosis and work-up of undifferentiated patients, and review and decision-making in more complex cases. And, in turn, I also needed help. Many of the patients I was being asked to see had complex social needs, or multiple overlapping problems. To look after these patients effectively takes a village – or a team.

This is where we should be positioning general practice: as community medicine practised by an integrated multidisciplinary team of healthcare practitioners who all respect and value one another’s roles.

It is well known that the outcomes for complex chronic conditions such as pain are far better when a specialist team takes responsibility, working on a biopsychosocial model.¹ It works in secondary care; it will work in primary care too. This is the adult conversation we need to have.

Orna McGinn is an Auckland-based specialist GP and chair of the New Zealand Women in Medicine Charitable Trust