Deputy O'Reilly asked a question on the changing role of nurses in the new teams, particularly that of a GP and nurse in prescribing medication. The current situation is that only a nurse working in the public sector can prescribe. The HSE only supports the prescribing module for nurses it employs directly. Practice nurses privately employed by GPs are not on the module. It is not prevented by legislation but is not currently supported financially.
The nurse prescriber is not an advanced practice role but is available to every nurse who has three years' experience. The module and presentation of prescribing is within guidelines set by a committee which includes medical practitioners working in the acute sector, GPs, pharmacists and other parties expert in the area. The nurse prescriber can prescribe within his or her scope of practice in the particular area in which they are working. For example, if a nurse works in care of the elderly those are the medications which will be prescribed.
The benefit is that in hospitals we term as band 4 and band 5 where there is no on-site medical practitioner, the nurse can reduce the delay in access to medication for patients by prescribing. The benefit is entirely for the patient. In the first week of nurse prescribing the first nurse prescriber was in a maternity hospital and prescribed 30 pain relief medications over one weekend. The direct benefit was a mother in labour had a reduced pain time.
The benefit and interrelationship between the medical practitioner is that during the period of training, the clinical governance is provided by the medical practitioner. In the community, it would be provided by a GP or area medical officer. It is done by consent and is not mandatory.
The benefit is the ability to deliver particular medication at an earlier stage. There are situations in some care of the elderly where a GP or medical officers are involved for 15 hours a week. The rest of the care involves a nurse telephoning the doctor to ask them to come to the facility or transferring the patient to an acute hospital. We think situations such as that need to be reduced in number or eliminated.
There is no need to transfer a patient who requires IV fluids to an acute accident and emergency department where they will be put on a trolley for four hours to wait to see a house officer or non-consultant hospital doctor to receive treatment. A nurse prescriber could do it at the time. The main benefits are that it cuts down on transfer time, on discomfort for the patient and overcrowding in accident and emergency departments.
We believe the interaction between the primary care setting and acute hospital must focus on a significant liaison role between both service. Diagnostics is one area but there are many patients who currently sit in outpatient departments who are coming back for review. This is a particularly important point for the cancer strategy. Perhaps I can answer both questions at the same time. Professor Tom Keane, who is currently leading the cancer strategy, states categorically that a number of follow-up clinics for post operative patients do not all need to be in an acute hospital.
The cancer strategy, as the committee knows, will have eight designated centres which will also provide initial follow-up care. In our meetings with cancer strategy personnel we have been told the remainder of the follow-up care will be provided at the referring hospital. Many of these will be led by a clinical nurse specialist in breast care or any of the other cancer cares, under protocol with the designated centre.
There is a significant role in primary care, and in the development of it, for nursing-led services. The advance nurse practitioner role is another role which is advanced in a specific specialty. When we describe nurse prescribing it is across the board, in all specialties and is not focused on one particular specialty. We believe that the beauty of expansion into that area is that it cuts down on many of the current issues patients face when they are in the non-acute sector. Rapid treatment in a timely fashion can be delivered with the protocols provided.
Another question concerned the co-ordination of nursing services. All the nurses currently working in primary care are public servant and are employed by the HSE, apart from practice nurses employed directly under contract with a GP. During meetings with primary care teams and the HSE team we have been advised that GPs do not object to the practice nurse being part of the team once the GP is part of it, which is how that will work. We believe, and have heard, that practice nurses are imperative to the team.
The difference from the other grades of nurses is that two systems operate in primary care. One is the team and the other is the network. Our difficulty and criticism to date of the HSE is that it has not yet developed the networks and is instead focusing on the teams. Many nurses, particularly specialist nurses such a public health nurses who specialise in travel or health, would not be in every team but would be placed in a network. However, because the networks have not developed, the interaction between the team and the network is not at an advanced stage, which is a problem.
Likewise, nurses currently refer between disciplines. A nurse can refer to a physiotherapist or a midwife can refer directly to a public health nurse. The inter-referral model is in place and is not a medical-based model but a referral by other members of a primary care team.
Deputy O'Sullivan asked if we have engaged with the HSE on expansion. We have engaged with it but unfortunately it is all down to numbers, to circulars being issued, placing embargoes on public service recruitment and cutting the numbers of places for basic nurse training next year by 300. We are hampered by recruitment policies that are not well-disposed toward the development of primary care.
