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Society o

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Private Nurse Practitioners (PNP)

A Professional Nurse and Midwife,

Registered by the South African Nursing Council

Provides nursing care on a fee for service basis,

Reimbursed directly or indirectly by the patient.

* Does not include practitioners who are salaried, eg. agencies

(duty nurses), doctors consulting rooms, pharmacy or occupational health clinics nurses on salaries.

* But these practitioners also contribute toward reduction of cost of care & face most challenges being presented

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SERVICES PROVIDED BY PNPs

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SERVICES PROVIDED BY PNPs Consultation, not shift based

• General – frail care, home visits

• Wound care – Basic & Advanced

• Psychiatry

• Lymphoedema mgt.

• Stomatherapy

• Dermatology

• Palliative care / end of life

• Childbirth education

• Midwifery – ANC, PNC, Births

• Lactation consultants

• Immunization and Well Baby clinics

• School nursing

• Occupational health / wellness

• Renal dialysis

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Practice Models

• Independent practitioners – sole proprietor, partnership, companies (Pty & cc)

• Health centre & pharmacy-based clinics

• Franchise-type model – Unjani & Owethu / Sha’p Left primary health clinics

Reimbursement

• Fee-for-service

• Direct or 3rd party funding

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PRACTICE SETTINGS

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1

57,6

27,5

7,8

4

2,3

Other

Residential areas

Business district / malls

Industrial areas

Rural towns /regions

Informal settlements

SPNP PROFILE OF PRACTITIONERS 2014 N=371

*Feb 2016: Rural towns / region practitioners now 30%

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AGE DISTRIBUTION OF PNPs: 2016

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48%

45%

7%

> 55 years 40 - 55 years < 40 years

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STATISTICAL SNAPSSHOT

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No

. P

Ns

Cli

nic

Ho

spit

al

Ho

me

Pts

pe

r m

on

th

Mixed practice KZN

Infant vaccines given 3 804 77 604

Well baby clinic visits 3 357 357

Wound care visits 3 137

Unjani clinics National 19 15857 835

Sha’p Left clinics W Cape 1 450 450

Wound care visits Gauteng 2 25 18 169 212

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FEE STRUCTURE • Tariffs previously set by BHF, currently subject to

High Court ruling as for other professions

• Linked to public sector nursing salaries

• Does not take practice expenses into account

• 2016: 2006 tariffs + annual inflation

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Revised statement of Issues Feb 2016

Sha’p Left clinic under construction in Cape Town

FOCUS OF SUBMISSION

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BARRIERS TO ACCESS OF CARE

• REGULATORY FRAMEWORK – Authorisation of advanced practice PNPs

– Advertising / listing restrictions

• FUNDER CONSTRAINTS – Procedural codes

– Specialist nursing services

– Reimbursement

• PRIVATE SECTOR POLICIES – Access to services for patients

– Indemnity insurance

– Recognition of PNPs legal authority

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39.2. Consumers are unable to make informed choices in the selection of health products (i.e. insurance, services and products) due to lack of transparency in the healthcare sector. 39.5. The coherence of the existing configuration of regulatory interventions on the supply-side (services and products) requires careful review to assess the extent to which contradictory objectives are currently pursued with harmful effects for efficient competition.

Revised Statement of Issues 11 February 2016

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REGULATORY FRAMEWORK Authorisation of Advanced Practice PNPs

Nursing Act, 33 of 2005 10 years after promulgation, regulations still not adopted

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• S38(A) / S56(6) authorisation to perform functions beyond the basic scope of practice to provide primary health care not available to private practitioners, which provides for diagnosis, treatment & prescribing by PNs

Scope of Practice

• S22(c ) Medicines and Related Substances Act, 101 of 1965 - Private practitioners excluded, leaving patients in rural areas without access although appropriate nurse practitioners available.

Dispensing licenses

• Act requires Minister to make regulations (refer Acts or Omissions)

Regulations regarding

PNPs

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REGULATORY FRAMEWORK Advertising & Practice Restrictions

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Regulations regarding Acts or Omissions for which the SANC may take Disciplinary steps

• Prohibits nurses from making their services known to patients or other healthcare providers

Prohibition on Advertising

• Restricts partnerships to other nurses only, therefore cannot be part of a multidisciplinary group, therefore cannot be included in proposed NHI proposals, unless as employees. Mirrors HPCSA ethical rule.

Group practice

restrictions

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FUNDER CONSTRAINTS Procedural codes

Authority

Codes required

• HIV testing & STIs Rx

• Diabetic education - insulin therapy

• Lactation consulting – promotes breastfeeding

• Contraception, insertion of implants & intrauterine devices

• Lympheodema management by nurse practitioners

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No mechanism to generate new / additional codes for nursing procedures or those not “authorised” by BHF prior to 2006

• BHF, CMS – not within their

remit • SANC not part of funder /

reimbursement system

Mechanism

• Claims are being rejected, patients become responsible for payment

• Not recognised as part of Prescribed Minimum Benefits

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FUNDER RESTRICTIONS Reimbursement for Specialised nursing services

• Insufficient or unspecified benefits for nursing services, leaving patients at the discretion of case managers’ interpretations

• Medical schemes ward accommodation includes nursing, but will also reimburse Stomaltherapy and fund Midwife-assisted births

• Not funded - psychiatry, advanced wound care, diabetic nurse education, lactation consultants

• Commonly schemes may authorise, but later reverse authorisation, leaving patients responsible for fee

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In hospital Out of hospital

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CASE STUDY

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Why have PNP when the hospital is being paid to provide nursing?

“The dramatic increase in hospital-based claims, …. is argued to be, in significant part, driven by nurse salary increases”

113.3 Revised Statement of Issues 11 February 2016

• Private hospitals have reduced / eliminated nurses with advanced level skills

• Patients still require these services to improve outcomes, reduce hospitalisation, continue recovery in the home setting

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PRIVATE SECTOR POLICIES Access to services for patients

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HOSPITAL RESPONSE

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• Medical practitioners request advanced nursing services • Funders and hospital management restrict funding

although the service is not provided by the hospital • Patients may also not access their own nurse

practitioner while in hospital due to this policy, as well the reluctance of ward staff to follow nursing care plans recommended by the advanced nurse practitioner

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Key cost driver influencing choice of Caesarian sections

Women pressurised to accept C/S as the norm

• High cost of professional indemnity for obstetricians

• Limited indemnity for Midwives

• Restricted access to obstetric units and small number of obstetricians to backup midwives, who have limited privileges (public & private sector)

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PRIVATE SECTOR POLICIES Indemnity Insurance

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RECOGNITION OF PNPs LEGAL AUTHORITY

• Refusal by pharmacists to dispense prescriptions from nurses with legal authority to prescribe as per S22( C) permit / S38(A)

• Refusal by employers to accept sick certificates issued by nurses, even where authorised to diagnose and treat selected conditions in primary health settings.

Patients incur additional costs to see FP, further absenteeism, additional out of pocket costs

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CURRENT RESEARCH

• “The Clinical Nurse Specialist also plays an essential role in care coordination and transitions of care that result in reduced hospital length of stay, fewer hospital readmissions and hospital-acquired conditions “ NACNS 2013

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CONCLUSION

Nursing services can contribute significantly to the reduction of hospitalisation costs and access to affordable health care

• Requires review and acceleration of regulatory framework, particularly authorisation, licensing & advertising

• Inclusion of critical nursing practices within PMB framework

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