27 September 2024

Nursing an NP-led practice through tough times

Reporter Alan Perrott visited the nurse-led practice Family Health Matters in pre-pandemic 2020. He recently returned to check if the ambition survived.

I’m saying, ‘I can help’, and they say, ‘Oh no, not that kind of help’

After a troubled birth, the pandemic and an ongoing battle to prove her worth, it’s a minor miracle Michal Noonan’s smile remains in place.

Because if there has been one constant since the nurse practitioner first opened the doors at Auckland’s Family Health Matters in January 2020 it’s that sense of “what’s next?”

That, and the much-loved tropical wallpaper in the waiting area.

Long story short, the builder charged with transforming a crusty Glen Innes lawnmower repair shop into a brandnew practice ran off with their money, costing Ms Noonan not just cash and time but also her staff. Then, only months after finally opening and just shy of enrolling her 15th patient, COVID-19 arrived, and the doors were slammed shut again.

But admitting defeat was not an option, says Ms Noonan. Starting a VLCA practice from scratch was never simply a business venture; it was a mission to show how a nurse-based model of care can not only succeed but should also be part of the fix for an overburdened primary care sector.

“And we’ve had some fantastic support. But we’ve also had a decent amount of detractors and people who just push and push. It’s taken its toll, but I’m still smiling.”

Even now, she doesn’t see that volatility ending any time soon, not with GPs feeling increasingly unappreciated, undervalued and overworked.

“I know lots of people see me as a threat, but I have never tried to say nurse practitioners are a complete solution to everything. But we have to be part it. Just as GPs are not the complete solution, if they were, we wouldn’t be having conversations on new models of care.

“We all know about the ageing population, comorbidities, patient complexity, so we need to start looking at things differently, and we need to talk differently. General practice should become primary healthcare practice because our patients require a team that covers all the skills, and what upsets me is that some of our colleagues are saying, ‘We need more help, we need more help’, and I’m saying, ‘I can help’ and they say, ‘Oh no, not that kind of help’.”

Doubts about the validity of NPs have got to where Ms Noonan no longer states her role when she calls hospital services: “I can’t believe that I can still call a hospital to talk about a patient, ideally for admission, and they will say ‘I want to speak to the GP’. So, my thing is say what your name is, but don’t say your designation, because a GP doesn’t say their designation.

“So, that’s my advice: don’t say you’re a nurse practitioner.”

Now, having survived the pandemic income plunge via telehealth and locum work at providers such as Papakura Marae, Ms Noonan has built her enrolled population to about 1600, with approximately 50 to 60 new enrolments per month, mainly from the thousands of new homes that have rapidly sprouted in the area.

New patients are always welcome, and their books remain open, but she is especially chuffed with the families who were among her earliest patients and have since moved on and now make the cross-town commute to see her. That is affirmation.

While Celeste Gillmer, the initial co-owner and director, left in October 2023 to become manager of testing operations at Te Whatu Ora, Ms Noonan has since increased her practice staff, including an additional NP, Zoey Zhao, and practice manager Petrina Couper.

She has also hosted seven NP interns to support the workforce pipeline and convinced a district nurse to join the training programme.

Extra income comes from renting spare rooms to a pair of district nurses, and while the practice is trialling latenight Wednesdays, weekends remain “sacrosanct” to preserve everyone’s mental health, an intent Ms Noonan further supports via monthly sessions with mentor and healthcare leadership coach Katie Quinney.

Consultations have also been extended to 20 minutes and the practice has a policy of same-day appointments for under-fives. Ms Noonan says the team puts a lot of effort into parental education: “Teaching and educating the parents every time they come in is important to us. So, you might see them a lot in the beginning, then that dissipates because they are learning skills, and you are encouraging and supporting them to use those skills and keep on going.”

Ultimately, she hopes to develop Family Health Matters into a multi-skilled health hub with scope for up to 3200 patients.

If this all makes perfect sense to an experienced nurse or GP, it was a mind melt for the new practice manager.

Ms Couper came from a private plastic surgery practice where freshly buffed patients were handing over $50,000 a time. “I didn’t really know what a nurse practitioner was,” she says, “and when I came in it was: ‘Why are you charging so little? What’s wrong with you? We need more patients, we need this, we need that’...it took some getting used to.”

The arrival of fresh eyes became an ideal opportunity for a practice makeover, says Ms Noonan, or as the newcomer puts it, “We threw all the toys out of the cot and questioned everything.”

Change, such as extended hours and cold calls to check in with vulnerable patients, has been rapid and driven by patient feedback, surveys and some harsh self-analysis: “We’re not scared to have uncomfortable conversations,” says Ms Couper, “as long as it gets to the bottom of the problem.”

Videos were also posted on social media platforms to explain what an NP is.

But while the smile abides, Ms Noonan makes no secret of the challenges she has faced. As far as she knows, hers is the first NP-owned practice in the country to start from scratch.

“I can say, no question, I would not advise anyone to start a practice from zero, and definitely not right before a pandemic. Go and buy a practice; it’d be much easier.

“Also, accept the fact you will need to outsource because you will need certain knowledge in different areas at different times because it takes time to develop a new business. We found you get started, and then your needs change, so there’s quite a lot of fluctuation around what the business needs and the skill sets you need around you.

“Practice management, it’s a very particular role; there’s no manual, and what is needed seems to change almost on a dime. Funding and forms, the paperwork is absolutely overwhelming. Insurance stuff is just becoming more and more and more, and it’s all of those pieces that really have the potential to take the joy out of some of it.”

But she is adamant the struggle is worth it, and for reasons familiar to all GPs: “There are some real characters in this community. That’s really fun; some are just gorgeous, and you know there’s always going to be some who are a challenge for a variety of reasons, but that’s primary care, and that’s people.

“So, it’s good and I’m really enjoying seeing the nurse practitioners I have supported and mentored come through. We’re actually quite proud of the fact we have got to the point where we can see all that growth now because, everyone in primary care, we are all in this together, and we all want to use our skills to enhance our patients’ health.”