In their analysis of Medicare claims data for general practice consultations published in this issue of the Journal, Taylor and colleagues report a recent decline in Level C and D (long) consultations and an increase in Level A (short) consultations — a pattern they consider to be “at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management”.1 They hypothesise that the increased use of Level A consultations may reflect:

• the administrative burden created by the complexity of Medicare Benefits Schedule (MBS) special items;

• an increase in encounters for “vaccinations, prescriptions, medical certificates or test results”; or

• greater use of practice nurses.1

Data from the BEACH (Bettering the Evaluation and Care of Health) program2 suggest that the third option — greater use of practice nurses — explains most of the increase in claims for short (Level A) consultations.

The introduction of MBS items for practice nurses in May 20043,4 had a significant impact on the use of Level A consultations. Trends in utilisation of short consultations can be followed in BEACH data, with the lowest proportional use occurring in April 2004 to March 2006, when 1.0% of all claimable consultations (Medicare or the Department of Veterans’ Affairs [DVA]) were short consultations. By 2008–09, short consultations accounted for 1.5% of all consultations.5 However, the mean duration of measured consultations (claimable from Medicare or the DVA) did not change over this period (average, 15 minutes; median, 13 minutes).5 This suggests that the increase in shorter-duration consultations has been offset by an increase in longer-duration consultations.

Short consultations in 2008–09 included a large number of procedures, and practice nurses were involved in 24% of these consultations, a much greater proportion than the average for all consultations (6.4%).2 This led us to compare consultations for 2008–09 with those for 2003–04,6 just before the introduction of MBS items for practice nurses.

In both years, short consultations were relatively straightforward, involving, on average, 1.2 patient reasons for the encounter (fewer than the average for all consultations of 1.5–1.6 reasons) and management of fewer problems (single-problem consultations represented 89% of consultations in 2003–04 and 87% in 2008–09). However, in 2003–04, 26% of the problems managed were chronic conditions, while in 2008–09 this proportion had increased to 36%.

Prescriptions, referrals and counselling were provided at low levels in both 2003–04 and 2008–09. However, procedures increased 3.4-fold, from 112 per 1000 short consultations in 2003–04 to 385 per 1000 in 2008–09 when practice nurses undertook almost two-thirds of all recorded procedures. More specifically, there was a fourfold increase in the categories “dressings” (from 20 to 78 per 1000 short consultations) and “excisions” (commonly cauterisation) (7 to 26 per 1000 short consultations), and a threefold increase in “incisions” (venesection and ear syringing being the most common) (5 to 14 per 1000 short consultations). There was no point-of-care INR (international normalised ratio) testing in 2003–04 but, in 2008–09, 31 INR tests were conducted per 1000 short consultations. Further, the number of vaccinations administered doubled, from 105 to 214 per 1000 short consultations.

As regards administrative activities, these almost doubled between 2003–04 and 2008–09, from 19 to 35 per 1000 short consultations; in both years, almost half were for sickness certificates. Other administrative procedures recorded, including those related to health care plans, increased from 10 to 17 per 1000 short consultations.

These BEACH study results show an increase of about 45% in claims for short consultations between 2003–04 and 2008–09. Two-thirds of these claims are accounted for by increases in vaccinations (23% of the increase), dressings (25%), INR tests (10%), and excisions (8%). Practice nurse involvement in procedural care accounts for about three-quarters of the increase in short consultations. By contrast, the rise in administrative activities accounted for only 5%–6% of the total.

Taylor and colleagues suggest that their findings of an observed rise in Level A consultations1 is directly contradicted by reports from the BEACH study of a decrease in the number of single-problem encounters.5 While this decrease is true for the average of all consultations, it does not apply to short consultations, which are, in the main, single-problem encounters.

Finally, Taylor et al propose that the increase in Level A consultations1 means there is an increasing proportion of “obvious” and “straightforward” patient encounters, and this “may support targeted delegation of such consultations to nurse practitioners or physician assistants”.1 As we have shown, assistance from, and delegation to, practice nurses may already be the main reason for the recent increased use of Level A consultations, with administrative activities accounting for only a small proportion. The newly announced enhanced role for practice nurses in primary health care (the federal government’s 2010 Budget),7 planned to commence in 2012, may further influence GPs’ utilisation of short consultations.