‘The art of medicine consists of amusing the patient while nature cures the disease.’ (Voltaire)
This humbling comment by Voltaire sets the scene for a controversial discussion focusing on the delivery of primary health care. In the last 10 years, two new GP contracts and the introduction of an NHS internal market have dramatically altered the day-to-day workload of the GP. These vast changes have also been accompanied by ever broadening roles for different health professionals, notably practice nurses. As a GP registrar, I have been struck by the amount of traditional general practice that is now being provided in nurse-led clinics, often in longer consultations and by experienced nurses, who have gained considerable autonomy after completing supplementary training. Notably, the first totally nurse-led pilot practice was set up 5 years ago and at least two others have expanded,1 suggesting a viable alternative to traditional general practice. This paradigm shift in healthcare delivery is radical and cannot be ignored. Some may resent these changes as a perceived erosion of the GP's traditional role. However, the evidence evaluating the effectiveness of these different health professionals in their changing roles does deserve careful examination and has implications for the future of general practice.
WHAT IS TRADITIONAL GENERAL PRACTICE?
Traditional general practice took shape at the turn of the 20th century as the role of the GP, the personal doctor working in the community, separated from that of physicians and surgeons, who specialised in a particular field and controlled the hospitals' scientific and technical facilities. Three major roles characterise the traditional model of general practice:
The use of clinical skills and knowledge as diagnostic and therapeutic tools. The clinical skill of the GP is adapted to the undifferentiated nature of the problems presented in primary care and the low technology setting, with the potential of using time as a diagnostic tool.
Continuity of medical care. The commitment of the GP is to the needs of the individual, providing continuous longitudinal relationships with patients. This inspires mutual confidence, enabling the GP to match appropriate services to the particular needs of each patient.2
Gate keeper/advocate for patients who require specialist services. GPs in the UK deal with 90% of the problems presented to them3 providing a filter into secondary care, together with a coordination role for patients with comorbidity, and between secondary care specialties.
A number of different primary healthcare professionals, in particular nurses4 and pharmacists,5,6 have extended their roles to include aspects of traditional general practice. These changes, borne out of changing workforce aspirations, financial concerns and a chronic GP shortage, are now very much a reality within general practice. But how effective have these changes proved to be?
AN EXTENDED ROLE FOR NURSES
A recent Cochrane review4 evaluated the impact of doctor–nurse substitution in primary care on patient health outcomes (morbidity, mortality, satisfaction, compliance and preference); process of care (adherence of practitioner to clinical guidelines, quality of care and advice given); and resource utilisation (frequency and length of consultations, return visits, prescriptions, investigations ordered, referral rates and other costs). Randomised controlled trials and ‘controlled before and after’ studies dating from 1969–2001 were included in the review.
In terms of emergency care, patient health outcomes did not differ significantly between doctors or nurses, however nurses tended to provide more information to patients, give longer consultations and recall patientsmore frequently than doctors. A meta-analysis showed that overall patient satisfaction was higher with nurse-led care. The numbers of investigations ordered was examined in two studies; two outcomes were measured of which one showed a higher rate for nurses. Only one study demonstrated clear cost savings with nurse-led services since the lower salary costs of nurses were offset by their increased use of resources or lower productivity.
The management of patients with chronic conditions was assessed in four of the Cochrane studies. Apart from a significantly higher level of patient satisfaction with nurse-led care in one study, no appreciable difference was noted between nurse- and doctor-led care. In general, however, longer consultations involving primary care nurses with a special interest in a particular chronic disease do seem to be effective. Trials examining nurse-led management of smoking cessation,7 hypertension,8 cholesterol lowering,9 ischaemic heart disease10 and weight reduction11 all showed significant improvements in morbidity outcomes relative to standard care. This was mainly due to rigorous application of national guidelines and increased or more appropriate use of medication.
Overall, the nursing profession may have got it right: longer consultations, delivered in disease-focused clinics, tailored to individual patient needs and combined with a strong health promotion message.
HOW WILL THIS AFFECT GPS?
Recognition that the scope of general practice was broadened far beyond ‘traditional general practice’
The introduction of a market ideology into the NHS in the early 1990s, followed by two new GP contracts, have dramatically altered the day-to-day workings of general practice.12 Not only have nurses' roles evolved, but the scope of general practice itself now also includes disease prevention and health promotion and, increasingly, chronic disease management is shifting from the hospital into the community.2
Given that the burden of chronic disease in the community is becoming more and more significant due to an ageing population and increased life expectancy, multidisciplinary teamworkingmust become a priority. In Halton PCT, Cheshire, multidisciplinary care plans, disease registers and nurse-led clinics using computerised clinical protocols have been shown to significantly reduce emergency admissions and days spent in hospital for the elderly.13
A diversified role for GPs
Clinical leadership is known to be a key factor in effective patient care.14 Appointment of a ‘clinical lead’ in charge of the management of a particular chronic condition within the practice, is known to improve patient care. While retaining a generalist background, GPs are well placed to provide this leadership role, or even diversify further to become GPwSI and provide enhanced services for patients.15 Teaching is likely to become a key element in the workloads of even more GPs, to supervise the extended roles of other health professionals, hopefully leading to increased job satisfaction and a better service for patients.
Consultation length
Length of consultation has been noted to be a good predictor of patient satisfaction.16 Given that patient satisfaction was higher with the longer-nurse-led consultations, should we be pursuing longer surgeries with longer appointments? A recent Cochrane review17 examining the effect of altering the length of primary care physicians' consultations surprisingly showed no consistent differences in problem recognition, examination, prescribing, referral or investigation rates or in patient satisfaction. Given the small number and heterogeneity of studies in the review, the jury remains out on this issue.
A choice of health professional for patients
The broadened nursing role gives increased choice, enabling patients to decide whom to consult with a particular problem. Doctor–nurse preferencemay depend on the nature of the presenting complaint; nurses being preferred when the problem is perceived as minor and doctors when it is thought to be serious or difficult.18 It remains to be seen whether continuity of care, a key feature of traditional general practice, then suffers as a result, despite multidisciplinary team working.
Ensuring safety for patients
GP registrars have appointed GP trainers and are appraised by assessment of video consultations and discussion of difficult cases. To ensure a high standard of longterm clinical care, nurse practitioners should be assessed similarly and also hold their own indemnity cover.
A key role of the GP is the making of a diagnosis, instigating investigation and the synthesis of a management plan in patients with more than self-limiting illness, whose symptoms do not fit ‘a pattern’. Coming from more limited pathological background, the ability of nurse practitioners to identify these ‘rare but important health problems’, needs further research.4 However, in keeping with all health professionals including doctors, an awareness of the limits of competency is vital for nurse practitioners practicing independently, as is a willingness to refer on to GP colleagues where necessary. If this more limited pathological background were to be addressed and became equivalent in depth and breadth to a doctor's training then arguably a medical student has been created, not just a nurse practitioner. This therefore has training implications.
In conclusion, evidence from short-term studies does suggest that the majority of traditional general practice can now be delivered by the nursing profession. However, the scope of general practice today has also evolved beyond the traditional model and the increased community disease burden is most effectively tackled by a multidisciplinary approach.
Extended nursing roles, delivered in longer consultations, lead to a high degree of patient satisfaction and enable the targeting of at-risk populations. Rather than resent these extended roles, they should provide GPs with food for thought. Doctors' roles must inevitably diversify to accommodate them and GPs are well placed to provide clinical leadership within the multidisciplinary team and in liaising with secondary care. In addition, while aiming to retain a broad background, GPs can now also provide enhanced services within a special interest and supervise the teaching of other health professionals in their newly-extended roles.
- © British Journal of General Practice, 2006.