Should primary care be nurse led? Yes

Nurses and doctors have overlapping skills which makes it possible for one to substitute for the other within the area of overlap. In primary care this overlap is substantial. Systematic reviews of research indicate that primary care nurses can deliver as high quality care as general practitioners in the areas of preventive health care, routine follow-up of patients with long term conditions, and first contact care for people with minor illness.1 2 Within the range of care studied, no aspects were found in which general practitioners outperformed nurses. Indeed nurse led care tended to be superior in that nurses gave patients more information and patients were more likely to be satisfied.

High satisfaction with nurse led care does not mean that patients inevitably prefer nurses to general practitioners. Patient preferences in most studies are mixed.1 3 Nurses may be favoured when patients see their problems as “minor” or “routine” but doctors are preferred when the problem is thought to “serious” or “difficult.” Given the assurance that nurses working in advanced roles are well qualified for that work, however, most patients accepted being allocated to a nurse and were subsequently satisfied with the care they received.

Surprisingly little research has been conducted into whether substituting nurses for doctors saves money, but the available research suggests substitution is cost neutral. In most studies, savings on nurses’ salaries were offset by their lower productivity (due to longer consultations, higher patient recall rates, and occasional increased use of tests and investigations) leading to no overall reductions in cost.1 However, as salary differentials and productivity vary from place to place, cost savings may be achieved in some situations.

Substituting nurses for doctors also has the potential to improve the efficiency of health care. Too often general practitioners continue to provide the same services as nurses, leading to duplication, rather than substitution, of care.4 Efficiency gains are possible if general practitioners discontinue the services that nurses provide and focus on the tasks only doctors can perform.5 General practitioners’ skills might usefully be targeted to health problems with a high degree of uncertainty regarding diagnosis or treatment, such as the management of people with medically unexplained symptoms or undifferentiated presentations and those with complex co-morbidities.

Research that has focused on nurses with exceptional skills could give a false impression of the likely outcome in everyday practice. But the nurses studied varied widely in their training and experience, and encompassed both nurse practitioners and practice nurses.1 All nurses were adequately trained for their role, as shown by the positive findings from the research. As employers, general practitioners need to ensure their nurses are appropriately trained if they wish to reap the full benefits of nurse led care and avoid vicarious liability for errors.6 The Royal College of Nursing, together with higher education institutions, has made good progress in defining the competencies needed by primary care nurses and implementing training programmes to equip them with the requisite skills.7

A key obstacle to nurses realising their full potential has been legislative restrictions on their scope of practice, in particular the right to prescribe drugs. However, from spring 2006, suitably qualified nurses have been able to prescribe any licensed medicine for any medical condition, with the exception of controlled drugs.8

General practices in the UK are already aware of the value of using nurses to improve the quality and scope of primary care. The biggest stimulus for change was brought about by the 1990 General Medical Services contract, which paid general practitioners to provide chronic disease clinics and meet population targets for immunisations, vaccinations, and cervical cytology. Employing nurses to provide these services was the most efficient and effective way to meet performance targets and fuelled a rapid expansion in the numbers of practice nurses.9 10 11 12 The momentum seems to have been sustained by the General Medical Services contract of 2004. This contract is held by the practice, not the individual general practitioner, making it even easier to shift care from doctors to nurses. Payment is linked to the attainment of quality of care targets for people with long term conditions—work that is ideally suited to nurses’ skills.

UK general practitioners have already yielded considerable ground to nurses in the interests of improving the quality and efficiency of primary care. It is time this trend moved to its logical conclusion, acknowledging nurses to be the true frontline providers of primary care. Nurses are well able to undertake the bulk of work in general practice, including preventive health care, the management of long term conditions, and first contact care for minor illness. General practitioners’ role should evolve to become that of a consultant in primary care receiving referrals from nurses.