Published 4 September 2008, doi:10.1136/bmj.39661.694572.59
Cite this as: BMJ 2008;337:a1169

Head to Head

Should primary care be nurse led? No

Nurses should be acknowledged as the true frontline providers of primary care, says Bonnie Sibbald (doi:10.1136/bmj.39661.707083.59), but Rhona Knight says that moving to a purely nurse led service would be a backward step

Narrow minded? Lacking insight? Having been both a partner and a salaried doctor in a nurse led service, my view is informed by respect for the nurses I have employed, worked with, worked for, mentored, and taught. The roles of general practitioners and nurses—while dynamic—are different and complex. Each needs appropriate, role focused training.

Nurses as effective leaders are not new. Florence Nightingale with her skills in leadership, evidence based health care, and nursing transformed care and saved the lives of many under her influence.^{1 2} As the NHS passes its 60th birthday, new 21st century Nightingales continue to venture into exciting, uncharted territory in both primary and secondary care. But concepts of nurse led primary care, where the nurse takes the place of a general practitioner as the first point of patient contact and leads the primary health care team,^{3 4} can restrict patients’ choice, lack supporting evidence, and raise many questions.

The varied roles in primary care nursing have inconsistent titles, training, knowledge, skills, and experience.⁵ Even the term "nurse" can be used liberally, and many nurse practitioner colleagues have been called "doctor." When I take my son to the nurse led, primary care out-of-hours unit with yet another rugby injury, I do not know if the emergency nurse practitioner (ENP) I meet has completed two weeks’ ENP training or a longer, more complex course.⁶

Taking time, the nurse communicates well. If a patient satisfaction survey is requested, she is likely to be rated highly—unsurprisingly, as a randomised controlled trial comparing same-day consultations with GPs and nurse practitioners found that patients were generally more satisfied with nurses, reporting receiving more information about their illness, in significantly longer consultations.⁷ A systematic review exploring equivalence of care identified similar findings.⁸

Yet this evidence should be analysed more deeply. Satisfaction is influenced by patients’ pre-existing expectations, and comparing nurses with doctors is rather like comparing oranges with pears. Although research indicates that ENPs may be as effective as junior doctors in the accident and emergency department,⁹ and nurse practitioners may be as cost effective as salaried doctors,¹⁰ the Cochrane review on substituting nurses for doctors justifiably advises caution.¹¹ Are longer consultations with more investigations cost efficient?¹²

What of the patients’ views and choices, which should surely carry a great deal of weight?¹³ We know patients prefer to consult with a GP if they think their symptoms are serious.¹⁴ Might this be due to their understanding of GPs’ training, and uncertainty concerning the ability of nurses to diagnose "rare but important health problems"?¹⁵

GPs’ training takes 10 years. Medical undergraduates follow a broad, assessed curriculum. They accumulate vast amounts of theoretical knowledge and develop practical strategies to access and apply this. They develop good consultation skills to facilitate the integration of expertise in diagnosis and management in an evidence based, patient centred, holistic, and professional way.¹⁶ Foundation school and three years of specialist training follow, where an extensive GP curriculum encourages learners to cultivate and use clinical wisdom in situations of uncertainty.¹⁷

This demanding and complex assessed training enables the development and practice of the generalist skills, which continue to make frontline general practice the most economical part of the NHS,¹⁸ highlighting the importance of GP leadership. We do general practice a disservice if we denigrate this generalist expertise¹⁹ and the tacit knowledge acquired over many years of training and application which enables GPs, as deliverers and leaders of generalist healthcare, to make patients their first priority.

Nursing is in flux, and the role and training of the nurse in a changing climate is being reconsidered.^{20 21} What is nursing, and what makes it unique? Advanced nurse practitioners (ANPs), likely leaders in a nurse led service, have a less developed training route than that of GPs. There is a career pathway,²² and the Royal College of Nursing has produced a guide to the ANP role competencies and programme accreditation, recommending a set of standards of practice and education.²³ Although "advanced nurse-practitioners in primary care need to look for comparison to the standard of a GP," part time ANP programmes are to include a minimum of only 500 indirect or direct supervised hours, and the domains and competencies cover just nine pages. I believe that nurses might be trained to work as GPs, and help lead primary care, but the suggested ANP education seems woefully inadequate.

To enable nurses to lead in dealing with all undifferentiated illness, increased training time and a curriculum similar to the GP curriculum would be needed—as would a bespoke approach to learning the necessary basic medical science. However, a better way may exist. Nurses who wish to take on the responsibility and work autonomously as GPs could access graduate health science medical courses, as many healthcare professionals currently do. They will then become doctors, with the option of adequate training and the entitlement to appropriate remuneration for the role they perform.

As for team leadership, moving to a purely nurse led service would be a backward step in a climate of increasing multiprofessional working, where leadership teams benefit from many perspectives. The concept of nurse led primary care, driven by cost cutting agendas rather than adequate evidence,^{11 24} devalues medical training and the complex expertise of the GP. Restricting patient choice, it also undermines the importance of nurses in delivering their unique contribution to primary health care.

Competing interests: None declared.

Provenance and peer review: Commissioned; not peer reviewed.

Cite this as: BMJ 2008;337:a1169

References

1. Singh S, Ernst E. Trick or treatment? Alternative medicine on trial. London: Transworld, 2008:26-37.
2. Gill G. Nightingales: Florence and her family. London: Hodder & Stoughton, 2004.
3. Cook S. Seeing sense. Guardian. 2002 May 22. www.guardian.co.uk/society/2002/may/22/nhs2000.primarycare.
4. Baraniak C. Can nurse practitioners provide equivalent care to GPs? BMJ 2002;325:166.[Free Full Text]
5. NHS Working in Partnership Programme. Varying roles within general practice nursing. 2006. www.wipp.nhs.uk/tools_gpn/toolu5_varying_roles_for_gpn.php.
6. Hastings A, Redsell S, eds. The good consultation guide for nurses. Radcliffe, 2006.
7. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care. BMJ 2000;320:1043-8.[Abstract/Free Full Text]
8. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002;324:819-23.[Abstract/Free Full Text]
9. Sakr M, Angus J, Perrin J, Nixon C, Nichol J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999;354:1321-6.[CrossRef][Web of Science][Medline]
10. Hollinghurst S, Horrocks S, Anderson E, Salisbury C. Comparing the cost of nurse practitioners and GPs in primary care: modelling economic data from randomised trials. Br J Gen Pract 2006;56:530-5.[Web of Science][Medline]
11. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2004;(4):CD001271.
12. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002;324:819-23.[Abstract/Free Full Text]
13. Department of Health. High quality care for all: NHS next stage review final report. 2008. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825.
14. Redsell S, Stokes T, Jackson C, Hastings A, Baker R. Patients’ accounts of the differences in nurses’ and general practitioners’ roles in primary care. J Ad Nurs 2006;57:172-80.
15. Woodroffe E. Nurse-led general practice: the changing face of general practice? Br J Gen Pract 2006;56:632-3.[Web of Science][Medline]
16. Wright AF. GP 2000: a general practitioner for the new millennium. Br J Gen Pract 1996;46:4-5.[Web of Science][Medline]
17. Royal College of General Practitioners. GP curriculum. January 2007. www.rcgp-curriculum.org.uk.
18. Royal College of General Practitioners. The future direction of general practice: a roadmap. London: RCGP 2007.
19. Charles, Prince of Wales. The importance of the generalist. Br J Gen Pract 1992;42:222.[Web of Science][Medline]
20. Department of Health. Towards a framework for post-registration nursing careers: a national consultation. 2007. www.dh.gov.uk/en/Consultations/Closedconsultations/DH_079911.
21. Longley M, Shaw C, Dolan G. Nursing: towards 2015—alternative scenarios for healthcare, nursing and nurse education in the UK in 2015. Nursing and Midwifery Council, 2007. www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=3550.
22. NHS Working in Partnership Programme. Career pathway for general practice nurses. NHS, 2006. www.wipp.nhs.uk/uploads/GPN%20tools/Tool5.12-Career%20pathway.pdf.
23. Royal College of Nursing. Advanced nurse practitioners—an RCN guide to the advanced nurse practitioner role, competencies and programme accreditation. London: RCN 2008.
24. Kernick D, Scott A. Economic approaches to doctor/nurse skill mix: problems, pitfalls, and partial solutions. Br J Gen Pract 2002;52:42-6.[Web of Science][Medline]

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