Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

Horrocks , et al (1) have demonstrated that nurses may competently complement the work of general practitioners. However the primary health care team includes many more disciplines than doctors and nurses, such as patients consulting pharmacists for over the counter influenza remedies and physiotherapists for the diagnosis and assessment of sports and musculoskeletal injury. Also the primary health input of an occupational therapist may be the most useful intervention to prevent falls in the older patient.

There is no doubt that nurses are significant care providers although I disagree with the paper’s summary which suggests that nurses should be relegated to “same day appointments for minor illness”. It is more likely that nurses should be dealing with the chronic and complex care needs of a patient with an established diagnosis where management and treatment are more important to quality of life than attendance by a GP or equivalent.

The encouragement to general practitioners in Australia to develop multidisciplinary management plans for patients with chronic and complex conditions through a Commonwealth funded enhanced primary care program has placed GPs at the head of this team. Individual primary health care providers working as a multidisciplinary team have the opportunity to achieve efficiency and improved health outcomes through synergistic rather than competitive practice.

References:

1.Horrocks S, Anderson E, Salisbury C, Systematic review of whether nurse practitioners working in Primary care can provide equivalent care to doctors. BMJ 2002; 819-23

Can Nurse Practitioners provide equivalent care to G.P.s?

EDITOR – Horrocks et al. state in their title, that the focus of their review, is the role of Nurse Practitioners in Primary care [1 ] . They concede that ambiguity exists over the definition of a Nurse Practitioner, yet go on to include studies involving nurses working in Hospital departments [2, 3, 4]. Before large sums of money are thrown at such projects, it would be wise to compare like with like. In addition, ‘Policy Implementers’ aught to consider several other points, not covered by the above review: -

1. A G.P. registrar in their final 3 months of training, has a minimum of 4 years of post-graduate work experience, yet is deemed unfit to practise, without first passing various elements of Summative Assessment. Approved video consultative technique is not a criteria needing to be passed, to be a Nurse Practitioner.

2. If Nurse Practitioners wish to be considered as independent Practitioners, then they need to have their own comprehensive indemnity, so that litigation stops with them, rather than their employing practice.

3. During employment of a Nurse Practitioner on a 3-month trial basis, we asked our Trainer to ‘Hot’ review each of the Nurse Practitioner’s surgeries, as he would a G.P. registrar. The trainer felt that there was little insight into why specific questions/investigations/drugs were used. The basic understanding of the pathology and pharmacology, lagged far behind the automated efficiency of following guidelines.

Whilst there certainly seems to be an evolving role for Nurse Practitioners, it is important that future studies clearly document the context in which patients are seen, and that there is some form of assessment of Nurse Practitioner consultation technique, similar to that seen in General Practice.

Ian O’Connor, General Practitioner, Oldcastle Surgery, South St., Bridgend, South Wales, CF31 3ED. T
email elaineianoconnor@hotmail.com

References:

1. 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: 819-823.

2. Hoekelman RA. What constitutes adequate well-baby care? Pediatrics 1975; 55: 313-326.

3. Saker M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999; 354: 1321-1326.

4. Cooper M. An evaluation of the safety and effectiveness of the emergency nurse practitioner in the treatment of patients with minor injuries: a pilot study. Glasgow: Accident and Emergency, Glasgow Royal Infirmary, 2001.( Typescript.)

With regards to the results of the “Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors”, certain conclusions need to be considered at more than face value. One conclusion was drawn that quality of care was equivalent, but the NP’s ordered more investigations. It would be interesting to note whether these additional investigations were beneficial or harmful to the patients or whether they merely increased expense and discomfort. Unnecessary testing can lead to other unnecessary tests and inappropriate treatments, so on, and patients might benefit or be harmed. Since this issue was not settled, the conclusion that care was equivalent is in question.

Thank you for your report on the systematic review of whether nurse pratitioners working in primary care can provide equivalent care to doctors. It was illuminating and reinforced much of my experience as a nurse running a general practice under the auspices of a Personal Medical Services Pilot.

My practice has been open for three and a half years and operates the philosphy that the patient should be seen by the most appropriate person to help them with their problems. To facilitate this approach, the nurse is identified as the first point of contact for patients, although they are able to choose to see a gp if they wish. On average, about 65% of patients choose to see a nurse. A very small proportion of patients are referred back to the gp.

Concerns for patient satisfaction emerged from my need to ensure patient acceptability of a nurse-led service. Without this I would not have a list and thus no practice. Commercial forces and survival were my initial motivations but by listening to the concerns of patients regarding their health care and by implementing their suggestions to improve services and by including patient representatives in the management of the service we have developed a practice with very high patient satisfaction levels.

Some might argue that patient satisfaction is a fickle concept and impossible to measure. Some are concerned that such commercial concepts have no place in health care. Patient satisfaction in my practice has been measured using the recognised GPAS patient satisfaction survey questionnaire and we came top in 5 out of 8 categories in our locality. Comments from the survey revealed that patients felt that we offer a personal service, that they feel valued and that their opinions count. They commented that they felt nurses made better listeners than doctors and that nurses had more time to spend with patients. This perceived time factor issue is not the case in my practice as the nurse is frequently seeing more patients than the doctor. The doctor also tends to spend more time with the patients than the nurse does, but this is not surprising when it is considered that he tends to see significant medical problems for most of his surgery. Patients also expressed confidence in the nurses clinical abilities and are surprised that such a system of primary health care delivery has not been thought of before.

Whether this has anything to do with nurses versus doctors -I think not. There certainly seems to be an attitude (or mind set) amongst many patients that they can relate better to a nurse because they see a nurse as an equal (or peer) and for this reason they feel able to communicate their needs more readily. There are many doctors (who are really honorary nurses) who exude this quality too and this is an honourable estate. My practice has shown that nurse-led practice does work well. Evaluations of the pilot are beginning to emerge in the literature to back up this claim. But underneath the titles and the first point of contact issue is the concept that the professional with the right skill should be the person the patient sees and that nurses and doctors working together can complement each other, generating an environment where patients receive prompt, competent care, where staff enjoy a high level of job satisfaction and fulfilment, and where value for money is achieved.