Intended for healthcare professionals


The future of primary care nurses and health visitors

BMJ 2006; 333 doi: (Published 07 December 2006) Cite this as: BMJ 2006;333:1185
  1. Christopher Derrett, general practitioner (c.j.derrett{at},
  2. Lydia Burke, senior lecturer (l.burke{at}
  1. 1Barton House Group Practice, London N16 9JT
  2. 2Middlesex University, London N19 5LW

    Increasing fragmentation threatens the primary healthcare team

    New policies, new contracts, and financial pressures have altered the roles of primary care nurses and health visitors and their relationship with general practitioners (GPs). How will the primary care trust survive?

    In remote areas of some rich nations (such as rural Australia) highly trained nurses provide the core of primary medical care for adults and children. In many developing nations (such as Bangladesh and China) locally trained nurses tend to work in hospitals and private clinics in towns, whereas health care in rural communities often depends on lay medical aides and occasionally doctors. In the United States nurses manage care for chronic disease.1

    In the United Kingdom, some nurses are employed by independent contractor GPs, while others including health visitors are attached to general practice teams but are paid and managed by primary care organisations. They have worked alongside GPs for many years: good communications between such primary care professionals lead to better quality care for patients with complex clinical and social problems.

    Pressure to save money, improve patient access, and tackle shortages in the medical workforce has led the UK government to develop alternatives to traditional general practice. These include National Health Service (NHS) walk-in centres, NHS Direct, primary care trust medical services, and alternative provider medical services. These changes threaten the traditional primary healthcare team and raise questions about the future of primary care nursing and health visiting.

    Nurses and health visitors are withdrawing from primary healthcare teams in England for two main reasons. Firstly, their numbers are declining. A third of primary care nurses and health visitors are approaching retirement age,2 and training restrictions, vacancy freezes, and staff cuts have exacerbated the shortfall. The number of health visitors is the lowest for 12 years.3 Recent proposals in Scotland advocate that specialist community nurses and health visitors are replaced by generic community nurses.4 In England, some health visitors have moved to new children's centres. The recruitment of “community matron” managers from district nursing has also left gaps in the primary care nursing workforce.

    Secondly, primary healthcare trusts are threatened by competition, which has altered the way that primary care providers view each other. The UK government is keen to develop alternative ways of providing health care, and by stimulating competition it hopes to improve quality and value for money. Clinical services run mainly by nurses and nurse practitioners are thought to provide better access for patients at less cost. Such nurses may take on senior posts with considerable strategic and operational responsibility. In England, practice based commissioning, with general practices taking control of budgets for secondary care services, may stimulate other innovations where privately or self employed nurses work for specialist services.

    None the less, other factors may encourage nurses to remain in primary healthcare trusts led by GPs. Primary care nurses see an opportunity to become entrepreneurs5 as alternative (private) providers embracing “social enterprise.” However, they are hesitant to leave the clinical support, relative financial security, and pensions provided by the NHS. In addition, the 2003 GP contract6 has stimulated many practices to think about staffing and skill mix,7 which has led to initiatives to improve the professional status of nurses. New systems that reward practices for good management of chronic diseases have highlighted the financial and clinical importance of input from nurses. Many general practice nurses are acquiring advanced skills in diagnosis and prescribing; others are taking strategic and leadership roles or even becoming practice partners.

    Fitzpatrick8 suggests that many aspects of promoting healthy lifestyles could carry on outside general practice with lay trainers so that GPs and primary care nursing professionals would have more time for patients with acute and chronic diseases. Although general practice does need to define its boundaries regarding social care and education, we think that targeted promotion led by nurses still has a place in general practice.

    It is time to re-examine the divisions of power, responsibility, and rewards within general practice primary healthcare trusts. We believe that such trusts should remain central to the provision of primary care but wonder whether changes in the role of primary care nurses and health visitors, and the fragmentation of the organisations that employ them, will have a negative effect on patient care and discourage democratic team work.


    • Competing interests: None declared.


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