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Head To Head

Should primary care be nurse led? Yes

BMJ 2008; 337 doi: (Published 04 September 2008) Cite this as: BMJ 2008;337:a1157

The ongoing demise of General Practice in England! But multi-morbidity may be the stumbling block.

Sadly Sibbald is probably right!

Primary Care in England is being reduced to disease management,
protocol-based, and targets funded services that are increasingly
privately outsourced. This is entirely an appropriate environment for
nurse lead management. The general physician role and responsibilities of
the previously very successful model of general practice has been
gradually eroded over the recent decades, whereas nurse specialism in
chronic disease management and various other components of primary care
has advanced. The diagnostic work up of patients by the GP is being
prohibited by very limited access to diagnostic tests and investigations,
that are controlled by specialists and their teams. Discipline based
consultant supervised practitioners such as radiographers, lab
technicians, specialist triage teams etc are sorting and gatekeeping with
a disease or target driven focus, armed with NICE protocols and
guidelines. In primary care, the practice managers, primary care nurses,
pharmacists and GPs are incentivised to deliver condition based care and
protocol based prescribing that address the UK targets with much effort
spent entering data for performance monitoring and on top of this, GPs
spend many hours per week signing repeat prescription forms.

Personal experiences in 2006-8 of working in urban general practice
in Canada, the UK and Australia in underserved areas convince me that the
UK has the ‘narrowest scope of practice’ for a GP of any of these three
countries, and in my opinion the least medical care coordination. A brief
hypothetical case study of the care of a person with multi-morbidity
illustrates these differences in the UK and Australia.

Take the reasonably common case of a person Mr X who has multiple
chronic conditions including diabetes, hypertension and mild renal
impairment, and with episodic unstable angina and shortness of breath, a
thyroid swelling and acute on chronic low back pain with anxiety and
Case 1. In an East Midlands PCT, the practice was close to a medium size
district general hospital and about an hour from a major centre. For Mr X:
the practice nurse was prescribing the diabetes drugs in liasion with the
diabetes clinic and referring directly to the renal physician acoording to
as a GP, I needed to refer the patient to the endocrinologist for
investigation for the thyroid (no GP access to thyroid ultrasound); to the
cardiologist or chest clinic (moderate atypical chest pain could not be
investigated in practice as tropinins; CT scans were not allowed to be
oredered by GPs); nor could the severe back pain be investigated or
treated necessitating referral to the physiotherapist via the pain clinic
(3 months wait for community physiotherapy) or the orthopaedic clinic for
an MRI or CT etc. As a GP I could only councel the patient in the brief 10
minute slots, as the wait for the practice councellor was 3 months.

The patient was being referred for investigation and managed by at
least 6 non primary care providers with and at least two primary care
providers - the practice nurse and the GP.

In Australia in a simlilarly or even more rural setting with a
smaller local hopital, such a patient could have all these tests requested
by the GP with results in a few hours or less. GP could charge or direct
bill Medicare for a longer consultation and care plan. A team care plan
could be set up to coordinate the medical and non-medical care including
physiotherapy, pharmacist medication review and psychology treatment by
the GP and the practice nurse. The specialist in multi-morbidity is the

While this is 'anecdotal', health outcomes in terms of life
expectancy (1), perceptions of care and cost per capita are better in
Australia than in the UK.(2)

Sadly, the adoption of US managed care style practices around disease
management targets to contain costs is possibly costing more, causing
great inconvenience and stress for the increasing number of patients with
multi-morbidity, as well destroying generalism and an appropriate medical
role for the GP in England. Even more unfortunately, England is a trend
leader and Australia and Canada are following, seduced by the perceptions
of quality and efficiency through selective performance management.

(1)United Nations World Population Prospects: 2006 revision -Table A.17[2]
(2)K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J.
L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International
Update on the Comparative Performance of American Health Care, The
Commonwealth Fund, May 2007

Competing interests:
None declared

Competing interests: No competing interests

14 September 2008
Carmel M Martin
Associate Professor Family Medicine
Northern ontario School of Medicine, Canada