Should nurses replace GPs as frontline providers of primary care?

Sep 7 2008

Should nurses be the frontline providers of primary care, taking the place of general practitioners as the first point of patient contact? Two experts debate the issue on bmj.com.

Nurses can deliver as high quality care as general practitioners in most areas of general practice including preventive health care, the management of long term conditions, and first contact care for people with minor illness, writes Bonnie Sibbald, Professor of health services research at the National Primary Care Research and Development Centre, University of Manchester.

She argues that substituting nurses for doctors has the potential to improve the efficiency of primary health care. Too often GPs provide the same services as nurses and this leads to duplication rather than substitution of care. In fact, she says, GPs skills would be better used to tackle more complex health problems which have a higher degree of uncertainty about their diagnosis and treatment.

According to Sibbald, general practices in the UK are already aware of the value of nurses to improve the scope and quality of primary care. Over the last twenty years, there has been a rapid expansion in the numbers of practice nurses recruited to meet new service contracts. For instance, nurses now provide immunisations, vaccinations, and cervical screening services and will be a key part of meeting the quality of care targets for people with long term conditions set out in the General Medical Services contract of 2004.

She believes that recent changes to legislation, such as the right for qualified nurses to prescribe licensed medicines, have begun to allow nurses to realise their full potential. This trend, she concludes, must be followed "to its logical conclusion, acknowledging nurses to be the true frontline providers of primary care"& [while the] "general practitioners' role should evolve to become that of a consultant in primary care receiving referrals from nurses".

But Dr Rhona Knight, a GP from Leicester who has first hand experience in a nurse led practice, argues that nurse led primary care would restrict patient choice and undermine the importance of nurses' unique contribution to primary health care. She acknowledges that patients report a high level of satisfaction with nurse consultations, but points to evidence that patients prefer to consult with a GP if they think their symptoms are serious. She points out that GPs' training takes 10 years and that they are hugely experienced in dealing with undifferentiated illness which enables them to be key deliverers and leaders of generalist healthcare. In contrast, she says, advanced nurse training is less developed and recommends a minimum of only 500 indirect or direct supervised hours and the competencies cover "just nine pages".

Currently, she says, a lack of nationally agreed standards means that nurses have varied roles with inconsistent training, knowledge, experience and titles. Nurses would need increased training and a similar curriculum to GPs to be able to take the lead in dealing with all illnesses, she argues. One solution could be for nurses to take a graduate health science medical course and train to be a GP and be appropriately rewarded for this role, she concludes.

In an accompanying feature, Rebecca Coombes outlines some of the major impediments to senior nurses taking on some medical roles including a lack of professional regulation, low pay, and cultural objections from doctors.

http://www.bma.org.uk