Nursing and the future of primary care

Set against what we already know about nurses working alongside general practitioners,¹ the four trials of nursing in primary care in this week's BMJ give us a better idea of what the future of primary care might look like.^2–5 Most people seeking a rapid response to their symptoms or concerns accept practice nurses or nurse practitioners in front line roles, although a substantial minority continue to prefer a doctor's opinion after experiencing nursing attention.²

On average, nurses have longer consultations, arrange more investigations and follow up, provide more information, and give more satisfaction than general practitioners. Primary care nurses are not cheaper than general practitioners,³ but they are as safe in managing self limiting illnesses.

Nurses undertaking triage assessments by telephone with computer decision support may reduce the number of visits to general practitioners, hospital use, and costs.⁵ The trials do not tell us anything about the medicalisation of discomfort that might follow from increased investigation and follow up, but one study suggests no reduction in patients' intended help seeking behaviour after seeing a nurse.⁴ When it comes to coughs, cystitis, earache, sore throats, and other common acute conditions seen in general practice, nurses are a safe but less productive alternative to doctors. When working in triage roles on the boundary between community and hospital care, they may avert some inappropriate short stay admissions.

Proving the obvious?

Apart from the economic evaluation of nurses working in a triage role out of hours,⁵ none of these findings is very surprising and none contradicts conventional wisdom on nurses' safety, acceptability to patients, and costs.¹ A general practitioner who has worked alongside nurse practitioners or practice nurses in extended mode for a decade or so without anxieties about their safety and acceptability might even wonder why so much time and money has been spent on proving the obvious. From this sceptical standpoint, the trials may seem to be closer to the trailing edge of knowledge than to its leading edge, with perhaps more emphasis on the elegance of the research design than on the relevance of the research question. Such a view may be reinforced by the clinical focus on self limiting minor illnesses, the small sample sizes, and the short follow up of two weeks in three of the studies. If nurses are as safe as doctors they will miss no more of the uncommon major illnesses with minor presentations than their general practitioner colleagues, but these small, short trials cannot detect this.

An opposite opinion would accept the validity of the trial results but discount their generalisability. The studies conducted in practices used experienced nurses, but their usual working relationships may have been altered to fit professional activity into an experimental design, potentially biasing performance in various ways. The variation in performance between practices, shown more clearly in the local research network study⁴ than in a conventional national trial,³ hints at the powerful human factors shaping clinical activity and patient satisfaction.

Enrolling nurse practitioners on a wide scale in general practice may not achieve the desired effects because the trials were conducted by experienced volunteers, not a wider range of variably skilled and motivated nurses. The division of labour, the rules and funding systems, the perceptions of local professional and lay communities, and the available resources all combine to produce or impede changes in practice,⁶ but trials only hint at the contents of these black boxes.

Expansion of primary care nursing

Whatever the implications of these studies for future research approaches, primary care nursing is likely to expand as a discipline, and these papers will be cited widely and correctly as evidence of its importance for modernising the health service. This may be good news for primary care nursing, vindicating the efforts of some nurses to use their skills fully and to extend their clinical roles. It may be good news for general practitioners, who will be able to delegate the demand for immediate care for minor illness to nurses and escape from a sense of being overworked but underemployed. And it may be good news for primary care groups and hospital trusts if unnecessary hospital admissions can be reduced and resources saved by nurse triage. The public may have more mixed feelings, however, and a few may continue to seek medical rather than nursing authority—the affluent with their credit cards and the rest by learning the new system's rules.

The issues for the NHS could be more complex. What roles should primary care nurses occupy? Is demand management in general practice the best use of this skilled professional resource? Perhaps we might learn from north America, where nurse practitioners made up for the physician shortage of 40 years ago and now face managed care and competition. Their future may lie in substituting for doctors in aggressive case management of patients along care pathways and in organising and coordinating team care.⁷ Could this be our future too?

General practice pp 1038, 1043, 1048, 1053