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At the heart of general practice since 1960

Can nurses do a GP's job?

Nurses are as good as doctors at delivering many aspects of care and could take on as much as 70% of GP work, argues Professor Bonnie Sibbald. Not so, insists Dr Dermot Ryan, who argues that while nurses are good at following protocols, they are entirely incapable of the high-level problem-solving that is the hallmark of a doctor

Nurses are as good as doctors at delivering many aspects of care and could take on as much as 70% of GP work, argues Professor Bonnie Sibbald. Not so, insists Dr Dermot Ryan, who argues that while nurses are good at following protocols, they are entirely incapable of the high-level problem-solving that is the hallmark of a doctor

Yes

The past few decades have seen a trend in general practice towards large multidisciplinary teams employing six or more doctors and a wide range of clinical and administrative staff.

Practice nurses and nurse practitioners increasingly substitute for GPs in the care of minor illness and routine management of chronic diseases.

The expectation is that nurses can enhance the quality of services provided by GPs, relieve pressure on GPs and cut costs, since they are cheaper to employ.

A recent systematic review of research on doctor-nurse substitution suggests nurses can provide as high quality care as GPs for unselected patients, both for first contact and ongoing care1.

Indeed nurse-led care was superior in that nurses tended to give patients more information and patients were more likely to be satisfied.

There were no aspects of care in which doctors performed better than nurses, although the range of care studied did not encompass doctors' full role.

Research also shows that nurses are highly effective at managing chronic diseases2.

If care is well structured – with a patient register, recall system and clinical reviews in accordance with evidence-based guidelines – health outcomes are good.

General practice diabetes clinics have been shown to provide care as high in quality as hospital outpatient clinics when they are well structured3.

In CHD, nurse-led clinics appear to be as effective as doctor-led clinics, and more effective than care provided by doctors in routine consultations4.5.

So nurse-led chronic disease clinics may improve the quality of clinical care in general practice.

Overall, appropriately qualified nurses could safely undertake up to 70% of the clinical workload in general practice, in preventive health care for well people and treatment of minor illness, as well as in the management of chronic disease.

Barriers coming down

And while the barriers to nurses achieving their full potential in primary care have been considerable, they are now crumbling.

Good progress has been made in defining the competencies needed by nurses in extended primary care roles and developing training programmes.

From spring 2006, suitably qualified nurses have been able to prescribe any licensed medicine for any medical condition with the exception of some controlled drugs.

Employers have only to show nurses have been appropriately trained and supervised to avoid vicarious liability.

The most difficult obstacle is that practices are mostly owned by doctors, who may be reluctant to delegate.

This, too, is changing. The demands of the 1990 and 2004 GMS contracts have made it economically sensible for general practices to employ nurses – rather than doctors – to expand services.

The past decade and a half has seen a rapid rise in the number of primary care nurses and an unparalleled expansion in their roles.

So where does this leave GPs? Doctors increasingly will be left to manage patients who have complex medical problems.

Some may wish to extend their role to overlap with that of hospital consultants. Greater specialisation and differentiation of skills among GPs might enhance the quality of community-based care and would certainly improve access to specialist advice.

It may be that the GP of the future looks more like a consultant in general internal medicine, while the practice nurse of the future looks more like the GP of today.

Professor Bonnie Sibbald is deputy director of the National Primary Care Research and Development Centre

This article was based on the following original publications:

Sibbald B, Laurant M, Reeves D. Advanced nurse roles in UK primary care. Medical Journal of Australia 2006;185:10-2

Sibbald B. Who needs doctors in general practice? Quality in Primary Care 2008;16:73-4

No

Academics and politicians, and others who view the world through rose-tinted spectacles, certainly seem to believe that nurses can do a GP's job.

Why else would we see such a massive expansion in the delivery of services by nurses, and such a proliferation of job titles – nurse consultant, nurse manager (a paradox if ever there was one) nurse specialist and community matron.

This expansion is nothing to do with provision of quality care and everything to do with economies – and false ones at that. It is true that patients prefer nurses' concerned, considerate approach.

Nurses have all the time in the world, and are much more approachable and understanding than doctors. But would you prefer to be killed by well-intentioned kindness or helped by someone thoughtful but to the point?

Nurses and doctors are different in their approach to patients and their problems.

Doctors are trained in an analytical, problem-solving approach, gathering and sifting through information to make a diagnosis around which is built a management plan, often involving investigations, medications and follow-up.

Nurses are trained in a task-orientated manner.

Given a defined task and working within tight parameters they often perform very well and frequently surpass their medical colleagues at sticking to the job in hand, even when it becomes obvious that it is not working.

The upside of this is that the job is done with precision. The downside, and where nurses fall down, is that when a patient does not fit the template, as is often the case, they either struggle to know what to do or keep doing it anyway.

The weakness of protocols

One of my patients had an MI and developed heart failure, and was referred to the cardiac failure nurse. He became increasingly breathless and kept gaining weight.

He was put on a 1,200 calorie diet (‘but I just could not eat that much doctor') and his dose of diuretics progressively increased. He finally came to see me.

I thought how pale he was and marvelled that he could not manage a 1,200 calorie diet and was still gaining weight. On examination there was no evidence of heart failure, undoubtedly because of the tight adherence to the protocol.

But TFTs demonstrated gross myxoedema and an FBC revealed a haemoglobin of 9.5. Adding iron and a PPI restored his haemoglobin to normal.

On thyroxine he rapidly lost weight and gained fitness. His breathlessness disappeared and his diuretics stopped. Just one example of the benefits of a problem-oriented approach.

Nurses are supposed to be cheaper than doctors.

But because they take more time with patients, and because of missed and misdiagnoses, over-investigation and over-treatment, any economy from their lower salaries is eroded.

A good bedside manner is no substitute for good clinical judgment.

So do nurses have a role at all? Of course they do.

At the top end there are many highly skilled nurses undertaking specialist tasks extremely well. But most will never perform at this level.

Academic studies base their conclusions on a cohort of expert nurses, carefully observed and evaluated. Any practising GP will tell you that these results do not translate into the real world.

We have all witnessed the fiasco of nurse-led care through NHS Direct and walk-in centres. We surely know a nurse cannot do a GP's job.

The evidence is plain to see, unless your perspective is from an ivory tower – or Westminster.

Dr Dermot Ryan is a GP in Loughborough, Leicestershire, and a member of the General Practice Airways Group's research committee

Nurse Professor Bonnie Sibbald

It may be that the GP of the future looks more like a consultant in general internal medicine, while the practice nurse of the future looks more like the GP of today.

Dr Dermot Ryan

Would you prefer to be killed by well-intentioned kindness or helped by someone thoughtful but to the point?

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