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At the heart of general practice since 1960

Focus on....are nurses the new GPs?

With new 'GP-led' health centres set to have three nurses for every GP, By Gareth Iacobucci asks how far the skill mix can go.

By Gareth Iacobucci

With new 'GP-led' health centres set to have three nurses for every GP, By Gareth Iacobucci asks how far the skill mix can go.

A modern general practice wouldn't get very far without its nurses. They run everything from chronic disease clinics to vaccination services, many of them can now prescribe and they play a vital role in easing pressure on GPs.

But for all that, nurses are still nurses, and there is a growing queasiness in the profession at moves to use them in place of doctors.

Those moves were vividly displayed last week as Pulse revealed that Lord Darzi's so-called GP-led health centres would actually employ three nurses for every GP.

And leading primary care academics seem convinced that such as skill mix will become commonplace in the future.

Professor Bonnie Sibbald, professor of health services research at the National Primary Care Research and Development centre, claims nurses can take on the majority of GPs' work, and expects the Government to push for a similar skill mix across the whole of primary care.

She says: ‘I know that the Government supports the idea primary care should be delivered by multi-disciplined teams. Nurses have a very prominent role already, which is well developed within many practices and could be extended to many more.'

But is she right? Certainly, there are plenty of concrete signs that, even without Lord Darzi's influence, nurses are being handed an increasing role in general practice.

Prescribing duties

The Nurse Practitioners' Association recently claimed nurses were carrying out 90% of QOF work in some practices.

And the latest figures from the Nursing and Midwifery Council show that the number of nurse prescribers in primary care is growing at a rapid rate.

In 2007/08 there were 12,762 nurse prescribers in England, up from 10,750 in 2006/07, and vastly increased from just 1,457 in 2003/04.

There remains doubt over the extent to which nurses are willing to take responsibility for their prescribing decisions, but the number of items they prescribing is growing rapidly – by as much as 49% in the first year after nurses were handed access to the entire BNF, in May 2006.

Howard Catton, director of policy, at the Royal College of Nursing, expects the influence of nurses to continue to grow, insists they are vital to meeting the Government's aim of shifting more care into the community.

He says: ‘Nurse prescribing has developed fairly slowly. Yes, the numbers are growing, but at the moment, I don't see a peak to that trend. I think there's some way to go.

‘This isn't a sudden quick change in policy direction,' he adds.

‘Nurses have been expanding and extending their roles for a number of years. If we want to deliver on the acute to community shift, then nursing is arguably going to be the most important profession in terms of delivering that shift in care.

‘It absolutely isn't about nurses replacing doctors, but it is about an expansion of those nurse roles.'

But Dr Chaand Nagpaul, GPC negotiator and a GP in Stanmore, is alarmed by the latest moves to expand the nurse role. He believes the ratio proposed in the GP-led health centres makes a mockery of the term and risks second-rate care.

He says: ‘GP surgeries are largely run by GPs, with nurses supporting the practice. This skill mix is a nurse-led health centre, not a GP-led health centre.'

Mr Catton strongly rejects such claims as ‘unhelpful' and insists they represent a ‘minority' view among GPs.

He insists: ‘A lot of nurses tell us their GPs have been very supportive of nurses taking on some additional roles which often are related to meeting QOF requirements. I think it will jar that there is a suggestion of second-rate care. Some nurses may say, hang on a minute here, we're getting a mixed message.'

Some GPs agree. Dr Alan Keith, a GP in Rotherham, believes that a greater ratio of nurses to GPs is ‘the only sensible way forward'.

He says: ‘The whole problem is burgeoning demand. The idea of having 3:1 in Darzi centres is most sensible and the most imaginative thing I've heard in a long time. It will give doctors the chance to do a much more satisfying and wide range of things.'

Indeed, most doctors would accept that an increasing role for nurses is inevitable – where things get more contentious is in deciding what exactly that role would be.

Nurses are highly effective at following protocols in running chronic disease clinics, for example, but there is nervousness over the use to make frontline clinical decisions.

Low cost service

A Pulse survey of 600 GPs this week reveals that of those who were familiar with their local out-of-hours service, two thirds said the PCT was replacing GPs on shifts with nurses and emergency care practitioners.

Only 21% of GPs supported those moves – with the GPC fearing that such ‘lower cost general practice' will be particularly attractive to the private sector.

Dr Thomas Reichhelm, a GP in West Malling, Kent, whose GP-led company is currently bidding for polyclinics in Southern England, admits he is concerned that competitors will ‘abuse' the system by employing fewer GPs to save money.

He says: ‘I'm sure it will be abused. We come from a GP background and we want a good mix, but GP-led, which the name implies. But I'm quite sure we're up against some of the bigger competitors hoping to get away with relatively little in that way.'

Dr Rory McCrea, founder of Chilvers McCrea, is also involved in bidding for Lord Darzi's centres but rejects claims that nurse-driven services will lead to a poorer quality.

He says: ‘Chilvers McCrea Healthcare runs both GP and nurse-led services, and we are confident both provide a high quality service to patients. Most people agree it is appropriate for many of the diagnostic and clinical tasks carried out in a primary care setting to be performed by nurses.'

Shortage of nurses

RCGP chair Professor Steve Field is an enthusiastic supporter of teamwork in primary care, but he says the mix has to be right. ‘The first priority is that you have the appropriate number of GPs. Because we know that the evidence is that healthcare outcomes really depend on the number of GPs.'

And he sees another problem with moves to recruit nurse practitioners instead of GPs. There are, he says, simply not enough of them.

He says: ‘There needs to be an appropriate skill mix of those nurses, not just enough to make the numbers up. The workforce planning and training for nurses in primary care really lags behind the need. Nursing is still a secondary care dominated experience.'

He says the RCGP had met with the DH in the last fortnight to offer assistance in workforce planning, but warned that it would be difficult to train a large number of nurses overnight.

He adds: ‘We were very encouraged that the DH acknowledged there were problems, but the problem is, it will take a while to get the appropriate numbers of nurses trained and out into primary care.'

Anyone hoping that employing nurses might be an easy answer to the shortage of GPs may have to think again.

Timeline - The rise of the nurse

2004 As new contract is introduced, nurses begin taking on greater role in primary care, assisting GPs with more non-complex work, and helping the achieve QOF points

2006 Independent nurse prescribers permitted to prescribe any licensed medicine except for some controlled drugs, for any condition

2007 New data obtained by Pulse shows explosion in nurse prescriptions for antidepressants, anti-biotics and cardiac medication. The use of some medicines leaps by more than 200% in the year since prescribing regulations were changed.

2008 Government announces plans to staff new polyclinics with 3 nurses to every one GP. Latest figures show 12,762 independent nurse prescribers, compared with just 1,457 in 2003/04.

Nurse consultation Dr Chaand Nagpaul, GPC negotiator Dr Chaand Nagpaul, GPC negotiator

This amounts to a nurse-led health centre, not a GP-led health centre

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