This site is intended for health professionals only

Nurse-led PMS pilots: how are they doing?

Richard Lewis
Visiting Fellow
The King's Fund
London

Personal Medical Services (PMS) pilots were ­introduced by the 1997 NHS (Primary Care) Act, one of the final acts of the Major government. PMS pilots introduced local service agreements for primary care and replaced the infamous "Red Book" (the national system for remunerating GPs). PMS pilots also allowed new types of providers to take responsibility for delivering primary care. These included NHS trusts, Primary Care Trusts (PCTs) and other NHS professionals acting as independent contractors. 
When the first wave of PMS pilots was announced, Frank Dobson (then Secretary of State for Health) called on nurses to use the pilots to establish themselves at the centre of primary care. As a result, nine 'nurse-led' pilots were established. These pilots saw nurses as the leaders of the primary healthcare team and introduced extended nursing clinical roles. An evaluation of the experiences of these nine nurse leads has recently been carried out by the King's Fund and is reported here.(1)
The importance of these pilots has been underlined by The NHS Plan, the government's agenda for the NHS.(2) The government's vision is of an NHS that can offer rapid, high-quality care. These objectives rely in part on a radical review of skillmix within primary care and the development of new gateways to the NHS. These in turn require a renegotiation of the roles of nurses - nurses are expected to carry out extended roles (thus offering greater access to care for patients and freeing up GP time) and to run new primary care ­services such as NHS Direct and walk-in centres. 
The Chief Nursing Officer has identified ten "key roles" that appropriately trained nurses will be expected to routinely fulfil in the future.(2) These include the ordering of diagnostic investigations, making and receiving referrals to specialists, admitting patients directly to hospitals and carrying out triage. The PMS nurse leads have been carrying out these roles in primary care for the last three years.

The nine 'nurse-led' pilots
Of the nine pilots, eight were created as new teams, providing services where none had previously existed. One pilot inherited the practice of a GP who had recently died. Six of the nine pilots were designed to provide services specifically targeted at a variety of vulnerable populations (most commonly, homeless people and refugees) although many pilots also offered services to the general population.
Managerial arrangements were of three types: five of the pilots were managed by a community NHS trust; two pilots by an existing GP practice; and two pilots were created by nurses acting as independent contractors. In the latter case, the two nurse leads took personal responsibility for employing other members of the team, including salaried GPs.
The number of patients registered with each pilot ranged from 500 to 2,600 (with a mean of 1,311). Generally, pilots tended to have smaller list sizes than would have been expected with a "traditional" general practice model (however, the needs of the patients registered are likely to have been relatively high). Similarly, the clinical teams of these pilots were substantial given the list size. It was not uncommon for three whole-time clinicians (a mixture of GPs, nurse ­practitioners and practice nurses) to serve registered populations significantly lower than the national ­average for a single GP principal.
The nurse leads defined the 'nurse-led' qualities of their pilots both in terms of the skillmix within their teams and their philosophy of care. Nurse leads carried out extended nursing roles, specifically taking responsibility for first-contact care (in some cases patients were able to choose whether or not to be seen by a GP or nurse, in others they were automatically directed to the nurse practitioner). The nurse leads also distinguished their pilots from traditional general practice by their emphasis on professional equality within the clinical team and on the empowerment of patients (although, no doubt, many "traditional" GPs might claim the same philosophy). The nurses saw their own profession as more receptive to innovation. As one commented:

"If you were to say to doctors 'provide an open-access service', it would terrify them, absolutely. Whereas, all the nurses you say that to say 'oh yeah, that's a really good idea"

Their emphasis on professional equality means that, perhaps perversely, the term "nurse-led" is inaccurate. Nurse leads ­generally sought to create equal status between clinicians and to challenge the assumption that doctors were the natural team leaders:
 
"What we are saying is there is a different way to deliver primary care that may be led by anybody"

Redefining medical-nursing relations
The ability of nurses to substitute effectively for doctors in a wide range of settings is now well demonstrated through research.(3-5) Nevertheless, some doctors fear the shifting of this clinical boundary and nurses are frustrated by the apparent subservience of their role in relation to their medical colleagues (who may also be their employers).(6) The nurse-led PMS pilots have achieved a significant shift in medical-nursing relations within their teams. However, this has not been universal - one nurse lead commented:

"Although it was supposed to be nurse-led, the power was still all in the hands of the doctors; so nothing changed really … actually we were doctors and nurses at war in the end"

Current legislation and guidelines also inhibited the development of this new relationship. Nurse leads relied on doctors to prescribe and were unable to register patients directly (even though, contractually, they were responsible for their care). In addition, nurse leads were unable to sign a range of official documents including those for sickness benefit and death certificates.

Scepticism, if not hostility, towards the pilots was perceived from other doctors practising locally, ­particularly from local medical committees. This was perhaps in response to the more general unease about PMS pilots among some GPs than about the nurse-led variant in particular. However, in one case hostility was accentuated once an NHS trust sought to offer nurse-led services to "mainstream" patients rather than the vulnerable groups that have traditionally been unattractive to general practice. This suggests that nurse-led pilots may encounter greater resistance if they seek to move beyond their current "niche" markets.

Nurse leads did achieve significant changes in their relationships with secondary care services. All but one had negotiated the ability to refer patients directly for diagnostic tests or for consultant opinion. As one nurse lead commented:

"Any referral I send comes back to me personally and I have a relationship with the consultants which two years ago, they say, there is no way [they] would have got into"

However, these arrangements are rarely formal or all-inclusive. A minority of specialties still refuse to deal directly with the nurse leads and insist on dealing only with other doctors.

Quality assurance of nurse-led services
Perhaps surprisingly, nurse leads expressed sympathy with consultants who were reluctant to deal with them directly. Rather than see this reluctance as medical intransigence, nurse leads suggested that it might be a reasonable reaction to the lack of standardisation and accreditation of the nurse practitioner role. Nurse leads expressed serious reservations about the way in which extended nursing roles had been introduced and, in particular, the fact that there were no nationally agreed competencies, standards or training curricula. This was perceived to be as much the fault of the profession's own leadership as that of government: "our house is not in order" suggested one nurse lead.
Pilots were also concerned that they had experienced little or no monitoring of the quality of their services through Primary Care Group clinical governance mechanisms. This they perceived might be because of local assumptions that, as recognised leaders in their profession, they were beyond scrutiny.

Lessons for further ­implementation of extended nurse roles
While the experiences of the first-wave pilots suggest that they have made significant progress in implementing a new model of care, we should not automatically assume that the government's objectives for nursing are easily achievable. Nurse leads emphasised the importance of local champions for their pilots. Without support and encouragement it is possible that pilots may have foundered. For independent contractor nurses, this support is more difficult to arrange, and consequently this managerial model has resulted in greater ­isolation for the nurses concerned. Implementing a nurse-led pilot, whatever the managerial model, can involve significant personal stress for the nurse leader.
While NHS trust management provides a readymade nursing support mechanism, it has proved an unresponsive vehicle for delivering services. Trusts had little knowledge of how primary care services were managed (which is perhaps unsurprising, given that it is a new role for them) and were unable to respond quickly enough to the day-to-day needs of a primary healthcare team. This is something that must be addressed by PCTs as they inherit the work of community NHS trusts. However, whether medically dominated PCTs will wish to promote the nurse-led model of care is open to question.

Conclusion
The nine first-wave pilots have made good progress in developing a new model of primary care. While the term 'nurse-led' might suggest the replacement of one dominant profession with another, in fact nurse leads have stressed the need for equal status between all ­primary care disciplines. The introduction of this model has not been without controversy, and nurses have ­perceived themselves the ­target of medical hostility. However, this tension between doctors and nurses should not be overplayed. Within the pilots, doctors and nurses have largely worked harmoniously (with a significant exception) and nurse leads have ­successfully renegotiated their relationship with secondary care clinicians.
The third wave of PMS pilots went live in April 2001 and represented a significant increase in the numbers of pilots nationally. Many of these pilots will have received additional resources for nurse practitioners. The government should feel satisfied by the outcome of their first-wave experiment and should now feel more confident that their proposals for new nursing roles in primary care can draw on real-life successes.  However, nurse leads have identified serious concerns with the ­regulation of extended nursing roles and the need to develop more effective support mechanisms for the individual nurses who must enact the government's strategy. Nurse leads have been critical of their own profession's ­leaders. These are areas where the ­government and the profession should act quickly.

References

  1. Lewis R. Nurse-led primary care - Learning from PMS Pilots. London: King's Fund Publishing; 2001.
  2. Department of Health. The NHS Plan - a plan for investment, a plan for reform. London: HMSO; 2000.
  3. Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000;320:1038-43.
  4. Kinnersley P, Anderson E, Parry K, et al. Randomised controlled trial of nurse practitioner versus general ­practitioner care for patients requesting 'same day' consultations in primary care. BMJ 2000;320:1043-8.
  5. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or ­physicians. JAMA 2000;283(1):59-68.
  6. Elston, S, Holloway I. The impact of recent primary care reforms in the UK on interprofessional working in primary care centres. J Interprofessional Care 2001;15(1):19-27.

Contact/Resources
The King's Fund
W:www.kingsfund.org.uk
Department of Health
W:www.dh.gov.uk
NHS
W:www.nhs.uk

Further reading
Lewis R. Nurse-led primary care - learning from PMS pilots. London: King's Fund Publishing; 2001.
Lewis R, Gillam S, editors. Transforming primary care - personal medical services in the new NHS. London: King's Fund Publishing; 1999.
National Primary Care Research and Development Centre. Can nurses replace GPs? An ­evaluation of a nurse-led PMS pilot scheme. Manchester: NPCRDC; 1999.