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Who needs doctors in general practice?

It has been suggested recently that nurses can deliver as much high-quality care as GPs in many areas. Is this the beginning of the end for GPs? Our new NiP advisory panel member, himself a GP, doesn't think that we should get rid of doctors just yet …

Who needs doctors in general practice? This arresting title is the opening salvo for a guest editorial in Quality in Primary Care, in April this year, and was followed up with a debate on the same topic in the BMJ in September (BMJ 2008;337:658-659).

Bonnie Sibbald, the highly respected and internationally known professor of health services research at the National Primary Care Research and Development Centre in Manchester, is the protagonist here, arguing, with her usual integrity from a firm research base, that nurses can deliver as much high-quality care as general practitioners in the areas of preventive care, routine follow-up of patients with long-term conditions, and first contact care for people with minor illness. And patients tend to be highly satisfied with the care delivered by nurses.

But high satisfaction doesn't necessarily mean that patients prefer to see a nurse rather than a doctor. They do, Sibbald argues, when they perceive their problem as minor, preferring a doctor when they perceive the issue as serious or difficult.

Overall, the position is that patients are happy to be allocated to a nurse, and don't feel fobbed off that they are seeing someone less professional. GPs have yielded a lot of frontline work to nurses, and Sibbald argues that this movement should be taken to its organisational conclusion - placing nurses as the lead professionals in primary care, and deploying doctors as consultants in primary care, taking referrals from frontline nurse practitioners.

Arguing against this in the BMJ portfolio GP Rhona Knight worries about the variability in training for nurses, and specifies the training of advanced nurse practitioners (ANP) as a key worry. "Nurses might be trained to work as GPs, and lead primary care," Knight asserts, "but the suggested ANP training seems woefully inadequate." When she takes her son to the walk-in centre, Knight worries that the emergency nurse practitioner (ENP) might simply have had had a two-week ENP course as opposed to longer, more complex training.

Our practice in Exeter is nurse led: my partner in the practice is a nurse practitioner, and we are staffed with another specialist nurse (diabetes) as well as a healthcare assistant. Two-thirds of all the 15 minute appointments are with nurses (triaged by one of the two senior nurses, not by the receptionists), and the practice has 1.2 doctors for its list of 3,500 patients.

Does it work OK? Well, yes, if you take our QOF points (among the highest locally) and patient satisfaction levels (as judged by repeated questionnaires).

So, is ours the model for the future? Well, I am less sure. The senior nurses in our practice have 45 years experience between them, I have known them both for 20 years, and we know exactly how each of us works.

And while the nurses can prescribe, they do so with self-imposed safety criteria, prescribing in those areas they feel most confident and experienced with.

GPs, I think, are paid to interpret undifferentiated illness, accept and handle uncertainty, and manage the inevitable deterioration in someone with chronic disease. Sure, nurses might be able to do all that too - but my take is that to do it as well as UK general practitioners currently do it (and UK primary care is the envy of the world), nurses would pretty well have to be trained as doctors, and you wouldn't catch them doing it full time for forty grand.

Do you agree with Kieran? Can nurses ever really replace GPs? Your comments: (Terms and conditions apply)

"I was a patient of yours 12 years ago, and am glad to hear
that your practice continues to be a real success, offering great care from a multidisciplinary approach. I am now working as a Nurse Practitioner myself, and love the fact that every day I stretch myself to the limits rather than trudging the same well-worn paths as a DN. I am doing my Prescribing Course, and learning so much, but get sick of explaining to family and friends that I don't want to be a Doctor - just a really good nurse! Let's accept that general practice is a team sport, and works best when we all do what we're good at, and pull together
for the benefit of the patient." - Sarah Bellamy, West Sussex

"I work in a practice as a nurse practitioner, with two GPs and approx. 3,500 patients. I find that we are a complete team - each clinician is appreciated for their individuality and skills. So yes of course we still need GPs." - Karen Dukes, Chesterfield, Derbyshire

"No, but while the article suggests nurses are not necessarily up to interpreting undifferentiated illness, and that some nurses may have just done a 2-week course before working at a higher level, there are other compounding variables in this equation.
What about GPs who do not feel they need to update beyond the minimum, who have been in practice for years and do not even open their eyes to new procedures or ways of doing things? Would you choose one of those or a keen nurse, enthusiastic at keeping up-to-date? What about the subjective experience accumulated by nurses who just have that 'gut' feeling or intuition that 'something' is wrong, and pick up and explore problems the GP has overlooked? In the end, we are a team, and thankfully the medical and nursing view on patient care just needs to be pleasant, with communication, not competition. Sometimes nurses 'can do' without knowing from where that knowledge arose … and sometimes it is just knowing when we don't know, so that we can explore and look up the information we need while the patient is sat with us. Maybe it is the communcation skills that come with nursing - I think medical training has only recently acknowledged its importance." -  Lynne Hayward, Greater Manchester