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Evidence-Based Healthcare & Public Health (2004) 8, 335–338

KEYWORDNurse pracGeneralpractitioneWorkload;PracticemanagemeRandomisecontrolled

1744-2249/$ - sdoi:10.1016/j.e

$Abstractedpractitioners: r

www.elsevier.com/locate/ebhph

EVIDENCE-BASED HEALTHCARE MANAGEMENT

Nurse Practitioners do not reduce GeneralPractitioners’ workload$

Brenda Leese, BSc (Hons) DPhil (Commentary author)

Reader in Primary Care Research, Centre for Research in Primary Care, University of Leeds, Leeds UK.

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from: Laurant MGH, Handomised controlled t

Summary

Question Do nurse practitioners reduce the workload of doctors in general practice?

Study Design Randomised controlled trial.

Main results After 18 months, nurse practitioners did not significantly reducegeneral practitioners’ objective or subjective workload (see Results table).

Authors’ conclusions Nurse practitioners did not reduce general practitioners’ workloadafter 18 months. However, the result of this study may not apply if a different ratio ofnurses to doctor is employed, or if nurses have different levels of training; degrees ofautonomy and provide a different type of service. These factors need to be investigatedfurther to harness the potential benefit of nurse practitioners as part of a general practiceteam.& 2004 Published by Elsevier Ltd.

Commentary

There have been a number of studies investigatingthe acceptability of nurse practitioners/practicenurses for minor illness in primary care.1–3 Theconclusions have generally been that, for specificaspects of care e.g. first contact, health promo-tion, chronic disease management (CDM), nursesprovide care that is as acceptable as generalpractitioners (GPs). In terms of outcomes, patientsoften prefer to be seen by nurses. Studies havebeen prompted by GP shortages and the expecta-tion that nurses would be more cost effective. This

Published by Elsevier Ltd.

ermens RPMG, Braspenning JCrial. BMJ 2004; 328: 927–930.

has not been the case; although nurses cost lessthan GPs, they tend to spend longer with patients,so negating any cost benefits.1 Indeed, patientstend to prefer to see nurses precisely because ofthe time differential. So where do we go from here?

Laurant et al4 add to the evidence by showing,within the parameters of the study that nurses do notsubstitute for GPs, but tend to act in a supplementarycapacity. The authors themselves note that this maybe a function of the conditions investigated (COPD,asthma, dementia, cancer) which may require great-er input by GPs than the more traditional practicenurse/nurse practitioner activities identified above.

C, et al. Impact of nurse practitioners on workload of general

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Results table

Effect of nurse practitioner on the workload of general practitioner after 18 months.

With nursepractitioner(n=20)

Without nursepractitioner(n=15)

P value fordifference

Objective workload* during surgery hours

17.4 10.4 0.057 Objective workload* outside surgery hours 3.3 5.8 0.217 Available time** 2.8 2.8 0.285 Job satisfaction** 2.3 2.4 0.415 Inappropriate demands** 3.4 3.5 0.608 Cost benefit** 2.8 2.8 0.479

*Mean number of contacts with patients per week, for chronic obstructive pulmonary disease, asthma,dementia or cancer; contacts for other indications were not assessed**Subjective score on a five point scale; higher score indicates more negative perception

The literature shows that the expanding role of

nurses in primary care is not new. Increases in thescope and content of the work of practice nurseswere noted over ten years ago5,6 and with theintroduction of the new GMS contract in England,7

the pace of change is expected to increase evenfurther. Jenkins-Clarke et al6 quantified the aspectsof care in the GP consultation that could beundertaken by nurses, finding that 17% of consulta-tions could be delegated in their entirety. This doesnot resolve the issue, however, since identifyingthose areas appropriate for nurses in everydaypractice is not easy. The expanding role of nurses inprimary care faces a number of barriers includingperceived threats to GP status, concerns aboutnurse capabilities, provision of training,8 and thefeeling that GPs will be left with the more difficultcases, doing little to reduce their stress andburnout.

The new GMS contract7 identifies some advancedand specialised roles for nurses and other healthprofessionals: practice nurses to have access tocontinuing professional development and informa-tion technology training; advanced roles in firstcontact care, CDM and prevention with associatedtraining opportunities; opportunities for nurses andothers to work at all levels as part of the primaryhealthcare team. Nurses will be ideally placed toassist GPs in achieving their ‘points’ as part of thequality and outcomes framework. The classificationof some services as ‘enhanced’ (these do not haveto be provided by practices unless they so choose)e.g. anti-coagulation monitoring, drug and alcoholservices, care of the homeless, will also provideopportunities for nurses. The emphasis has been on

reducing GP workload and this was one factorbehind the introduction of the new contract,although the evidence presented by Laurant et al4

suggests this might be difficult to achieve.Moreover, the emergence of practitioners with

special interests;9 to complement GPs with specialinterests,10 adds further potential opportunities fornurses. Both of these developments may promoterecruitment and retention and have an impact onworkload. Liberating the Talents11 lists three corefunctions for primary care: (i) first contact/acuteassessment, diagnosis, care, treatment, referral;(ii) continuing care, rehabilitation, chronic diseasemanagement, delivering National Service Frame-works; (iii) public health/health promotion andprotection, programmes to improve health andreduce inequalities. These place nurses centrallywith a major role in delivering the new GMScontract.

Implications

The evidence suggests that nurses will continue toincrease the scope and capacity of their work, butwhether GP workload will reduce as a result hasbeen thrown into doubt by the findings of Laurantet al.4 Finally, the ongoing nurse shortage12 is rarelydiscussed in this context – the emphasis is usuallyon doctors. Perhaps the time has come to look atworkload and recruitment and retention across allprimary care professionals, to set up trainingschemes where required, and enhance the workingenvironment for all concerned.

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Further details

Question

Do nurse practitioners reduce the workload of doctors in general practice?

Study design

Randomised controlled trial.

Setting

34 general practices in both urban and rural areas in the Netherlands; follow up 18 months.

Participants

48 general practitioners, of whom 35 were included in the analysis.

Intervention

Community nurses with mean 12 years post-graduate experience and appropriate skills were trained fortwo weeks and randomly allocated to work for an average of 7 general practitioners. Control generalpractitioners received no nurse practitioner help. The nurses assessed patient health, performed diagnostictests, educated patients and their families and co-ordinated patient care with the general practitioner andother healthcare professionals.

Main outcomes

Objective workload information was determined from diaries. This included number of consultations perday for chronic obstructive pulmonary disease and asthma, dementia or cancer; type of consultation (inpractice consultation, telephone consultation or home visit); time of day (during surgery hours or aftersurgery hours). Measurements of objective workload were taken 6 months before and for 18 months afterthe introduction of nurse practitioners. Subjective workload (available time, job satisfaction,inappropriate demands and cost benefit) was measured by questionnaire.

Notes

Applicability may be limited to nurse practitioner services and primary care services that are qualitativelysimilar to those examined in the study, and of similar intensity. The study did not examine effects of nursepractitioners for objective workload due to conditions other than chronic obstructive airways disease;asthma; cancer and dementia. The number of general practitioners studied was small and the study mayhave lacked power to classify important effects as being significant. The drop out rate was high and is apotential source of bias; 12 of 48 general practitioners enrolled were not followed up.

Sources of funding: Local Association of General Practitioners (DHV Midden Brabant), Local CommunityNursing Authorities (Thebe thuiszorg) and the Insurance companies CZ Actief in Gezondheid and VGZMidden Brabant.

Abstract provided by Bazian Ltd, London

References

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Clement J. Nurse management of patients with minor

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