Negotiating the role of the practice nurse in general practice

The roles of physician associates and advanced nurse practitioners in the National Health Service in the UK: a scoping review and narrative synthesis

BACKGROUND

Mid-level practitioners (MLPs), including physician associates (PAs) and advanced nurse practitioners (ANPs), have emerged to address workforce shortages in the UK and perform specific roles in relation to population needs. This has resulted in new ways of working and changes to established professional hierarchies. We conducted a study to investigate the career development, competencies, effectiveness, perceptions, and regulation of PAs and ANPs, with the aim of understanding ways to effectively integrate MLPs into the NHS workforce.

METHODS

We conducted a systematic scoping review following PRISMA guidelines. Embase, Medline, the Cochrane database, Pubmed, and CINAHL databases were searched, using terms relating to PAs and ANPs in the UK. A total of 128 studies (60 on PAs and 68 on ANPs) were included in the final analysis. A narrative synthesis, guided by the pre-defined themes and emerging themes, was conducted to bring together the findings.

RESULTS

PAs are educated on a medical model with basic medical skills but lack formal professional regulation and do not have prescribing rights. ANPs are educated on a nurse model with enhanced skills that depend on roles within specific specialities, and their governance is mostly employer-led. PAs are primarily employed in secondary care. ANPs are employed widely in both primary and secondary care. No defined career progression exists for PAs. In contrast, becoming an ANP is a form of career progression within nursing. Both roles were regarded as cost-effective in comparison to doctors performing simple tasks. PAs were less understood compared to ANPs and received a mixed reception from colleagues, which sometimes undermined their professional identity, whereas ANPs were mostly welcomed by colleagues.

CONCLUSIONS

Potential ways to better integrate PAs and ANPs into the NHS workforce include further initiatives by regulatory bodies and the NHS to create more awareness and clearer role definitions for MLPs, outline potential for career progression, offer transparency with regard to remuneration, and introduction of prescribing rights. Future research might include more cadres of MLPs and explore the international literature.

Utilization of registered nurses in primary care teams: A systematic review

BACKGROUND

Registered nurses are increasingly becoming embedded in primary care teams yet there is a wide variability in nursing roles and responsibilities across organizations. Policy makers are calling for a closer look at how to best utilize registered nurses in primary care teams. Lack of knowledge about effective primary care nursing roles and responsibilities challenges policy makers' abilities to develop recommendations to effectively deploy registered nurses in primary care needed to assure efficient, evidence-based, and quality health care.

OBJECTIVE

To synthesize international evidence about primary care RN roles and responsibilities to make recommendations for maximizing the contributions of RNs in team-based primary care models.

DESIGN

Systematic review.

DATA SOURCES

The Meta-Analysis and Systematic Reviews of Observational Studies framework guided the conduct of this review. Five electronic databases (OVID Medline, CINAHL, EMBASE, PubMed and Cochrane Library) were searched using MeSH terms: primary care, roles, and responsibilities. The term "nurs*" was truncated to identify all literature relevant to nursing.

REVIEW METHODS

The initial search yielded 2243. Abstracts and titles were screened for relevance and seventy-one full text reviews were completed by two researchers. Inclusion criteria included: (1) registered nurses practicing in interprofessional teams; (2) description of registered nursing roles and responsibilities; (3) primary care setting. All eligible studies underwent quality appraisal using the Integrative Quality Criteria for Review of Multiple Study Designs tool.

RESULTS

Eighteen studies met eligibility across six countries: Australia, United States, Spain, Canada, New Zealand, and South Africa. Registered nurses play a large role in chronic disease management, patient education, medication management, and often can shift between clinical and administrative responsibilities. There are a limited number of registered nurses that participate in primary care policy making and research.

CONCLUSION

Integrating registered nurses into primary care has the potential to increase patient access to a primary care provider because registered nurses can supplement some of the provider workload: they renew prescriptions, address patient questions, and provide patient education. Clear practice protocols and nursing policy should be written by registered nurses to ensure safe, and effective nursing care. The use of a medical assistant or nurse's aide to perform non-nursing tasks allows registered nurses to take on more complex patient care. Future research should expand on emerging payment models for nurse-specific tasks.

An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background

Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs).

Aim

To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.

Methods

Development

We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs.

Implementation

The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence.

Evaluation

The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment.

Trial results

Depression trial

In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5;p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence.

CVD risk trial

In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9;p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management.

The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement.

Conclusion

The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs.

Trial registration

Current Controlled Trials ISRCTN14172341 (depression trial) and ISRCTN27508731 (CVD risk trial).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

The anachronism of policy for nursing in general practice: Conceptualising a way forward

This paper reviews the current rhetoric on changing professional role boundaries and mixing skills in general practice, particularly in relation to the general practice nurse. The issues relating to the effectiveness and efficiency of the general practice nurse role and to the professional development of general practice nurses, can be placed in a matrix, represented by parameters which relate to teamworking and to the 'doctoring/nursing relationship'. The question is asked: 'How can the reality of current nursing roles within general practice meet the rhetoric of the current NHS (Primary Care) Bill?' By providing conceptual matrices which place the key issues of general practice nursing in contingent relation, questions which relate to, for example, changing professional roles and the appropriateness of a general medical services infrastructure for primary health care can be explored — a process of contingent quality improvement.

Nurses in Australian general practice: implications for chronic disease management

AIMS

The purpose of this study was to describe the demographic and employment characteristics of Australian practice nurses and explore the relationship between these characteristics and the nurses' role.

BACKGROUND

Nursing in general practice is an integral component of primary care and chronic disease management in the United Kingdom and New Zealand, but in Australia it is an emerging specialty and there is limited data on the workforce and role.

DESIGN

National postal survey embedded in a sequential mixed method design.

METHODS

284 practice nurses completed a postal survey during 2003-2004. Descriptive statistics and factor analysis were utilized to analyse the data.

RESULTS

Most participants were female (99%), Registered Nurses (86%), employed part-time in a group practice, with a mean age of 45.8 years, and had a hospital nursing certificate as their highest qualification (63%). The tasks currently undertaken by participants and those requiring further education were inversely related (R2 = -0.779). Conversely, tasks perceived to be appropriate for a practice nurse and those currently undertaken by participants were positively related (R2 = 0.8996). There was a mismatch between the number of participants who perceived that a particular task was appropriate and those who undertook the task. This disparity was not completely explained by demographic or employment characteristics. Extrinsic factors such as legal and funding issues, lack of space and general practitioner attitudes were identified as barriers to role expansion.

CONCLUSION

Practice nurses are a clinically experienced workforce whose skills are not optimally harnessed to improve the care of the growing number of people with chronic and complex conditions. Relevance to clinical practice. Study data reveal a need to overcome the funding, regulatory and interprofessional barriers that currently constrain the practice nurse role. Expansion of the practice nurse role is clearly a useful adjunct to specialist management of chronic and complex disease, particularly within the context of contemporary policy initiatives.

Advanced training for primary care and general practice nurses: enablers and outcomes of postgraduate education

The aims of the present study were to understand enablers to participation in postgraduate education for primary care nurses (PCNs), and to explore how postgraduate education has advanced their nursing practice. Cross-sectional questionnaires were mailed out in April 2012 to current and past students undertaking postgraduate studies in primary care nursing at The University of Melbourne, Victoria, Australia. Questionnaires were returned by 100 out of 243 nurses (response rate 41%). Ninety-one per cent (91/100) of the respondents were first registered as nurses in Australia. Fifty-seven per cent were hospital trained and 43% were university educated to attain their initial nurse qualification. The respondents reported opportunities to expand scope of practice (99%; 97/98), improve clinical practice (98%; 97/99), increase work satisfaction (93%; 91/98) and increase practice autonomy (92%; 89/97) as factors that most influenced participation in postgraduate education in primary care nursing. Major enablers for postgraduate studies were scholarship access (75%; 71/95) and access to distance education (74%; 72/98). Many respondents reported an increased scope of practice (98%; 95/97) and increased job satisfaction (71%; 70/98) as an education outcome. Only 29% (28/97) cited an increase in pay-rate as an outcome. Of the 73 PCNs currently working in general practice, many anticipated an increase in time spent on the preparation of chronic disease management plans (63%; 45/72), multidisciplinary care plans (56%; 40/72) and adult health checks (56%; 40/72) in the preceding 12 months. Recommendations emerging from findings include: (1) increased access to scholarships for nurses undertaking postgraduate education in primary care nursing is imperative; (2) alternative modes of course delivery need to be embedded in primary care nursing education; (3) the development of Australian primary care policy, including policy on funding models, needs to more accurately reflect the educational level of PCNs, PCN role expansion and the extent of interprofessional collaboration that is evident from research undertaken to date. Nurses with postgraduate education have the potential to increase their scope of practice, take on a greater teaching role and provide more preventive and chronic disease services in primary care. Policies aimed at increasing access to education for nurses working in primary care would strengthen the primary care nursing profession, and enhance the delivery of primary health care services in Australia.

Roles and identities in transition: boundaries of work and inter-professional relationships at the interface between telehealth and primary care

Shifting the balance of care towards home and community is viewed as requiring interventions which enhance or complement primary care. Technology-based interventions are seen as key to the future in this work. Telehealthcare implicates a new agenda for inter-professional working across boundaries of healthcare. One such interface is between telehealthcare professionals and professionals located in primary care. This study reports the findings from a qualitative study forming part of a broader project examining the potential of developing and implementing telehealth interventions to support patients with long-term conditions. Semi-structured interviews were undertaken with telehealth nurse care managers, practice nurses and general practitioners in their respective work settings (39 interviews with 62 participants). Observation was undertaken at a telehealth call centre. The research took place between April 2010 and March 2011. Thematic analysis of qualitative data was undertaken. Telehealth nurse care managers' interviews suggested narrative constructions of new roles and identities to fit telehealth work, combining a holistic ideal and retro-appeal with 'traditional' values of nursing, which distinguished and distanced them from counterparts in general practices. Practice nurses and general practitioners were ambivalent and often sceptical about the contribution of telehealth to long-term condition work. Practice nurses' accounts suggested a sense of protectiveness about maintaining boundaries around established remits of managing long-term conditions; general practitioners, having devolved much of the care of long-term conditions to nurses, were keen to retain their positions as gatekeepers to resources. Perceptions of shifts of professional roles, new ways of working and how they are valued form a relevant contextual element to the introduction of telehealth interventions. A pre-emptive view and response to how professionals understand and approach increasingly complex and multi-faceted roles within primary care is likely to prepare and facilitate the introduction and integration of telehealth innovations into existing patient services.

Nursing in general practice: organizational possibilities for decision latitude, created skill, social support and identity derived from role

AIM

This article is a report of a study to describe the factors that support organizational opportunities for practice nurse decision-making and skill development for nurses employed in general practice in New South Wales, Australia.

BACKGROUND

Corresponding to the availability of subsidies from the Australian universal health insurer (Medicare), there has been an increase in the number of nurses employed in general practice. Currently, there is no Australian evidence as to the organizational possibilities for these practice nurses to make decisions, develop their own skills and abilities, derive identity from their role or how their role is influenced by social support.

METHODS

Over a 8-month period in 2008 practice, nurses employed in general practice in the State of New South Wales were invited to complete a 26-item self-administered online questionnaire utilizing constructs from Karaseks (1998) Job Content Questionnaire (valid n = 160).

RESULTS

Confirmatory Factor Analysis indicated that all scales demonstrated acceptable levels of internal consistency. Sequential regression models revealed that social support exerts a weak influence on decision latitude (R(2) = 0·07); the addition of self-identity through work significantly improved the predictive ability of the model (R(2) = 0·16). Social support and self-identity through work exerted a negative influence on created skill (R(2) = 0·347), whereas social support was effective in predicting self-identity through work (R(2) = 0·148).

CONCLUSIONS

  Collegial and supervisory support in the work environment predicts organizational possibilities for practice nurse decision-making.

The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services?

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.

Impact of the 2004 GMS contract on practice nurses: a qualitative study

BACKGROUND

The new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF).

AIM

This study investigated how practice nurses perceive the changes in their work since the contract's inception.

DESIGN OF STUDY

A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores.

SETTING

Glasgow, UK.

METHOD

Individual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach.

RESULTS

Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient-nurse relationship, which were regarded as a core value.

CONCLUSIONS

The new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.

Renegotiating roles as part of developing collaborative practice: Australian nurses in general practice and cervical screening

This paper reports the findings from an action research study that used a reflective group method to work with nurses in general practice recently credentialed as cervical screeners. The research aimed to develop a new model of practice nurse service delivery within a multidisciplinary team. Findings demonstrated that poor interdisciplinary collaboration created barriers to changing the role of the practice nurse. Key themes identified were: renegotiating their roles, identifying and negotiating gendered patterns of cervical screening, and the effect of multidisciplinary teams and interdisciplinary collaboration on practice nurse retention. Recommendations from this study address the need for improved piloting of new initiatives and an increase in continuing professional development for practice managers who are potential change agents.

General practice nursing education in Australia

The quality of care delivered by nurses working in Australian general practices rests on a strong foundation of nursing educatlon and training. A national study of nurses working in general practice was conducted using qualitative and quantitative research techniques to explore their role and educational needs. Results from this research suggest that education for general practice nurses is seen by nurses and General Practitioners to be largely non-formal in nature and is seen by GPs and nurses to be tailored towards general practice nursing needs. Such education is often available locally through general practice support organisations; is strongly focused on National Health Priority Areas and clinical care; and is more appropriate for registered rather than enrolled nurses. The educational opportunities currently available to support nursing in general practice are largely ad hoc and vary in relation to quality, appropriateness and accessibility. Nurses working in general practices in Australia need a system of ongoing training and education to support their responsibilities and foster the development of the position as a viable career option for nurses.

Australian nurses in general practice based heart failure management: implications for innovative collaborative practice

BACKGROUND

The growing global burden of heart failure (HF) necessitates the investigation of alternative methods of providing co-ordinated, integrated and client-focused primary care. Currently, the models of nurse-coordinated care demonstrated to be effective in randomized controlled trials are only available to a relative minority of clients and their families with HF. This current gap in service provision could prove fertile ground for the expansion of practice nursing [The Nurse in Family Practice: Practice Nurses and Nurse Practitioners in primary health care. 1988, Scutari Press, London: Impact of rural living on the experience of chronic illness. Australian Journal of Rural Health, 2001. 9: 235-240].

AIM

This paper aims to review the published literature describing the current and potential role of the practice nurse in HF management in Australia.

METHODS

Searches of electronic databases, the reference lists of published materials and the internet were conducted using key words including 'Australia', 'practice nurse', 'office nurse', 'nurs*', 'heart failure', 'cardiac' and 'chronic illness'. Inclusion criteria for this review were English language literature; nursing interventions for heart failure (HF) and the role of practice nurses in primary care.

RESULTS

There is currently a paucity of data evaluating the potential role for practice nurses in a reconfigured, collaborative health care system. Those studies that were identified were, largely, of a descriptive nature. In addition to identifying the practice nurse as a largely unexplored resource, key themes that emerged from the review include: (1) current general practice services face significant barriers to the implementation of evidence-based HF practice; (2) there is considerable variation in the practice nurse role between general practices; (3) there are significant barriers to the expansion of the practice nurse role; (4) multidisciplinary interventions can effectively deliver secondary prevention strategies; (5) practice nurses can potentially facilitate these multidisciplinary interventions; and (6) practice nurses are favorably perceived by consumers although there is some confusion about the nature of their role.

CONCLUSION

On the basis of this literature review, practice nurses represent a potentially useful adjunct to current models of service provision in HF management. Further research needs to comprehensively investigate the role of the practice nurse in the Australian context with a view to developing effective and sustainable frameworks for clinical practice. In particular, high-level evidence is required to evaluate the efficacy of the practice nurse role compared to current disease management strategies.

Changing the skill-mix of the health care workforce

OBJECTIVE

Changing workforce skill-mix is one strategy for improving the effectiveness and efficiency of health care. Our aim was to summarise available research into the success or failure of skill-mix change in achieving planned outcomes.

METHODS

A systematic search for existing reviews of research into skill-mix was conducted. Databases searched included: MEDLINE, CINAHL, PsychINFO, Cochrane Library, HMIC, Centre for Reviews and Dissemination, and Department of Health Research Findings Register. Search terms included keywords defining the type of publication, clinical area, type of health personnel and the focus of the article (role change, skill-mix, etc.). English language publications from 1990 onwards were included. Two reviewers independently identified relevant publications, graded the quality of reviews and extracted findings. In addition, the wider literature was scanned to identify which factors were associated with the success or failure of skill-mix change.

RESULTS

A total of 9064 publications were identified, of which 24 met our inclusion criteria. There was a dearth of research, particularly for role changes involving workers other than doctors or nurses. Cost-effectiveness was generally not evaluated, nor was the wider impact of change on health care systems. The wider literature suggested that factors promoting success include: introducing 'treatments' of proven efficacy; appropriate staff education and training; removal of unhelpful boundary demarcations between staff or service sectors; appropriate pay and reward systems; and good strategic planning and human resource management. Unintended consequences sometimes occurred in respect of: staff morale and workload; coordination of care; continuity of care; and cost.

CONCLUSIONS

In order to make informed choices, health care planners need good research evidence about the likely consequences of skill-mix change. The findings from existing research need to be made more accessible while the dearth of evidence makes new research necessary.

Stakeholder expectations in practice-based medicine

Competitive pressures are forcing physicians from solo practice into new organizational structures. These new structures and the technologies supporting them have generated suggestions for improving medical practice. This article examines the unspoken assumption often accompanying these suggestions that practice improvement can come about through a closer alignment of the practice's goals and values with its stakeholders' expectations. Because conflict among competing goals is inevitable in a resource-scarce environment, an important question for each practice, and for each individual physician in a practice, is how to adjudicate conflicts of value when the goals of the practice appear to collide. This essay concludes with a proposal for an adjudicating process to help resolve these conflicts in practice-based medicine.

Practice nurses and clinical guidelines in a changing primary care context: an empirical study

BACKGROUND

Practice Nurses form an increasingly large proportion of the English National Health Service primary care workforce and the delegation to them of clinical work from General Practitioners has attracted some academic attention. Central to this process are clinical guidelines, which provide the interface between the movement towards 'evidence-based practice' and a range of government-driven policy developments in primary care.

AIMS

To identify the attitudes of practice nurses to clinical guidelines; to investigate the impact of guidelines on nurse/physician relationships; and to describe the impact of the changing primary care context on nurses.

METHODS

We interviewed a sample of 29 Practice Nurses three times during a 16-month period to clarify their attitudes towards guidelines, their use of guidelines in practice and their assessment of guidelines' importance. We gathered further data on organizational culture and perceptions of national reforms of primary care structures.

RESULTS

We found that practice nurses are generally supportive of clinical guidelines. Moreover, nurses' role and influence within primary care is in a process of transition to one in which they may undertake responsibility for influencing General Practitioners' clinical behaviour so as to adhere to guidelines. Practice nurses themselves recognize and welcome this, though with some reservations.

CONCLUSIONS

Our findings support the proposal that explicit codification of the scientific basis of the work of lower paid groups may enhance their relative professional status.

Practice nursing: an evaluation of a training practice initiative

Globally, health care is moving towards a primary care approach. In the UK initiatives for nurses wishing to gain experience in primary and community care may be crucial with the advent of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). This paper outlines an initiative in practice nursing, developed as a pilot study by a Health Authority. The training practice initiative was aimed at nurses returning to practice and offered them an experiential and supportive career pathway into primary care. The evaluation (carried out over 1 year), highlighted that those primarily involved in the initiative--the trainees, educators and general practitioners--felt it had been successful, especially in relation to professional development issues. The funding bodies for the initiative, who previously had concerns over the recruitment and retention of practice nurses, were also optimistic that the support networks which developed as a result of the initiative had raised morale. The paper suggests several educational, organizational and professional issues which arose from the evaluation exercise. Further, it suggests how this initiative, in an extended form, could provide an effective basis for the training and development of nursing staff in PCGs/PCTs.

Crown II: the implications of nurse prescribing for practice nursing

Certain limited prescribing rights have now been granted to district nurses and health visitors. Proposals to extend prescribing rights to other health professionals have recently been put forward in the Review of Prescribing. Supply and Administration of Medicines (DoH, 1999). Practice nurses are one group who are likely to apply for such rights. This article reports on selected findings from a small-scale qualitative study designed to investigate the current and potential future of practice nurse in prescribing. It was found that practice nurses exercise considerable influence over prescribing in diverse therapeutic areas within general practice. However, it may be difficult to accommodate the prescribing requirements inherent in such a broad scope of practice within the framework of the present proposals. Important issues of accountability and patient safety are raised, and recommendations made for policy, research and education.

Were practice nurses distributed equitably across England and Wales, 1988-1995?

OBJECTIVE

To examine whether variations in the number of whole-time equivalent (wte) practice nurses across family health services authorities (FHSAs) can be explained by population characteristics and the organisation of general practice.

METHODS

Analysis of nine health and 16 social indicators for 98 FHSAs identified three factors underlying health care needs. These factors and seven practice characteristics were analysed by stepwise regression. A formula for allocating health care resources and a logistic growth model were used to estimate the 'expected' number of nurses.

RESULTS

Past trends indicate an eventual (wte) practice nurse workforce of 12,500 (95% CI +/- 3500). Although geographical disparities have declined, there was a two-fold variation in nurse numbers across FHSAs. Around 2000 (wte) posts would be required to bring under-provided areas, mostly in northern England and metropolitan districts, up to the highest level of provision. There were more nurses in areas with higher proportions of elderly people but fewer where deprivation, morbidity and mortality levels were above average. The number of general practitioners was the most significant predictor of practice nurse provision (t = 5.0); population needs and practice characteristics explained 24% of the variation.

CONCLUSIONS

The distribution of practice nurses scarcely corresponded with health care needs at the FHSA level. Despite a lack of evidence that nurses are a cost-effective addition to the primary health care team, their role and numbers will be driven by the extent to which they take on responsibilities performed by doctors. Achieving equity in practice nurse provision probably requires explicit consideration in a formula for allocating primary care funds, backed by audit of the services they provide.