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Nurses ‘at least as good’ as doctors for primary care provision

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Nurses delivering primary care obtain the same or better health outcomes as doctors and achieve higher levels of patient satisfaction, suggests a new review of research evidence.

The Cochrane Review comes amid a surge in interest in deploying nurses in advanced primary care roles in the UK and elsewhere in a bid to tackle widespread shortages of GPs.

“Trained nurses can probably provide equal or better quality of care compared to primary care doctors”

Miranda Laurant

The review, which updates a similar exercise carried out in 2005, specifically set out to explore the impact of substituting nurses for doctors with nurses carrying out a range of tasks including diagnosis, treatment, prescription and referral.

In all, findings from 18 trials were examined by the reviewers based in the Netherlands, Thailand and the UK. They included studies looking at nurses providing initial care – including urgent care – ongoing care for physical health issues and follow-up of patients with chronic conditions such as diabetes.

In many cases, nurses could get extra support or advice from a doctor if needed but the review deliberately excluded studies where nurses were in supporting or supplementary roles.

The reviewers found care delivered by nurses instead of doctors probably generates similar or better patient health for a wide range of conditions.

There was some evidence that nurse-led primary care may even lead to slightly fewer deaths among certain groups of patients compared with care led by doctors – although results varied.

Nurse-led care appeared to deliver better results when it came to blood pressure, while other clinical outcomes were pretty much the same as those achieved by doctors. Meanwhile, patient satisfaction and quality of life were likely to be higher for those seen by nurses.

“Whether nurse-doctor substitution is cost-effective remains unclear”

Miranda Laurent

The research team found nurse consultations were likely to be longer than those conducted by doctors and there was evidence that patients were more likely to attend follow-up appointments.

However, they found little or no difference between nurses and doctors when it came to the number of prescriptions issued and diagnostic tests ordered.

There was also little or no difference in patients attending accident and emergency, hospital referrals and hospital admissions.

The trials examined included several carried out in the UK, such as one where experienced nurses handled out of hours calls, and an 18-month trial comparing the effectiveness of nurse-led follow-up appointments for people with coronary heart disease with the same service provided by doctors.

Another included in the study compared a practice-based minor illness service led by nurses with routine care provided by GPs.

Nursing Times has previously reported on other schemes such as model of general practice being trialled in Scotland where advanced nurse practitioners take on many tasks usually done by GPs.

Based on the Nuka model developed in Alaska, this has led to improvements in the quality and continuity of care, increased patient satisfaction and was described as “a robust alternative to the GP recruitment crisis”.

Cochrane Review lead author Miranda Laurant said this latest piece of research demonstrated nurses could be deployed effectively to expand the primary care workforce.

“It doesn’t suggest that we can or should eliminate doctors from the primary care level; instead it shows that, in the cases assigned to them, trained nurses can probably provide equal or better quality of care compared to primary care doctors,” she said.

“This is very positive news, as doing so may allow doctors to spend more time focusing on more complex cases or cases that utilise their more advanced training,” she said.

Deploying nurses instead of doctors has been seen of one way of reducing costs in primary care. However, Ms Laurant stressed it was still not clear whether the strategy actually saved money.

“Whether nurse-doctor substitution leads to substantial savings or whether nurse-doctor substitution is cost-effective remains unclear; we hope that future research will examine this,” she said.

The researchers were also not able to say what level of nursing education led to the best outcomes when nurses were substituted for doctors.

Often the level of nursing in question was unclear and varied between and even within the studies examined.

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