The delegation of GPs’ work to nurses is set to increase following the white paper. Nurses must receive ongoing training to take on additional roles, says Claire Rashid
GPs are set to take on additional responsibilities, such as commissioning health care, under the coalition government’s proposed reorganisation of the NHS. Faced with this extra workload, they will be looking to delegate more aspects of their clinical role to practice nurses. However, delegation can result in potential problems for nurses, as I recently discovered when I carried out a literature review (Rashid, 2010).
In the past, the main driver for nurses taking on aspects of a GP’s clinical role has been to make the most use of limited NHS resources. However, there is little evidence to support the assumption that it is more cost effective for nurses to take on such work. Furthermore, any cost savings tend to be cancelled out because nurses tend to spend longer with patients.
The main evidence to support delegation is a literature review published in the Cochrane library, which explores the substitution of GPs by nurses in primary care (Laurant et al, 2004). This study concluded that nurse practitioners can provide similar health outcomes and levels of patient satisfaction as GPs.
However, these days it is actually practice nurses who provide the most nursing care in GP surgeries and they work very differently to nurse practitioners. Practice nurses have shorter patient consultations and often work on predefined tasks, such as checking a patients’ management of their diabetes.
The delegation of work to practice nurses has also been driven by the perceived increase in workload arising from the GP contract .This has resulted in a significant proportion of practice nurses’ days being spent collecting data for the Quality and Outcome Framework (QUOF). They often feel pressurised to perform tasks and meet targets rather than devoting time to understanding the backgrounds of patients and building emotional and personal relationships. This kind of delegation can leave them feeling their work is more about financial objectives than the traditional nursing values that drew many into the nursing profession in the first place.
Laurant et al’s findings are commonly used to support the premise that nurses should be able to carry out most of the clinical work undertaken by doctors. However, this premise is misleading as many of the nurses in the studies were qualified nurse practitioners, whereas most practice nurses do not have this qualification. The standard of education and training for practice nurses varies considerably with many only receiving task specific training from their GP. If nurses take on new roles they must receive adequate training and on-going support and supervision.
Delegating work to nurses provides a means of organising workload within a practice without necessarily allowing patient choice, as some patients may prefer to see their GP. The literature I reviewed emphasises the need to provide patients with information on nurses’ roles and competencies to enable them to make informed choices regarding which professional they consult. Rather than operating under triage - a system in which a nurse decides which professional a patient sees - practices could offer patients a choice by consulting a “menu” that provides patients with indications of how to choose the appropriate professional.
There remains a paucity of studies in this key area of health care policy. However, the available literature seems to point to some general recommendations when delegating medical care to practice nurses. They should be adequately trained and supported to take on additional responsibilities. Patients should be provided with information on nurses’ roles and competencies for them to make informed choices as to which professional they see. Delegation may be inevitable - but it needs to be implemented with care.
CLAIRE RASHID is clinical effectiveness lead, Leicestershire County and Rutland Community Health Services
Laurant M et al (2004) Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews; 5 CD001271.
Rashid C (2010) Benefits and limitations of nurses taking on aspects of the clinical role of doctors in primary care: integrative literature review. Journal of Advanced Nursing; 66: 8, 1658-1670.