Abstract
Arguments still reign over the difference between nurse practitioners in primary care and the general practitioner (GP). While this is being debated the demand for more GP consultations, the expansion of quality outcomes framework, extended opening hours, has seen an expansion in the nurses' role. The government has supported a proliferation of nurse-led primary care services supposedly allowing doctors to specialize in their areas of interest.
To save money, health care support workers now do the work of practice nurses, and nurse practitioners do the job of GPs. Some nurse practitioners are now ‘GP’ partners.
In the UK, the employment of nurse practitioners in primary care has also led to opposition. GPs have been concerned about the threat to their status, jobs, financial security and also whether nurses have adequate training and capabilities. Concerns have also been expressed about the quality and safety of nurse independent prescribing decisions. These debates have been continuing since the early 1990s in the USA but are far more recent here.
I am a qualified nurse practitioner with a Masters degree in Advanced Practice, am an independent nurse prescriber and have a teaching certificate. I also work as a Senior Lecturer teaching nurses physical assessment skills and prescribing. I have worked as a nurse practitioner in general practice for 14 years and worked in the NHS for 29 years.
Exploring differences
In some respects, there is little difference between a GP and a nurse practitioner. There is evidence that shows, in terms of patient health outcomes, both groups were similar (Horrocks et al., 2002). For ‘same day’ consultations, nurse practitioners have been found to give more advice on self-care and management and give better patient satisfaction (Kinnersley et al., 2000). Nurse practitioners are likely to be able to carry out home visits as competently as GPs (Edwards et al., 2009). It has been highlighted that nurses need longer consultations than GPs (Kinnersley et al., 2000; Venning et al., 2000), but in my experience, nurse practitioners attempt to work within the same 10-minute appointment slots as GPs (and many doctors struggle to keep to time).
The training, on the other hand, differs dramatically. Nurse practitioner training is variable and not ‘joined up’ unlike the 10 years it takes GPs to qualify from entering medical school. Many nurses will have completed their initial training for 2 or 3 years full time. Once qualified, they have then gone on to study part time while working, typically undertaking short courses, for example Family Planning and Asthma Diplomas, then spending 3 years to gain a health-related degree.
The independent and supplementary non-medical prescribing training takes a further 6 months. Nurse practitioners have often been working and studying over 10 years before they feel competent and confident to take on this role. Knight (2008) suggests that nurse practitioner training is inadequate and that nurses should retrain as doctors. However, most nurses would find it undesirable to sacrifice their wages and study for 8 more years. Nurse practitioner training is inferior to GP training but usually leads to safe, motivated practitioners.
Regulation and pay
The professional regulation between these groups differs greatly. GPs are regulated while unfortunately nurse practitioners are not, despite the Nursing and Midwifery Council's support for regulation of the advanced nurse practitioner role in 2005. In 2008, The Royal College of Nursing (2008) produced a guide to the competencies required to be an advanced nurse practitioner. Sadly, there are still nurses with the title nurse practitioner who do not have these competencies.
The most obvious difference between nurse practitioners and GPs is their pay. Venning's study in 2000 found that nurse practitioners cost the same as GPs, taking into account clinical care and health service costs. Later in 2006, Hollinghurst's team found that nurse practitioners cost less than GPs but the same as salaried doctors. In my opinion, the government's enthusiasm to substitute nurse practitioners for doctors is because they earn less than half the salary of GP principals. The average nurse practitioner is paid somewhere between £29 000 and £38 000.
I love my work as a nurse practitioner but feel exploited because I earn less than half that of a GP principle. My role is identical to my GP colleagues. Despite this I do not agree that the future of primary care should be nurses taking the roles that used to be carried out by GPs. Research suggests that patients value doctors for their technical skills and would prefer to see one if they think their symptoms are serious, while they value nurses for their empathy and information-giving abilities. Nurse practitioners and doctors should organize together to safeguard GP jobs, as well as recognizing the contribution of nurses. If nurse practitioners are offered doctor's roles, they should be paid the same as doctors.