The number of the government's PMS - "personal medical services" - pilots has soared and ministers are confidently predicting that 20% of GPs will have joined up by the end of this year. But while the focus has been on recruiting doctors to PMS schemes, nine of the first-wave pilots - now three years old - have been testing a wholly new approach to primary care.
In these schemes, nurses - not doctors - lead the primary health care team and, in some cases, employ the team's GP members. These pioneers have been quietly turning the traditional health service hierarchy on its head.
The significance of this experiment has been raised by the government's new strategy for modernising health care. Nurses are seen as key to reducing waiting and to countering the recruitment crisis among GPs. Nurses are already leading new initiatives such as NHS Direct and walk-in centres, and nurse-led PMS pilots now put them at the centre of mainstream primary care.
In theory, if nurses extend their range of diagnoses and treatments, they can manage patients currently waiting to see a GP. And they will also release GPs for more specialised work.
The chief nursing officer has set out 10 roles that appropriately trained nurses are expected to undertake routinely in the future. These include ordering their own diagnostic investigations, such as x-rays; making and receiving referrals to specialists and other therapists; and admitting patients directly to hospital. This is exactly the territory now occupied by nurse-led PMS pilots. Their success (or failure) can be seen as a barometer for the prospects of the government's new policy.
What can we learn from the first three years? In an evaluation by the King's Fund health policy institute, to be published tomorrow, we have charted their progress from the point of view of the nurse leaders. In a relatively short time, these pilots have successfully implemented a very different model of care. Nurses handle a far higher proportion of care than in traditional general practice and normally act as the first point of call for patients contacting the surgery. While this will be welcome to the government, the evaluation also rings some alarm bells.
The pilots have managed to redress the power balance between doctors and nurses. Interestingly, nurse leaders have emphasised the need for equal status rather than sought to ram home their formal leadership role. But establishing this has notalways been straightforward or successful. In one pilot, the nurse leader described a scenario of "doctors and nurses at war".
However, more opposition to these schemes has been detected from GPs practising locally than from those who have chosen to join the pilots. In particular, local medical committees - which represent family doctors in each health authority - have been perceived as sceptical, if not downright hostile. The use of salaried GPs within pilots, as an alternative to the traditional independent contractor role, has been seen by some doctors as undermining the collective strength of GPs. Among practical problems, one pilot was charged three times the going rate for out-of-hours cover by the local GP co-operative.
On the other hand, this suspicion on the part of some GPs has not stopped neighbouring practices from encouraging certain of their existing, or would-be, patients to register with them. This is because the nurse-led practices have often targeted their services at particularly vulnerable people, such as the homeless or refugees. Traditional general practice has tended to serve such people poorly, the financial incentives offered to GPs inadequately reflecting the high workload involved. So it is perhaps sensible that GPs should seek to deflect these patients to a service equipped and willing to deal with them.
It does raise some difficult ethical issues, however. Should refugees and the homeless not have a choice of primary care provider like every other patient? Are they destined to have nurse-led care, whether or not it is what they would have chosen for themselves? After all, any GP deflecting patients on the grounds that they were black or gay would be roundly condemned.
Nurse leaders have been remarkably successful in changing the practice of hospital staff. Hospital consultants have always received their referrals from GPs. Yet nurse leaders have negotiated the right to refer directly to consultants and to request their own diagnostic test. This is a major step forward. But it has not been universal. Some consultants have been resistant to direct communication with nurses and have insisted that referral letters are signed by the pilot's GP. In these cases, the nurse leaders have had little leverage to change their minds.
So it seems that nurse-led PMS pilots have successfully challenged some of the most entrenched mores of the NHS, while raising worrying issues. The nurse leaders are concerned that the regulations governing advanced nursing roles are inadequate. They are acting as "nurse practitioners", but this is not a title formally recognised by the nursing regulatory body. There are no national standards or training curricula for nurse practitioners, nor are there agreed competencies. The pilots also reported that they had been subject to little or no local assessment of the quality of their service or the appropriateness of the new nursing roles. Nurse leaders are critical of their own profession for failing to grasp this nettle.
A final area of concern is the personal stress that this ground breaking role has brought to the nurses involved. Trailblazers are always likely to face tougher challenges than will those who follow, but nurse leaders have struggled to thrive in a sometimes hostile environment. They underline the importance of good personal support networks and local champions in the success of the pilots. Where nurse-led schemes are managed by NHS or primary care trusts, such support should be available. But nurses acting as independent contractors are likely to be more isolated. Without greater focus on developing these networks for all, only a limited number of nurses is likely to take this route.
As one independent contractor told us: "I wouldn't want anyone to face what I had to face because I don't think it is fair."
Richard Lewis is a visiting fellow at the King's Fund
Teamwork the key to good practice
The Appleton primary care health centre is in an increasingly affluent area of Warrington, Cheshire, which is being colonised by young, highly educated couples with small children. The pilot site has two part-time nurse clinicians, two part-time GPs and a practice nurse, but doesn't see itself as a "nurse-led" practice.
"We work as a team," says nurse clinician Annaliese Willis. "All of us, including the practice nurse, have equal responsibility with regards to patient care."
Willis and her colleagues believe their approach is paying off. An evaluation by Warrington community health council, published last month, found that 92% of patients were completely, or very, satisfied by the centre's service. Their response to being treated by nurses was also positive: 80% rated the quality of care as excellent or very good.
Teamwork is the key, says Willis. "Say one of my older patients had congestive cardiac failure and had some prescription complication, I can liaise with my GP colleagues to formulate the best care for them." It is also an egalitarian way of working. "I have a truly collegiate relationship with my colleagues, which differs greatly from my experiences when I worked in traditional practices where I was regarded as just an employee."
This spirit is reflected in Appleton's practice of offering patients a joint consultation with a GP and a nurse, should they prefer, although many have been satisfied to see a nurse alone. And patients are seen very much as partners in the process.
"The patients get a print-out of every consultation," says Willis. "We encourage them to use our internet connection and provide them with useful sites with which they can educate themselves."
The practice team reports none of the difficulties with referrals or diagnostic tests that have surfaced at some of the other pilot sites. "Consultants have had no problems with taking referrals from me," says Willis.
There has also been little hostility from local GPs, says Eric Hodgson, acting chief executive of the Warrington Community Health trust. "When we first started, local GPs were curious about what we were doing but remained neutral. Now, that neutrality has changed into enthusiasm and six of the practices will go PMS in October."
But Willis, who has an MSc in clinical nursing from Liverpool University and teaches the subject there two-and-a-half days a week (taking her total income to just over £28,000 a year), does recognise the problem of lack of recognition on the part of nursing's regulators. They are, she says, "still behind what is happening".
