We had such an overwhelming response to a single question on this issue, Medical Forum has decided to devote a page to general practitioner comment. We start with the E-poll question....

Autonomous nurse practitioners: They can prescribe specified drugs and order tests appropriate to approved protocols within specified medical fields. This includes aspects of primary care. Will their work advance General Practice as a career path for doctors, in your view?

No   65.1%  

Uncertain   18.3%  

Yes   16.6%  

Do you have any comments on nurse practitioners in General Practice?

This question unleashed 139 responses, more than half the respondents. We have attempted to categorise responses for easier reading.

Dead against

Those dead against the idea of NPs either gave no reason (n=7), or suggested NPs should do medicine if they wanted GP work (9), or that they were "another nail in the coffin" for GPs (3). Surprisingly, a larger number against NPs showed they had not fully grasped the concept of NPs (i.e. autonomous, with prescribing and investigative rights) when they suggested NPs should work under GP supervision (12). Other reasons given for opposing NPs related to poor efficiency or cost-effectiveness (4), the lowering of clinical standards (6), fragmentation of primary care (3), the need to increase doctors not substitute with nurses (4), questioning the ability to prescribe or diagnose (3) and patient safety (4).

Other anti-NP comments were:

• "Definitely do not impress as independent practitioners - not one I have spoken to feels confident to prescribe or diagnose."
• "I don't think they want to be part of general practice because they would have to answer to doctors."
• "All general practice knows that the patients don't always present with a problem as per text-book or protocols."
• "It will adversely affect the status of GPs as some of the work done by general practice will be shared by these nurse practitioners."
• "More fragmentation of primary care. Less contact with the GP for opportunistic care. More ‘stuff' will land on the GP's plate - my nurse says this, my naturopath wants this, my osteopath thinks this..... Time to retire!"
• "Nurse Practitioners were supposed to fill the gap in care in the isolated rural settings. Have any taken up these positions? I don't think so: they seem to want to be doctors, and get paid the same without taking the responsibility or doing the training."

Other GPs (n=12) raised concerns about the adequacy of NPs for the task ahead of them in primary care with comments like, "GPs must set the agenda and protocols: the RACGP should be taking the lead" and "How will the government ensure that they have sufficient training to make diagnoses?".   

Guarded approval

Around 30 GPs gave conditional approval to the concept of nurse practitioners in primary care. The conditions they placed included:

• Rural or remote general practice (8).
• They need to work closely with the GP (6).
• Need to be part of a general practice team (7).
• Must know their limitations (4).
• Must be properly screened, with specific guidelines or roles (5).

Here are some of the comments:

"I think there's a lot of scope for better integration and to broaden the skills of practice nurses - possibly where we should start."

"If we choose not to be threatened by them and enjoy their talents, we will be well served by nurse practitioners. I am more fearful for the future when the tsunami of young docs come through training and need to find their niche in a more competitive environment."

"If working in a GP surgery, their input is invaluable, but when working alone, they could potentially create more problems."

"In previous practice in the UK they have been a useful compliment to the team but one has to choose your practitioner."

"NPs have a valuable role in performing some of the tasks that the GP might traditionally do e.g. Pap smears, some suturing, wound care, diabetes care, warfarin, dietary instruction. To prevent fragmentation of care it needs to be overseen by the GP."

"NPs would be an evolution of our existing nursing service. Our nurses already operate autonomously in a number of areas and would enthusiastically upgrade their qualifications as required."

Full support

Unbridled approval was given by 11 GPs with comments like "great idea", "very effective", "could assist GP++" and "the only sensible efficient way to run general practice".

More qualified but enthusiastic approval was given by 8 other respondents who pointed to barriers like expense, the need to complement GP services, that we should expect variable talents (like GPs locums), and that NPs would free GPs from the mundane to use their clinical skills to deal with the more complicated matters.

Comments on GP-nurse interaction

Reading between the lines, comments offered by GPs show they are grappling with a number of ‘interface' questions, especially:

• There is not equality in training or experience, so how can there be in performance?
• The buck will always stop with the doctor, so why have NPs further fragmenting the relationship GPs have with patients?
• Autonomy is a scary idea - too much and mistakes will be made, too little and the GP burden worsens.
• Will NPs threaten GP incomes: by doing care plans; and by siphoning off the easier cases.

One GP seemed to be stating the obvious with a suggestion there was "an urgent need for an integrated model for their role, to avoid negative effects".

Another provided a different angle. "I wonder why nursing organisations are demanding more responsibility in primary care, when at the same time they are demanding that existing RNs undergo ‘competency' assessments for tasks that should be part of basic training. Earlier this year, the experienced RN running an Aged Care Facility was not permitted to give flu vaccines because she did not possess a competency to do this! Although I support upskilling nurses and the concept of nurse practitioners, I believe that the proponents have grossly underestimated the activities GPs carry out in primary care. The comment ‘you don't need to be a doctor to give antibiotics to someone with a cold' assumes that the diagnosis is already made. It is the process of diagnosis that is the lynchpin, along with a willingness to accept risk that the diagnostician is incorrect. This takes 12 years' minimum training for general practice. The approach of nursing bodies so far has suggested they are very risk-averse. There will be a significant cost in pathology and radiology and referrals. The recent suggestions for reform say that allied health workers will refer at 25% of the rate of GPs. The figure is likely to be 250% and will cause a massive increase in costs to the MBS."

Finally, just four respondents said NPs were a tool for cutting health costs by providing a cheaper tier of care at a time of high demand.