Professor, NIVEL – Netherlands Institute for Health Services Research, European Forum for Primary Care, Utrecht, Netherlands
Received date: 17 April 2008; Accepted date: 4 July 2008
Primary care is one of the drivers of change in health-care systems, especially in the countries of central and eastern Europe (CCEE) but also in western Europe. Part of this change is the development of new pro-fessional roles. Particularly in western Europe, the most eye-catching of new professional roles in pri-mary health care is that of nursing.
Linked to primary care centres or general practices, nursing is rapidly becoming first-contact care with, in some countries, the authority to prescribe drugs. Practice nurses develop their own role in the care of chronically ill people, and modern disease-manage-ment programmes give increased autonomy to spe-cialised nurses. These changes in the nursing profession are an innovation in itself, but they are also linked to and reinforced by other innovations in primary care.
Primary care faces a number of challenges. Health care needs are increasing and changing. People live longer and stay longer at home, but also have multiple health problems. At the same time, increasing levels of education and access to information and market-oriented policy changes lead to more-demanding patients. These challenges have to be met by a limited workforce. Therefore, innovation is needed.
Innovation takes three forms: organisational, pro-cess and workforce innovation. Organisational inno-vation is necessary because of a general trend of increasing scale of organisational units. This in turn leads to a differentiation between professional work and management. In the CCEE, privatisation has led to a new organisation of primary care, while in other countries, for example Germany, network integration and the need for co-ordination in disease-management programmes challenges the organisation of ambulatory care. Organisational innovation in primary care in western European countries shapes the conditions for new roles for nursing in primary care. However, in the CCEE, privatisation also leads to small, unidisciplinary units based in general practice. As a consequence there are large differences in the role of nurses in primary care in different European countries. Influenced by financial incentives, such as pay-for-performance in the UK and the Funding of practice nurses and add-itional services in the Netherlands, general practitioner (GP) group practices have developed into multidiscip-linary primary care teams. However, in Germany net-work formation and disease-management initiatives have largely developed within the medical axis, with only minor roles for nursing.
Process innovation, new ways of organising care processes, is the answer to changing healthcare needs, with changing roles of patients and changing relations between primary and secondary care. Patient-centred care organisation, case and disease management, and integration of prevention in the care process are examples of process innovation. The way that process innovation takes shape is influenced by the structure of healthcare systems and, in particular, the position of primary care. As a broad generalisation, it seems that gate-keeping primary care systems have more opportunities to organise specialised functions within primary care even though this challenges horizontal integration.
The third type of innovation is workforce innova-tion. Here the professional role of nursing comes in. The existing occupational structure of the professions is changing rapidly as a result of task delegation within primary care and transfer from secondary to primary care. New roles develop for existing professions, and new professions develop. Nursing plays a crucial role in these processes: think of practice nurses, liaison nurses and nurse practitioners. On the physician side, physician assistants are developing as a new profes-sion, first in the hospital setting but probably diffusing to ambulatory care.
Research on task delegation from GPs to nurses has shown that nurses provide the same quality of care. They have an effective role in screening and vacci-nations, and in managing chronic disease. At the same time there is no reason to be optimistic about this development as a solution to problems of workload and cost containment. Task delegation leads to dupli-cation or increase of services rather than substitution and not to cost savings, because lower salaries are offset by longer consultations.
In the long run, these innovations, and especially the workforce innovations, might lead to blurring of the boundaries between nursing and medicine. The higher end of the nursing educational continuum, with nurse practitioners and specialised nurses, meets the lower end of the medical educational continuum, represented by physician assistants. At this point the two educational continua overlap and this may lead to shared education. The prescribing monopoly of the medical profession is or will be abolished in some countries. Partly this reflects a gradually grown situ-ation, and partly it will necessitate retraining of nurses with new educational programmes.
In conclusion, the previous system of the profes-sions is changing and primary care, and especially nursing, plays an important role in this process. This will give tensions over established roles as the pro-fessional identity of doctors is challenged. Although patients in general seem to be happy with the extended role of nurses, they are probably still adjusting their expectations. Finally, nurses themselves may be un-certain about their new role.
Commissioned, based on an idea from the author; not externally Peer Reviewed.