Featured Review: Nurses as substitutes for doctors in primary care

Delivery of primary healthcare services by nurses instead of doctors probably leads to similar or better patient health and higher patient satisfaction

Current and anticipated problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and efforts to move care from hospitals to communities encourage countries worldwide to develop new models of primary care delivery. Interest in using nurses to expand the capacity of the primary care workforce to address these problems is increasing. The substitution of trained nurses (such as nurse practitioners, practice nurses, and registered nurses) for doctors is one strategy used to improve access, efficiency, and quality of care. Nurse tasks may include diagnostics, treatment, referral to other services, health promotion, management of chronic diseases, or management of acute problems needing same-day consultations. Gains in service efficiency may be achieved if doctors no longer provide the services they have delegated to nurses, enabling doctors to focus on complexity in their caseload and on utilising their role-specific  training and experience.

A team of Cochrane authors based in Netherlands, Thailand, and the United Kingdom worked with Cochrane Effective Practice and Organisation of Care to update the 2005 Cochrane Review that investigated the impact of nurses working as substitutes for primary care doctors on: patient outcomes; processes of care; and utilisation, including volume and cost. Nine randomized trials were added to this update, bringing the total examined to 18. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies.

Delivery of primary healthcare services by nurses instead of doctors probably leads to similar or better patient health and higher patient satisfaction. Nurses probably also have longer consultations with patients. Using nurses instead of doctors makes little or no difference in the numbers of prescriptions and tests ordered. However, the impacts on the amount of information offered to patients, on the extent to which guidelines are followed and on healthcare costs are uncertain.

“This updated Cochrane Review indicates that nurses can effectively expand the capacity of the primary care workforce, ” says Miranda Laurant, the lead author of the Cochrane Review. “It doesn’t suggest that we can or should eliminate doctors from the primary care level; instead it shows that, in the cases assigned to them, trained nurses can probably provide equal or better quality of care compared to primary care doctors. This is very positive news as doing so may allow doctors to spend more time focusing on more complex cases or cases that utilize their more advanced training. Whether nurse-doctor substitution leads to substantial savings or whether nurse-doctor substitution is cost-effective remains unclear; we hope that future research will examine this.”