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As the 'caring profession', nurses have always been seen as specialists in offering patients a personal, human touch. But in primary care, GPs are central to the concept of continuity of care, because patients have traditionally had strong links with doctors who know them.

However, research published last month shows that this dynamic has been changing and at the root of the change is the QOF.

Since it was introduced in 2004, nurses have been expected to carry out the lion's share of QOF work. Despite nurses' concerns that no one has noticed, and the fact that their pay has not increased to reflect this, the research found that 'most doctors and nurses acknowledged that nurses had become the primary provider of healthcare for patients with chronic conditions'.

Patient interaction

Along with the extra workload this expanded role entails, it appears to have brought about a fundamental shift in the way GPs, nurses and patients interact. The research suggests that as nurses have moved into the driving seat for chronic disease care, they have also assumed the lead role in offering continuity of care.

In response to the survey by researchers from the University of Manchester's National Primary Care Research and Development Centre and published in the Annals of Family Medicine¹, both GPs and nurses say continuity of care is a 'central feature' of their roles.

Most nurses said 'interpersonal continuity' was a 'relatively new feature' as they assumed responsibility for patients with chronic conditions.

Doctors, meanwhile, admitted that although long-term relationships with patients were important, the GMS contract had speeded up a decline in interpersonal continuity of care.

One GP told researchers: 'In the sense that it's still a patient presenting to a doctor with a problem, yes, it is the same as it always has been. The difference is that it's more likely that the patient and the doctor won't know each other.'

A nurse, meanwhile, said: 'With asthma, patients are beginning to see the same nurse, rather than a different GP. I see the diabetics, and ... I always try and make sure there is open access for them if they have got a problem.'

The survey was carried out across 20 practices, but seems to reflect the experiences of many others. Lynne Hughes, a nurse practitioner in Wrexham, north Wales, says: 'Because nurses have taken on much greater roles in chronic disease, the nurse is the person patients see, unless they have an acute episode.'

She also points out that because practice nurses often run specialist clinics, patients with these conditions often have strong continuity of care with that person.

Continuity, she explains, is important because if the same practitioner sees a patient regularly, they can spot something that may not be clear from notes. 'Sometimes you can just glance at the patient and see something is different. If they see different health professionals each time that can affect their care.'

Ms Hughes says nurses are ideal guardians of continuity of care in general practice, because they have a reputation for listening, taking more time, and considering more than just the reason the patient came into the practice.

Former vice-chair of the RCN Practice Nurse Association Sara Richards agrees that the nurse-patient relationship has intensified post-QOF. 'Doctors still like to see (chronic disease) patients once a year, and they see the more difficult patients. But, as more nurse prescribers come on board, nurses will increasingly become the only port of call.'

But Ms Richards says it is wrong to judge which health professional is better at delivering continuity: 'We need to stop that fallacy - nurses and doctors do different things, and neither the doctor, nurse or healthcare assistant is better. Patients should see the most appropriate person. Continuity of care should be with a practice - it is important that patients are cared for locally.'

She admits that 'it would be lovely' if patients could have a personal doctor or nurse, but points out that it is not a practical way of working. The dynamics of patients' relationships will evolve further as larger primary care units are rolled out, she adds.

Maintaining good continuity of care should not be a problem, however, as long as key principles remain in place, she says. 'I don't think patients will lose out as long as it doesn't become so amorphous that you never see the same clinician - teams need to be small enough that patients know a group of maybe four or five.'

She adds that notes are far better since the introduction of computerised records, and emphasises that high-quality communication between members of the practice team is vital.

Keeping continuity
The Royal College of GPs' chair Steve Field says the natural home of continuity of care is neither doctors nor nurses, but primary care.

'GPs play a key role in primary care, but I welcome the fact that the report shows practice nurses have more of a role to play and they are being more involved in the long-term continuity of care. This is a team issue, not one for a single primary care professional.'

But he said the real threat was from short-term contracts that may come with increasing private provision of primary care, meaning practices are not able to develop long-term relationships with patients at all.

Nurses and GPs need to take that point on board - it's time to put aside squabbles about who's the best at continuity of care, and stick together to make sure it survives.

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Reference

1. Campbell SM, et al. Ann Fam Med 2008; 6: 228-34.