A nurse practitioner is defined by the Royal College of Nursing (RCN) as a registered nurse who has undertaken a specific course of study of at least first degree (Honours) level and who through this training is able to work autonomously, make clinical decisions, refer to other professionals, and instigate and evaluate treatment (Jones 1999).

Nurse practitioners have been established in North America for several decades but it was not until the 1980s that the role expanded in the United Kingdom. Nurse practitioner development in the UK was pioneered by Barbara Stilwell working in two general practices in Birmingham (Stilwell 1982) and by Barbara Burke-Masters working with homeless people in London (Burke-Masters 1986). During this time, the nurse practitioner was generally seen to be working within the primary care setting, but more recently, the role has been developed in a range of healthcare settings such as hospitals, mental healthcare and learning difficulties care.

The reasons for the development of nurse practitioner roles within the NHS are varied but include issues of cost, the need to increase provision of care to improve access, difficulties associated with the availability of doctors and the skills and expertise of nurses (Horrocks et al 2002). The Cumberlege Report (Department of Health and Social Security (DHSS) 1986), the Tomlinson Report (1992) and the NHS Management Executive (1993) all supported the development of the nurse practitioner role in primary care.

The development of the nurse practitioner role has enabled nurses to provide more holistic care to their patients. With the addition of nurse prescribing, the days of waiting outside doctors’ doors are diminishing. However, change can be accompanied by tensions and challenges and this role continues to face both.

The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) did not recognize the title of nurse practitioner for those nurses who had undertaken appropriate training and no record of these nurses was made on the nursing register. However, the Nursing and Midwifery Council (NMC) has indicated that it will work towards regulating nurse practitioners in the future. This is of paramount importance in order that the title is recognized among the profession and also to protect the general public from individuals who call themselves a nurse practitioner but who have not completed appropriate training. In December 2005, it was agreed by the NMC that:

The array of nurse titles within the NHS causes confusion, not only for service users but also among the nursing profession and other healthcare workers. Reveley and Walsh (2000) established that among six acute trusts, nurses were using 603 different titles.

Particular interest has been shown as to whether nurse practitioners can provide front-line care, and by doing so, replace doctors. In a systematic review of all research relating to doctor–nurse substitution, Laurant et al (2007: 9) concluded that appropriately trained nurses can produce ‘as high quality care as primary care doctors and achieve as good health outcomes for patients’. The review also suggests that nurse–doctor substitution has the potential to reduce doctors’ workload but will only do so if doctors stop providing the care that has been transferred to nurses. The issue of cost savings is questionable, as nurse practitioners tend to have longer consultation rates and an increased recall rate compared to doctors.

Horrocks et al (2002) suggest that future research should focus around identifying the factors responsible in leading to high patient satisfaction with nurse practitioner consultations. This research should be extended to include more patient groups. Nurse practitioners have worked very successfully in areas of the country where there is poor access to general practitioners and also with patients who suffer from long-term conditions. This role enables patients to have more choice in how they access healthcare. The RCN states that the nurse practitioner is not a doctor substitute but is a complementary source of care to that offered by the medical profession as well as acting as primary care providers in their own right.

Tony Blair launched the concept of the consultant nurse in 1998. This was picked up across the four nations of the UK in policy documents (Department of Health 1999, Scottish Executive 2001). There are currently 1200 of these posts across the UK and the majority are in England. The aim of this post was to provide a clinical pathway for senior nurses who did not want to progress through the managerial or academic pathways. This role aims to keep nurses by the bedside and to provide clinical leadership in facilitating the changes in nursing roles and the move to evidence-based practice. Clinical leadership is seen by many as central to the delivery of The NHS Plan (Department of Health 2000) and the reason for the development of this role was to ensure that there is a clinical role with the opportunity to influence strategy within the NHS at patient, staff and board level. Four key areas for these roles were defined:

All of these should be underpinned by a strong nursing foundation with education to Masters or Doctorate level and additional specialty-specific qualifications (Department of Health 1999).

Problems have emerged in terms of lack of:

There have been reports of work overload coping with the demands of providing activity within each of the four domains and lack of support within organizations both for the role and for initiating change (Guest et al 2001). Consultant nurses should be spending half of their time in expert practice. This has led to debates on the nature of expert practice and the definition of ‘clinical time’. Research into present roles has shown that this is an area where many consultant nurses struggle and a survey of consultant nurses in Scotland found that 4 of 13 nurses surveyed were not providing direct patient care (Booth et al 2006). It seems an important area for many reasons:

Many people describe this role as a creative and innovative one, which is making changes in the NHS to benefit patients (Sturdy 2004). Research supports this view in showing that the role has been influential in leadership roles and in developing innovative services (Guest et al 2001, Manley 2000). However, there has been no widespread formal role evaluation and some of the research that has been carried out has mainly been concerned with the role development experience (Booth et al 2006, Guest et al 2001).

There are difficulties in evaluation of outcomes but it is important, for this role specifically and for nursing generally, to attempt to measure the more intangible aspects of the role such as the impact of clinical leadership within an organization. Manley (2000) used an action research approach to evaluate the impact of the clinical leadership provided by the CN/M role on organizational culture and changes in practice. This work showed positive changes in terms of developing new roles, staff feeling more confident and a change to a culture of evidence-based practice. The reality of this role is that it is an exciting development for nursing. There are still very few of these posts in the community and the challenge for present and future consultant nurses lies in demonstrating that clinical leadership and improving the quality of services will facilitate the development of nursing for a future where nurses are at the forefront of creating new services and improving existing ones for and with patients.

The NHS improvement plan (Department of Health 2005b) focuses on the care of patients with long-term conditions and states that a case management approach is the best way to improve quality of life and reduce unnecessary hospital admissions. Reducing unplanned hospital admissions is currently central to the commissioning plans of all primary care trusts. In addition, the NHS has been set a public service agreement to reduce unplanned bed day usage by 5% by 2008 (Department of Health 2006d). The professionals pivotal in the implementation of this are community matrons, 3000 of which were expected to be in post by 2008 (Department of Health 2005a).

The role of the community matron is to provide case management for the most vulnerable elderly people who may have one or more chronic diseases. These nurses care for patients at the top of the ‘pyramid’ developed by Kaiser Permanente, an American health company (Department of Health 2005b). This divides the population of people living with long-term conditions into three levels: the bottom level, composed of approximately 70–80% of the ‘long-term condition’ population, who are stable and able to self-manage; the middle level indicative of a population with more complex conditions requiring disease-specific services; and the final small level identifying a population with highly complex physical and possibly social circumstances that require case management. It is thought that these people account for a disproportionate number of emergency admissions and bed days, being responsible for 42% of emergency admissions (Department of Health 2005b). Case study 22.1 illustrates the role of the community matron in a typical scenario involving a client with complex needs.

The case manager role is complex and requires the practitioner to acquire new ways of working, collaborate with other agencies while working across organizational boundaries and challenge existing ways of working in order to provide seamless patient care in the community setting. As an advanced practitioner, matrons should be able to comprehensively assess, perform physical examinations, diagnose, refer for investigations, design, implement and evaluate care plans to improve the quality of life and disease management for patients on their caseload (NMC 2006). Specialist courses are being developed to equip nurses for such advanced roles (Board 2007) and a framework has recently been developed to ensure competence (Department of Health 2006b).