When Linda Carey last updated this chapter in 2003, she wrote that ‘practice nursing has reached an important pinnacle in its development; no longer struggling to identify a clear role for itself, it has emerged as a discipline in its own right, acknowledged as making a significant contribution to the provision of care’ (p. 211). For many years practice nurses strove to develop their own voice and identity, the role being viewed for a long time as one that was pursued only by part-timers and a role that was inferior to the more fashionable nursing roles in other areas of the NHS, particularly the acute sector. Indeed Martin (2007) cites Baker (1988) who once made the comment that practice nursing was ‘not a step forward in a progressive career’! In part this was due to the origins of practice nursing, the role originally evolving from GPs’ wives, who were nurses, assisting them in their everyday practice and also from the ‘treatment room’ services provided by district nursing teams. In the community sector, roles such as district nursing and health visiting (now designated specialist practitioners in community public health nursing) were seen as having more defined career pathways and were thus a more fashionable calling. This view has now changed; the Department of Health (1990) GP contract provided the first impetus for nurses interested in a primary care career to move away from other nursing roles into general practice. Because of both practice nurses themselves who have lobbied to ensure they are a recognized discipline, and the influence of subsequent governmental healthcare policy, the role has continued to expand. Practice nursing is now seen as a popular career choice, not only for those well established in their nursing career, but also for those newly qualified nurses just starting out in their profession. A valid career pathway is rapidly developing, enabling those who enter the profession to have specific goals towards which they can aim, planning their personal and educational development needs towards a definite purpose. Without doubt it is a role that is shifting the boundaries of community practice.

General practice nursing has evolved rapidly over the past 16 years, with numbers across the UK increasing from 3500 in 1990 to 24 959 in 2003 (Royal College of General Practitioners (RCGP) 2004). The United Kingdom Central Council for Nursing, Midwifery and Health Visiting’s (now the Nursing and Midwifery Council, NMC) acknowledgement of general practice nursing as a community specialism in 1994 gave recognition to the role, ensuring qualified practice nurses had equality with other community nurses, such as district nurses, specialist community public health nurses and community mental health nurses, as specialist practitioners. Individual practice nurses themselves, however, have much to be proud of, having adapted and shaped their role to meet the needs of care provision in primary care and consequently having developed their role from one of delegated work to that of provider of specialist healthcare (Carey 2003). The role has continued to evolve and, with the current focus on the moving of services from secondary to primary care, is now viewed as increasingly important, practice nurses often taking on the ‘gatekeeping’ role, triaging patients requesting same-day care (Cullen 2005) in addition to their more traditional roles. The practice nurse role is varied and diverse but remains one that is continually growing, from originally concentrating on delegated general treatment room duties (e.g. wound management, venepuncture, injections and ear care) to the current picture of nurse-run clinics in areas such as public health and long-term conditions management. In addition, there is a recently increasing emphasis on providing first contact care in the form of triage, advanced assessment, management of minor illnesses and injuries, and since the advent of independent nurse prescribing yet another new role is opening up, that of medicines management.

The new General Medical Services (nGMS) contract (Department of Health 2003) created a further expansion of the role, with practice nurses increasingly taking on the responsibility of meeting the demands of the Quality and Outcomes Framework (see Chapter 2 for further information on developments in primary care). This has created new challenges for practice nursing along with further opportunities. An emphasis on skill mix has been seen as an integral feature of NHS reform and is seen as being particularly relevant in the context of the primary healthcare team. An RCGP information sheet on practice nurses, published in 2004, suggested that an estimated 10% of workload could be transferred from GPs to nurses by 2007/2008 with a consequent increase in the ratio of practice nurses to GPs from 60 per 100 to 70 per 100. More recent figures have indicated that practice nurses cover an estimated 28% of total patient contacts in practice, compared to 60% covered by GPs (Technical Steering Committee 2006/2007) and work an average of 22.8 hours a week in comparison to the 38.2 hours per week worked by GPs. An emerging picture of skill mix among practice nurses themselves is now being seen, with many practices now employing a team of nurses from healthcare assistants to specialist practice nurses and nurse practitioners (Table 13.1).

Cross (2006) noted that the Wanless Review suggests that up to 70% of the work currently undertaken by GPs might be moved to general practice nurses with the expectation that nurses working in these extended roles will:

Carey (2003: 213) commented that ‘delegation and relinquishment of traditional roles is crucial to the provision of primary care’. However, she argued that while taking on these delegated duties, it is important that practice nurses furthermore continue to establish their own knowledge base and define their own role, determining how they can contribute to care delivery in primary care, rather than the role becoming one that is simply based on delegation of GPs’ work.

This chapter will provide a four-nation perspective, first discussing educational preparation for the role, then providing an overview of the NHS policies that have both shaped and had an impact on practice nurse development. Case studies are included to demonstrate good practice and to encourage reflection. The reader will be updated regarding the latest NHS reforms that have influenced practice nursing in recent years, referring to Carey’s 2003 chapter. There will be an update on the current position in which practice nurses find themselves and finally there will be a discussion as to how the role may look in the future.