Delivering a different kind of primary care? Nurses working in personal medical service pilots

Delivering a different kind of primary care? Nurses working

in personal medical service pilots

NICOLA WALSHNICOLA WALSH BA, MSc, RGN

Fellow in Health Policy, Health Services Management Centre, University of Birmingham,

Birmingham, UK

BRENDA ROEBRENDA ROE PhD, RN, FRSH

Senior Lecturer in Social Gerontology, Centre for Geriatric Medicine, Keele University, Keele,

Staffordshire, UK

JUNE HUNTINGTONJUNE HUNTINGTON PhD, FRCGP

Honorary Professor in Primary Care Development, HSMC and University of Birmingham,

Birmingham, UK

Accepted for publication 23 September 2002

Summary

• This article examines the roles and responsibilities of primary care nurses in

England.

• The study was commissioned by the Department of Health to consider how

nurses were working in Personal Medical Service (PMS) pilots – a new initiative

launched in April 1998.

• All nurses in the study reported that they had extended their clinical role – in

varying degrees.

• Nurses were running new clinics and services, and general practitioner time

was freed up.

• Some of the nurses used PMS to deliver a different kind of primary care, one

that was more community and patient focused than other General Medical

Service providers.

• Many of the nurses in the study are successfully breaking down traditional

demarcations between primary and secondary care, between medicine and

nursing, and between professionals and patients.

Keywords: extended roles, nurse practitioners, personal medical services,

primary care.

Introduction

The roles of nurses working in primary care services in the

UK have changed dramatically over the last decade as

many have taken on new responsibilities in the care and

treatment of chronic diseases such as diabetes and coronary

Correspondence to: Nicola Walsh, Health Services Management Centre,University of Birmingham, 40 Edgbaston Park Road, Birmingham, B152RT, UK (tel.: +0121 414 7050; e-mail: [email protected]).

Journal of Clinical Nursing 2003; 12: 333–340

� 2003 Blackwell Publishing Ltd 333

heart disease, and this trend is set to continue. Changes in

nurses’ roles have been given added impetus by the

declining general practitioner (GP) workforce (Richardson

& Maynard, 1995). Fewer doctors are being attracted into

general practice, and there has been an increase in the

number of retirements (in the more socially deprived

areas), and a shift towards part-time working by the

increasing number of women GPs. Such falls in the

medical workforce, it has been suggested, cannot be

sustained without loss of provision, and in some parts of

the UK we are beginning to see this (General Medical

Services Committee, 1996). The UK government’s re-

sponse has been to encourage nurses to take on new roles in

primary care: in primary care trusts (PCTs), NHS walk-in

centres, NHS Direct and Personal Medical Service (PMS)

pilots. Many of these new policy initiatives provide an

alternative to traditional general medical services (GMS).

This may be good news for nurses, as they can use their

skills fully and extend their clinical roles. However, some

nurses have expressed concern that health care policies that

encourage nurses to undertake work formerly done by GPs

may erode nursing autonomy and values, thus impover-

ishing the quality of patient care. Yet, it is also plausible

that these new opportunities may enable nurses to achieve

greater autonomy and bring their distinct values to bear on

primary care services (Williams et al., 1997).

In this paper we discuss the way in which nurses

working in a range of PMS pilots are adopting new roles

and responsibilities and draw on our findings from a 12-

month study to demonstrate whether nurses are or are not

maximizing their nursing contributions and hence provi-

ding a different kind of primary care service (Roe et al.,

2001). We start with a brief description of PMS and then

go on to describe the study we undertook for the

Department of Health. We then consider the nature of

service being provided by nurses working in these PMS

pilots and briefly discuss the implications of our findings

for future policy developments in this area.

PERSONAL MEDICAL SERVICE PILOTS (PMSs)

Personal Medical Service pilots were introduced as a result

of the NHS (Primary Care) Act of 1997 (Department of

Health, 1997a). The Act brought in a range of new freedoms

to:

1 Test out new organizational models for the delivery of

primary care;

2 Address underprovision of services in deprived areas;

3 Encourage workforce flexibility and skill mix; and

4 Reduce unnecessary bureaucracy associated with the

national GMS contract.

It was believed that these new freedoms would alleviate

intractable problems in local primary care services such as

GP recruitment and poor access.

The Primary Care Act allows any constituent part of the

NHS to become a PMS pilot, thus enabling NHS trusts

and employees to become providers of personal medical

care services. In some instances, NHS trusts have

established nurse-led PMS pilots, employing a nurse

practitioner to become the first point of contact for a

specific population group, such as asylum seekers or

homeless people. In a small number of cases, nurses have

chosen to become independent contractors of PMSs. The

Act also enables practice nurses and other community

nursing staff to work with GPs in different ways as the

contract is no longer with the individual GP but with the

provider organization.

Personal Medical Service pilots are governed through a

locally negotiated contract with the commissioner – previ-

ously the health authority and now in England, the PCT or

the Strategic Health Authority. The commissioner,

together with the PMS provider, define the scope and

quality of services to be provided, and a contract value is

agreed. In contrast to the nationally negotiated GMS

contract based on paying individual GPs quarterly in

arrears, PMS pilots are paid monthly. These new arrange-

ments provide greater financial security and encourage GPs

and nurses working for a PMS contract to review and

change their mode of service delivery (Walsh et al., 2000).

For example, nurses in some PMS pilots are now taking the

lead in the way family planning services are run. These

opportunities have been created as GPs are no longer

required to complete FP 1001 forms (for repeat prescrip-

tions of the contraceptive pill) for payment purposes. The

PMS pilots are therefore able to use the skills of their staff in

different ways.

The PMS initiative is voluntary and the first wave of

PMS pilots went ‘live’ in April 1998. Since then we have

seen a new wave each year, and the total number of PMS

pilots in April 2002 was over 1700, covering just under a

third of the population in England (Department of Health,

2002). There are a small number of PMS pilots in

Scotland but none as yet in Wales and Northern Ireland.

Initially, pilot status was granted for a 3-year period but

the government has extended this until a decision about

permanency is reached.

The study

The study looked at 12 first and second wave PMS pilots

in England. Our focus was on the roles and responsibilities

of nurses working in a range of different PMS pilots.

334 N. Walsh et al.

� 2003 Blackwell Publishing Ltd, Journal of Clinical Nursing, 12, 333–340

In addition, we wanted to examine the degree of role

re-negotiation between GPs and nurses working in these

pilot sites to assess whether PMS enabled nurses to use

their nursing skills differently. We also identified the

motivating and de-motivating factors of nurses working in

these pilot sites; as such information is important to those

working in and with the NHS who wish to promote a

larger role for primary care nursing.

The study was undertaken over a 12-month period –

and our broad approach was based on notions of pluralistic

evaluation (Smith & Cantley, 1985) in the context of a

multiple case study design (Yin, 1994). By exploring the

same set of questions in purposively selected diverse

organizational forms, and within diverse demographic and

geographical contexts, we hoped to draw broad conclu-

sions about the impact of PMS on nurses and nursing.

Table 1 above sets out some basic details about our study

sites.

The status and responsibilities of the nurses varied in

that those who held the PMS contract were self-employed

and were responsible and accountable for staff, services,

equipment and estates, and as such carried greater

liabilities and responsibilities. Those nurses employed by

the community trust had fewer responsibilities or liabil-

ities. One of the PMS pilots that was trust-based was

multiprofessionally managed, clinicians and the project

manager providing joint leadership and management. In

another trust-based site the nurses were managed by

senior nurse managers at the trust. In the practice-based

sites the nurses were employed by the GPs and had

varying degrees of responsibility.

Nine of the nurses were called nurse practitioners (five

held a formal nurse practitioner qualification), one a

specialist practitioner, one a practice nurse and the other a

nurse clinician. One of these nurses was also employed

part-time as an educational adviser in the local university

department of general practice. Their roles were disparate,

and their qualifications, experience and training variable.

Five out of the 12 were newly established services

providing primary care services to populations who previ-

ously had been reliant on local hospital Accident and

Emergency departments or practices further afield. One of

the independent nurse-led pilots was awarded a vacant list

following the death of the incumbent GP, and another set

up a new service. Half of the PMS pilots were providing

services to deprived populations who had previously been

marginalized from traditional general practitioner services

(such as homeless people, ethnic minority groups), and half

were located in fairly mixed areas.

The study was designed as a research and development

project, deliberately using two methods of data collection:

1 A series of three workshops (an initial 2-day residential

workshop, followed by two single days). These used

individual and small and large group work to promote

inquiry into and reflection upon participants’ experien-

ces, which were captured on flipcharts and by two

members of the research team taking notes. Interaction

with each other and with the researchers also provided

support and development for individuals who were

usually the only one of their clinical kind in their work

contexts.

2 Four case study sites were chosen following the second

workshop to reflect several factors: geographical loca-

tion, organizational and contractual arrangements.

Face-to-face semi-structured interviews were conduc-

ted and recorded with nurses and key people working

in and with the pilot site, such as GPs, PMS leads in

health authorities, and senior managers working in

PCTs and NHS community trusts. The case studies

offered an opportunity to explore in detail issues related

to the nature of nurses’ roles and the degree of shift

occurring between the GP and the nurse. The inter-

views also offered opportunities to augment and verify

the data gleaned from the workshops.

Transcripts from the interviews were read by all

members of the project team and key themes that reached

saturation were identified and used to analyse all the data

(Morse, 1995). A member of the research team wrote up

data collected from the workshops and other members of

the team checked this before it was circulated to all nurses

participating in the study after each meeting to verify the

accuracy of the material we used. We also collected

documentary information relating to service developments

from the study sites. Our approach to data collection,

then, enabled us to follow the development of nurses’ roles

Table 1 Profile of the study sites by organizational type

Nurse

Organizational

status

Organizational

type Location

1* First wave Independent nurse-led Midlands

2 Second wave Trust-based nurse-led South-east

3 First wave Practice-based South-east

4* First wave Trust multidisc. Team-led North-west

5 First wave Independent nurse-led North-west

6* First wave Trust-based nurse-led South-east

7 Second wave Nurse–GP partnership South-east

8* Second wave Practice-based Midlands

9 First wave Trust-based North-east

10 Second wave Practice-based Midlands

11 First wave Practice-based Midlands

12 First wave Practice-based South-east

*Indicates case study sites

New approaches to service delivery Delivering a different kind of primary care 335


across a range of different PMS pilot sites, and this

enabled us to draw some generalized conclusions about the

roles of nurses within them and the nature of service being

provided by them.

Findings and discussion

EXTENDING NURSE ROLES IN PRIMARY CARE

In all the study sites nurses reported in varying degrees

that they had extended their clinical role to include

diagnosis of simple and/or chronic conditions, their

treatment and management. Such developments have also

been in other PMS pilot sites (Walsh & Huntington,

2000). In the nurse-led pilots, they were ordering a range

of diagnostic investigations such as X-rays and were

making referrals directly to consultants, but this had taken

time to be accepted and established. In many instances

there were no formal procedures and acceptance was

reliant upon the relationship between the nurse and

consultant or hospital. In our final workshop, it was noted

by one respondent that some of the changes occurring in

hospitals were facilitating their new roles as nurses began

to make patient referrals to other specialist nurses:

‘Together we oil the system as referrals are no longer

passed around obstructive medical staff…’

Nurses in this study were also developing a variety of

innovative services and clinics to meet the needs of their

local population. Participants described a broad range of

clinics they were now running such as skin and allergy,

family planning and substance misuse. In many sites, a

nurse triage service was also introduced and most tailored

a system to suit the needs of the population they served

and the skills available within the primary health care

team. The extent to which the introduction of this service

can be wholly attributed to the PMS initiative, however, is

uncertain as new government targets to provide a more

accessible service were set out in the NHS Plan (Depart-

ment of Health, 2000). However, it appears the additional

flexibility provided by PMS facilitated change. The GP

interviewees in this study and elsewhere (Walsh et al.,

2001) noted that, as nurses were dealing with the

straightforward problems through triage, they themselves

were now seeing an increasing number of patients with

complex conditions. Generally, these changes were viewed

positively by GPs as nurses were seeing ‘the crap we don’t

want to see’. However, some of the nurses questioned

whether demand management in general practice was a

good use of their skills.

As nurses were running and developing clinics, GP

time had been freed up, and this was used for a variety of

different purposes both within and outside the pilots. In

some cases, GPs used the time to develop specialist skills,

a few took up part-time academic appointments, and

others extended their external activities to generate

additional income.

Clinical competence was a key issue in all these PMS

pilots for both nurses and doctors. The GPs working in

these sites were generally not concerned that the nurses

were undertaking clinical diagnoses and prescribing drugs

or treatments that traditionally were general practice roles,

as long as the nurses were competent to do so. Reference

was made by both to the need to be ‘consciously

competent’ and the danger of being ‘unconsciously

incompetent’:

It’s like knowing when you are competent and

knowing when to push yourself a bit further. A lot of

nurses are hesitant about that – they know the

answers, but they don’t have the confidence that they

know the answers.

The mid-point was referred to as being ‘consciously

incompetent’ and knowing their limitations. The nurses

in this study believed this could be acted upon either by

ensuring that other members of the team or the GP are

competent in this clinical skill and/or by going on a

course or arranging clinical experiences to address these

issues. In the practice-based PMS pilots, nurses could

always consult a GP colleague if they needed to do so.

This was not always the case in trust-based or nurse-led

PMS pilots, particularly if, due to working patterns or

lack of accommodation, the nurse and GP were not

undertaking parallel consultations. These nurses tended

to use aspects of clinical governance to ensure clinical

competence and regularly consulted with the medical

adviser or clinical governance lead of the local PCT to

review clinical decisions. Innovative mechanisms were

established by all the nurses in these sites to surmount the

difficulties that current prescribing legislation presents for

nurse, doctor and patient. For example, one nurse

conducts parallel sessions with a GP. She takes the

consultation to the point at which the patient needs a

prescription, and then generates this on the computer,

which prints it out at reception. The receptionist then

gets it signed (by the GP) and hands it to the patient.

The proposed amendments to the extended prescribing

of prescription only medicines by nurse prescribers

(Department of Health, 1997b); should go some way to

resolving the issue.

The most significant motivator for a majority of these

nurses was that of securing greater autonomy within

which to develop and extend their practice, and for some

to create ‘a practice’. All the nurses, whether as nurse-led

336 N. Walsh et al.


contractors, trust-based or practice-based employees, felt

they had the autonomy and freedom to do what they

wanted within the limits of the United Kingdom Central

Council for Nursing Midwifery and Health Visiting

(UKCC) Code of Professional Conduct (UKCC, 1992).

Good information systems enabling clinicians (whether

nurse or general practitioner) to provide evidence-based

health care via protocols, guidelines and access to the

electronic NHS library facilitated a culture of openness

and accountability for clinical decisions. The majority of

the nurses subscribed to the view that protocols and care

pathways were useful for certain conditions, although

some were reluctant to follow this route, believing that

they would end up as technicians. They struggled to

reconcile the tension between using protocols to advance

their roles within safe and accountable limits according to

evidence-based health care and retaining their autonomous

caring role.

Another important motivating factor was being part of a

team particularly when it provided support. All the nurses

were motivated by what they perceived to be the ‘nurse

empowerment’ inherent in their pilots to make a differ-

ence, the opportunity to develop and extend primary care

and primary care nursing in order to bring benefit to the

populations they served, and to ‘push out and challenge

different professional and organizational boundaries’. This

was particularly the case for nurses working with formerly

under served or poorly served populations, such as

homeless people, travellers, ethnic minority groups and

asylum seekers.

Nurses working in these pilot sites were remarkably

self-motivating and keenly aware of which courses they

needed to attend as they extended their roles. They

undertook them as part of their continuing education.

Many of the formal short courses were clinical or ‘mainly

medical’, although others were related to non-clinical

subjects such as teaching and presentational skills, apprai-

sal skills or management. Those in nurse-led sites in

particular emphasized that further development of their

clinical knowledge and skills were acquired mainly from

medical short courses. As clinicians, these nurses made

sense of, kept, discarded, or built upon their knowledge

and skills through constantly testing them in the light of

the evolving challenges of their roles. They were reactive

when they became aware of gaps in knowledge and skill

and sought to fill them, and proactive when they chose to

build on their experience, knowledge and skill in pursuing

a clinical area of particular interest to them. These nurses

valued education, confidence and competence and believed

in the centrality of the patient.

SHIFTING DOMAINS: NURSING AND MEDICINE

The majority of nurses had been practice nurses and saw

their roles now as being different in that they saw clients

from the point of diagnosis, then initiated and prescribed

treatment, and evaluated their care at the end. Practice

nurses did not diagnose or prescribe treatment and saw

only part of a ‘patient’s practice journey’. Similarly, they

saw their role as totally different from that of district

nurses in that they did no wound management in the

surgery. The diagnosis, treatment and review of undif-

ferentiated patients’ conditions, these are what make these

nurses different from practice nurses and other commu-

nity nurses. In many instances their roles overlapped with

those of doctors. Role overlap was acceptable to both

parties when respective roles had been negotiated through

a process of regular dialogue.

On-going discussions informed staff working in these

pilot sites about the skills GPs and nurses were developing:

I think we have both extended our roles to a certain

extent and I’ve had a key role in developing that in

the nurse’s role. Of learning at the start you have

ways to do things and with anything new there is

always gaps… (roles) were different at the start than

they are now. The roles are still there, although

they’ve been extended; there are still boundaries for

nurses and boundaries for doctors, but some are

interchangeable ones… they are sometimes relevant,

sometimes required, sometimes not required. So they

are moving together, they’re not static. (GP)

Most participants noted the dynamic nature of their

new roles. One GP interviewee revealed how he felt his

role had shifted and been influenced by working more

closely with nurses:

…undoubtedly I have taken on a lot of aspects of

triple diagnosis, the other two parts, the social and

psychological aspects of health care (not just medical

diagnosis). Largely, not because I wasn’t aware of

them but the depth from which I now look is largely

because of my nursing colleagues. (GP)

Nurses in this study perceived an holistic approach to

health and illness to be the key difference between

themselves and GPs whereas the GPs were more disease-

or physiologically focused from a generalist perspective.

One GP interviewee noted the differences between GPs

and nurses and also the overlap with core competencies,

related to ‘problem solving health related problems’:

I think there are no specific roles between us, which

is why we deliberately got rid of the word general

practitioner and nurse practitioner. So we have got

medical clinician and nursing clinician and we



emphasize to our patients that we are all clinically

orientated and we have got the expertise to help sort

out or at least answer the problems they come with.

The core role of problem solving health related

problems all of us are capable of doing, but we all

have certain key areas of expertise where we have

developed either over time or out of interest or

whatever that our other colleagues may not have…medical training makes me biased in particular areas

and nurse training means my colleagues have par-

ticular biases in other areas but in the core compe-

tencies in looking after patients and what that means

we should all be able to do that, so make no

distinction. (GP)

Williams et al. (1997) have suggested that the difference

between GPs and nurses working in primary care is that

GPs are holistic in terms of the overall medical status of

patients whereas nurses are holistic in terms of dealing

with patients’ emotional and social needs. Our study

confirms these findings that care given by nurses is shaped

by knowing the individual as a whole person.

In the trust-based pilots, there was less evidence of

open, active role negotiation between nurses and GPs. In

some of these sites, senior trust managers were keen to

manage the PMS pilot just like any other community

service, and as a consequence did not necessarily see the

nurses and doctors working in the pilot as equal partners.

As the study ended and the management of these PMS

pilots transferred across to the PCT, there was some

concern that the different ethos of these nurse-led pilots

would not be understood or supported by the PCT,

particularly in cases where community trust managers had

moved across and were importing ‘the old culture…’. One

of these nurses, for example, was informed by a PCT

manager that ‘nurses like you are not in our strategic plan’.

In the practice-based settings, GPs tended to adopt the

more traditional role of leading the pilot; in some instances

they were happy to leave nurses to lead the nursing team

but there was less discussion about role changes. In some

instances, nurses were allowed to develop areas of interest

but generally tasks were delegated down to them.

A NEW MODEL OF CARE

It has been suggested elsewhere that nurse-led PMS pilot

sites have been encouraged to develop in areas that have

previously been unable to attract GPs (Lewis, 2001;

Baraniak & Gardner, 2001). These areas are often serving

populations, such as asylum seekers, that have been

marginalized from mainstream health services. The fact

that many of the nurse-led pilots are located in such areas

is allowing local GPs to ‘pick and choose’ patients, which

is counter to the vision of comprehensive and equal access

for all. We suggest that the successes achieved by nurse-

led PMS pilots in establishing a primary care service for

vulnerable populations, often with limited resources and

support, if transferred to the general population could

develop a radically different style of primary care services.

Nurses working in these sites, in contrast to the

practice-based sites, tended to adopt a more community-

orientated approach in their planning and delivery of

services. They used epidemiological data, community

profiles and local health needs assessment material to

shape the nature of primary care services they were

delivering. One site, for example, targeted sexual health

information for young men at youth groups, schools and

community centres; another established a range of healthy

initiatives such as healthy walking, in keeping with local

public health agendas. In these sites and the multidisci-

plinary team-led site, another key difference was that

patients were considered as partners in the consultation

process and were becoming involved in decisions about

their care and treatment. Patient groups or boards were

established to influence and inform future service devel-

opments.

Recruiting nurses to hold a PMS contract, however, has

proved difficult. Nurses working in this study enjoyed the

greater autonomy of nurse-led and team-led models, but

voiced a lack of personal support and feelings of isolation

and exposure far greater than those expressed by nurses

working in other settings. Current structures do not

necessarily support nurses who are interested and com-

petent to hold a PMS contract to develop a different

model of primary care. For example, there is no support at

national level, or in some cases at local level, to assist them

with their contract negotiations. There is also a series of

regulatory obstacles, such as prescribing medicines and

signing sick certificates, that currently hinder nurses

fulfilling their roles. Greater attention needs to be given to

areas such as liability and negligence, so that nurses are

supported to undertake tasks formerly carried out by GPs.

Overall, nurses working in these PMS pilots overcame

and worked around the obstacles facing them: ‘You

surmount one hurdle, pause – and another thing hits’.

The nurse-led pilot sites, for example, experienced diffi-

culties with local existing GMS providers, as they feared

loss of patients and income. The patient populations in one

of the trust nurse-led sites comprised homeless, travellers

and asylum seekers who were not receiving health care

from local GMS providers and in this case local GPs were

more accepting. In some practice-based pilots nurses also

faced difficulties over sharing insufficient accommodation

338 N. Walsh et al.


and facilities or just being different. Relationships between

the nurse-led PMS pilots and the Local Medical Commit-

tee and the Primary Care Group/Trust were also uncom-

fortable, but with time these improved. There is no doubt

that all the nurses in this study were highly committed and

determined. They worked long hours and ‘juggled’ other

commitments. Some also worked at a national level to raise

awareness about the difficulties facing and inhibiting them

in their new roles.

In sites where GPs and nurses spent time reflecting

together on what they were trying to achieve and sharing

an understanding of their professional issues and compe-

tencies, they were not only comfortable with their areas of

overlap but also capitalized on their different strengths –

providing a different model of care. Relations between the

GPs and nurses reflected new values of equality and

respect for professional competence. In these sites nurses

were not necessarily concerned with nurse leadership, but

more with equality of opportunity and respect among all

members of the team. Problems were approached in a

collaborative way and leadership was shared between the

two disciplines. In part, this freed GPs, nurses and other

staff to use their skills to the full. Westrop (1995) suggests

that shared leadership is not an easy process and can take a

considerable time to implement. In this site, team attitudes

and rivalries, individual career goals, the corporate culture

of the community trust and the political environment were

all obstacles.

Despite the difficulties, some interviewees believed that

an equal professional partnership model instead of a

nurse-led model might be a better option for the future.

The multidisciplinary-led pilot was highly successful in

developing a shared vision between medicine and nursing,

and over a period of time established a successful model of

working. Team members acknowledged that they brought

different but equally valid knowledge and expertise from

their professional and personal experiences, and they

capitalized on these differences to produce a different kind

of service.

Conclusion

Overall, the evidence shows that nurse-led PMS pilots and

multidisciplinary team-led pilots are delivering a different

type of primary care service, one that is more community-

and patient-focused than many GMS providers. Patients

are considered as partners in the consultation process and

are becoming involved in decisions about their care and

treatment. Such a model of patient-centred primary care

may not suit all population groups but it is providing

patients with a more accessible and responsive service.

To conclude, many of the nurses in this study are

successfully breaking down traditional demarcations

between primary and secondary care, between medicine

and nursing, and between professionals and patients. In

many cases, nurses used their increased autonomy to

maximize the contributions of nursing in their new

roles and thereby delivered a different style of primary

care service to that we have traditionally seen in

general practice. They did not simply take on routine

tasks previously performed by GPs, but expanded their

role to take a lead in the way local primary care

services were run and organized and nurtured a

different kind of relationship with the populations they

covered.

Acknowledgements

This project was funded by the Department of Health.

The views expressed here are those of the authors and not

necessarily those of the Department of Health. We would

like to thank the 12 nurses who committed the time and

enthusiasm to be involved with this project. We would

also like to thank the doctors, nurses and managers who

gave their time to be interviewed. Particular thanks are

due to Sarah Nines.

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Documents

Delivering a different kind of primary care? Nurses working in personal medical service pilots