Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.

An economic evaluation was conducted alongside a randomised controlled trial between May and October 2006, wherein 12 nurse practitioners and 50 GPs working in 15 general practices (study practices) participated. Consultations by study practices were also compared with an external reference group, with 17 GPs working in five general practices without the involvement of nurse practitioners. MethodDirect costs within the healthcare sector included resource use, follow-up consultations, length of consultations, and salary costs. Costs outside the healthcare sector were productivity losses. Sensitivity analyses were performed. ResultsDirect costs were lower for nurse practitioner consultations than for GP consultations at study practices. This was also the case for direct costs plus costs from a societal perspective for patients aged <65 years. Direct costs of consultations at study practices were lower than those of reference practices, while practices did not differ for direct costs plus costs from a societal perspective for patients aged <65 years. Cost differences are mainly caused by the differences in salary. ConclusionBy involving nurse practitioners, substantial economic 'savings' could be used for redesigning primary care, to optimise the best skill mix, and to cover the full range of primary care activities.

BackgroundDue to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation.MethodsA qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP.ResultsEmployment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs’ caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs.In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees’ motivation to start the master’s programme and GPs’ prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking.ConclusionsRole standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-017-0587-3) contains supplementary material, which is available to authorized users.

Effective and efficient health care can only be provided if the actual care needs of a population provide the basis for deciding which mix of professionals is best equipped to deal with the changing and increasing demand of care. A macro-level intervention is needed to help a broad-scale introduction of the nurse practitioner in general practice.

Several potential limitations influence the validity and generalizability. Full economic evaluations per se are of limited value for making decisions about substitution of skills. The tenuous relationship between structural, process and outcome variables is not sufficient investigated. For meaningfully placing the costs and consequences of substitution of skills in the context of health care and generating relevant data for decision making, it is strongly recommended to combine an economic evaluation (RCT) with an observational longitudinal study.