This article will discuss the implications of nurse prescribing in mainstream primary health care and its impact on the fields of mental health and learning disabilities. Complexities and issues which require serious consideration by those nurses wishing to pursue such a specialist and extended role will be discussed in relation to these practice areas. Titchen's (1998) critical companionship model will be illustrated as an example of one framework for clinical supervision. This is to allow the processes, competencies and contextual issues to be explored by both novice and expert prescribers. The article concludes that for safe, effective and competency-based practice, clinical supervision also assists in mediating the professional and political aspirations in support of supplementary nurse prescribing.

Specialist nurses within learning disability services have been identified and promoted as a result of the National Health Service and Community Care reforms (I990), as well as through intensified debate within the learning disability nursing profession. The Department of Health has further supported the analysis of the role and the function within the context of the health and social care divide, promoting practitioners to concentrate on addressing health gain concerns through the Health of the Nation targets (DOH I995). It is suggested within this paper that specialist nurses within the community have not been allowed to develop their professional and philosophical base for practice, and instead have been manipulated by economics, policy formulation and through medical and managerial domination. The philosophy of primary health care is identified as providing these specialist nurses a framework so as to effectively realize true primary health care, as well as recognizing the impact that clinical governance will have on ensuring the need for practitioners to provide evidence-based practice (DOH I997). Two conceptual models are proposed; a segretative model and an integrative model, which offer the specialist community learning disability nurse a way in which the practitioner can work more effectively within the primary health care arena. Four domains of practice and a preventative crisis intervention approach give the specialist nurse a clinical foundation, to use within the primary health care setting. The perceived benefits and potential difficulties of making these models workable will also be highlighted. It is recognized that integrating these models locally will be dependent upon how specialist learning disability services are configured in each locality and how newly formed primary care groups may include community learning disability nurses, and how co-opted members are utilized to examine the health needs of people with learning disabilities.

Since Valuing People (Department of Health, 2001), there has been a marked change in landscape for housing support and service provision for people with a learning disability. Care and supported living options are now provided by a myriad of providers across the healthcare, social-care and independent sectors. Due to the complexity of such individualized care arrangements, and the non-traditional roles of such service professionals and providers, examination of professional role boundaries with service users is essential; traditional role boundaries are not easily transferable or considered within such professional supports and services. This article discusses important facets of professional boundaries that impact directly on such contemporary, learning disability, person-centred services.

This article is intentionally reflective, partly autobiographical, and focuses on the challenges that existed for the author as a nursing student trained in the 1970s, and after qualifying as a learning disability nurse. The difficulties of getting changes accepted still exists today. The important messages concern promoting and demonstrating positive values, attitudes and skills when working with clients, other health care professionals and services at all levels.