ABSTRACT
Primary care is facing a time of rapid change and the climate for innovation and development has been encouraged by the government's willingness initially to consider personal medical services pilot sites, with particular emphasis on the development of nurse-led services (Marchant et al., 1997; DOH, 1997a, 1997b, 1998a). In 1999, the White Paper, Making a Difference (DOH, 1999c), also emphasized the need to strengthen the nursing, midwifery and health visiting contribution to healthcare with initiatives such as nurse consultant posts and extended nursing roles. Primary care groups (PCGs), established since the introduction of the White Paper, The New NHS - Modern and Dependable (DOH, 1997c), have been able to influence local primary care services and will be able to flex practitioners and resources once they become free-standing Trusts at levels 3 and 4 (DOH, 1997a, 1998b). Firstwave trusts came into being in April 2000 (DOH, 1999a). The recent Green Paper, Our Healthier Nation (DOH, 1998c), and subsequent White Paper, Saving Lives: Our Healthier Nation (DOH, 1999d) have highlighted the need to tackle health inequalities and develop services for deprived people and to meet unmet needs. Educational courses for nurses working at an advanced level also appear to have proliferated since their introduction in the late 1980s. The current drop in the number of general practitioners (GPs), particularly working in inner city areas, has also encouraged the development of extended nursing roles (Chapple et al., 1999). Recent innovations facilitating the development of such roles also include walk-in centres (DOH, 199ge), out-of-hours services (DOH, 1995) and NHS Direct (DOH, 1999f, 1999g). In light of all these factors, it appears particularly opportune to explore autonomous practice and the variety of extended roles which are developing in the community.
