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Are GPSIs a waste of money?

GPSI services are likely to be more expensive than hospital care and may not cut waiting times or be more convenient for patients, argues Professor Chris Salisbury. But Professor Ram Dhillon disagrees, insisting GPSIs dramatically cut waiting times and improve care, and should not have to constantly justify their efforts.

GPSI services are likely to be more expensive than hospital care and may not cut waiting times or be more convenient for patients, argues Professor Chris Salisbury. But Professor Ram Dhillon disagrees, insisting GPSIs dramatically cut waiting times and improve care, and should not have to constantly justify their efforts.

Yes

When we ask whether GPSIs are a positive development for the NHS, it is important to be clear about what they are meant to do.

Are they supposed to be additional to, or a substitute for, hospital outpatient services?

If they are additional, they may cut waiting lists but at extra cost. The question then is whether employing a GPSI is the best way to do this – it may be more cost-effective to employ staff-grade doctors or specialist nurses.

In any case, the Audit Commission found employing GPSIs did not necessarily reduce waiting times1.

Rather, it may simply lead to more referrals, increasing costs even further.

Increasing specialist capacity using GPSIs may also mean reducing capacity in primary care – and replacing these GPs may be more expensive than employing specialist doctors in hospital.

But if GPSIs are a substitute for hospital services, it is essential patient outcomes are as good as for treatment in outpatient clinics.

Many hospital consultants are concerned that GPSIs have insufficient expertise. It is essential they have appropriate training, accreditation and specialist support.

My own study of dermatology GPSIs reassuringly suggested patient outcomes were as good as for hospital care2,3. But we need much more evidence about quality and safety.

Some of the arguments for GPSIs are based on softer benefits for patients, such as accessibility.

But this is not straightforward. In our study, although convenience and waiting time were important to patients, they were less important than seeing the doctor with the most expertise, and people were prepared to wait for this.

GPSI services will be more convenient for some than others – for many people, it is easier to get to a hospital in the town centre than a suburban health centre, particularly if they have to use public transport.

And the argument that GPSIs improve patient choice by increasing the range of providers is also questionable. Many referral pathways insist that patients are referred to GPSIs – reducing choice.

Where is evidence?

Then we come to costs. GPSIs would cut costs if they substituted for outpatient care and were less expensive. But where is the evidence?

It is important not to confuse the artificial price paid by PCTs under Payment by Results with true cost. Under the tariff, hospitals are paid an average price for all referrals within a given specialty.

In a classic case of skimming the cream, PCTs can provide care for minor cases using a GPSI at less expense than the price they have to pay the hospital.

This may save the PCT money in the short term, but is not sustainable, and does not save money for the NHS as a whole.

The hospital still costs the same to run and saves very little money by seeing slightly fewer minor cases. If large numbers of minor cases are diverted to GPSIs, the tariff price for other cases will go up.

Estimating the true cost of providing NHS care is difficult, and the evidence limited, but no rigorous studies have shown GPSI care is less expensive than outpatient care.

Some studies, including my own3, have suggested GPSIs may be more expensive.

This should not be surprising. GPSIs are often paid higher salaries than consultants – and many hospital consultations are conducted by junior or staff-grade doctors.

Much of the work now done by GPSIs was previously provided at much lower cost by the same doctors working in hospitals as clinical assistants.

Many GPSI clinics see relatively few patients per session and economies of scale mean hospitals can provide care more cheaply.

Becoming a GPSI may provide an interesting career sideline for some GPs, but we must be wary of any suggestion that career progression must involve specialism.

Policy makers tend to assume specialism is best – but generalism can be important, challenging and fulfilling.

If we do not defend generalism, we will end up with a much more expensive, less accessible, more inequitable and less personal health care system.

Professor Chris Salisbury is professor of primary health care at the University of Bristol and a GP in the city

No

Why should GPs who wish to provide enhanced levels of care constantly have to justify themselves?

Yet so often their efforts have been greeted with suspicion by their clinical colleagues in both primary and secondary care.

Once formalised into a discrete role, termed a GP with a special interest, there was a focus for that suspicion, and in some cases criticism and denigration.

Yet the facts suggest these services ought to be actively encouraged and resourced to provide high-quality and cost-effective care.

GPSI services are invariably developed in conjunction with the local PCT, GPs and secondary care services.

Those that initiate such a service in isolation deserve umbrage. But to suggest GPs are simply deciding unilaterally to set up such services is simply untrue.

Because GPSI services are normally set up with tripartite involvement, their objectives are clearly agreed upon – in terms of clinical outcomes, waiting times, cost and so on.

Whether such criteria are fulfilled can only be determined by analysing GPSI services that are up and running.

For this purpose, I have taken data from three separate services whose work has been audited – a cardiology service at Newham PCT in east London, a urology service at Havering PCT in north-east London and an ENT service at Horsham PCT in West Sussex.

In these cases, concerns over the GPSIs' knowledge and skills was overcome by following an accredited programme of training, which was subject to external review and a final summative examination.

All three GPs underwent training approved for higher professional development by the RCGP. The training included the acquisition of requisite competencies under the supervision of a local consultant specialist.

The recent mandatory accreditation requirements for GPSIs put in place by the Department of Health will ensure regulation that was previously absent.

And all three of my case study GPSIs have formally agreed criteria for selecting patients. There was never any intention of reproducing a secondary care service in the community.

False mantra

The mantra that GPSI services should reduce demand is false. Enhanced training and skills are likely to unearth unmet need and so increase demand.

But the ability to provide one-stop clinics, for an agreed range of disorders, shortens the length of the patient pathway in primary care and is likely to reduce hospital referrals.

In our case studies, this has resulted in a reduction in waiting times from 26 to four weeks for urology and from seven weeks to 10 days for cardiology.

The patients referred to these GPSIs would have gone for a hospital opinion. Analysis reveals that 23% of patients in the urology clinic and 10% for ENT required onward referral.

The DNA rates are very low when compared with secondary care – less than 4% for ENT and less than 2% for cardiology.

Evaluation of patient benefits is required by PCTs. Overall patient satisfaction was high, at 87% for the urology clinic and 86% for cardi ology.

Comprehensive analysis of our three GPSI services revealed the following figures.

Based on national tariff rates, annual savings were £62,000 for the urology clinic, £50,000 for the cardiology clinic and £30,000 for the ENT clinic.

It is apparent that GPSIs do, on a personal level, derive significant satisfaction in providing enhanced services.

For some it has been a new lease of professional life, reinvigorating punctured enthusiasm.

The argument that generalism would suffer is a non-starter. Our three GPSIs value their normal GP clinics as much as their GPSI sessions.

GPSIs, although carrying a different label, have been with us for decades and will continue to flourish.

They can provide excellent services with benefits for patients, GPs, secondary care and the taxman.

Professor Ram Dhillon is a consultant surgeon at Northwick Park Hospital, Middlesex, and a spokesperson for the Association of Practitioners with Special Interests

Professor Chris Salisbury

Economies of scale mean hospitals can provide care more cheaply

Professor Ram Dhillon

GPSIs have benefits for patients, GPs and the taxman

Dermatology minor surgery

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