Can GPSIs get up to scratch?
By Daniel Cressey
GPs with special interests have been on the ropes lately, with a series of reports branding the services they provide as expensive, frequently substandard and insufficiently well planned.
The criticism comes as hospital specialists get increasingly tetchy at the loss of services to primary care, and has intensified calls for a more formal set of standards for GPSIs.
'When the Government came in it deliberately left the field open. It didn't put in any enforceable standards,' says Dr Martin Hadley-Brown, chair of the Primary Care Diabetes Society and a GP in Thetford, Norfolk. 'That's not proven to be the best way of doing things.'
Dr Clare Gerada, a GP in Lambeth in south London and former RCGP representative on the Government's GPSI framework group, adds: 'The vision is right but at the moment it's a muddle. It's not being well led at national level. We risk creating second-rate specialist services run by primary care practitioners.'
In order to avoid 'second-rate services' primary care societies are urgently developing their own standards for GPSIs.
Dr John Galloway, treasurer of the Primary Care Society for Gastroenterology, one of those putting together guidelines, warns: 'It's got to be properly regulated. It is very important otherwise the whole grade of GPSIs will come under scrutiny and people will say it's a waste of NHS money.'
He adds: 'If you want to do a specialty you do have to undergo some extra training.'
The Primary Care Dermatology Society and British Association of Dermatologists are currently setting up firm criteria for GPSIs, including having a diploma, having already conducted 25 to 50 supervised clinics, ongoing training and on-the-job assessments.
The General Practice Airways Group has also developed standards designed to ensure 'confidence GPSIs working in respiratory medicine provide high- quality care'.
The standards include training, systems for supporting GPSIs and competence assessment by a multi-professional panel. They also suggest having an active educational portfolio.
Dr Gerada agrees there is more to being a GPSI than just looking after patients: 'It's about providing clinical input, strategic direction and education and training to others in the locality.'
Those involved in setting up GPSI services also believe the involvement of secondary care is crucial, with clear guidelines about who should deal with which cases.
Dr Richard Stevens, chair of the Primary Care Society for Gastroenterology and a GP in Oxford, says: 'There is a place for them to get the patient in front of the right person. With secondary care clinicans you're going to need their help and to work with them.'
Dr Stephen Hayes, a GPSI in dermatology in Southampton, insists GPSI services must work closely with and be complementary to secondary care.
He says: 'These are very important issues and recent developments have been alarming and could undo all the good achieved by community dermatology schemes.
'Our referral guidelines make it clear severe, widespread and worrying rashes, large or facial BCCs and any suspected SCCs or melanomas must be referred to hospital in the usual way. GPSI services must always be as well as not instead of dermatologists.'
PCTs are increasingly looking to stave off criticism by gaining approval from primary care societies before taking on GPSIs.
Dr Jamie Dalrymple, secretary of the Primary Care Society for Gastroenterology and a GP in Norwich, says his society is working together with trusts to set standards. 'The PCTs have grasped that they have to ensure the quality of services is good.'
But even with more rigid standards, not everyone is convinced GPSIs will prove value for money.
Professor Chris Salisbury, professor of primary health care at the University of Bristol, who is researching the cost-effectiveness of GPSIs, says: 'In our [study] the GPSIs seemed to provide equally good if not better care, but we didn't find any evidence they cut waiting lists and were more effective.'
'If I was the Department of Health I wouldn't rush to a great expansion. I would think hard about why we are doing this.'
Rough ride for GPSIs
Primary Care Dermatology Society says it has received 'disturbing reports' GPSIs are cherry-picking easy work, while King's Fund study warns 'a range of key issues need to be resolved' on pay, training and clinical governance
Centre for Health Economics report on GPSIs warns of unclear clinical governance, poor links with secondary care and questionable cost-effectiveness
Government-commissioned research concludes GPSI clinics are almost twice as costly as equivalent outpatient services
NHS Alliance says GPSIs could
be more expensive than employing hospital consultants in primary care