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Independents' Day

GPs face pay cut as Brown puts brake on public sector

By Rob Finch

When the GPs with special interests programme was unveiled in 2000, it was seen by many doctors as a rare example of cohesive policymaking by Government.

With spiralling waiting times for outpatient appointments and the erosion of pay for portfolio posts, the plan was envisaged as a win-win ­ take the strain off hospitals and provide GPs with a new career option.

The Department of Health now boasts it has 1,553 GPs with a special interest, though given the loose definition of a GPwSI, there are probably double that number. Indeed, it is this loose definition of a 'special interest' that sceptics highlight as one of problems with the initiative.

Others less-enamoured with the drive to turn GPs into specialists have highlighted the lack of evidence that GPwSIs are either clinically effective or cost efficient.

Given those doubts, some GPs believe the introduction of Payment by Results and practice-based commissioning will bring the age of the GPwSI to an end.

Under these twin reforms, they argue, GPwSIs are set to have their position challenged by consultants looking to work in the community as work is shifted into primary care.

Dr David Jenner, NHS Alliance practice-based commissioning lead, claims consultants will be cheaper than

GPwSIs at providing specialist work in the community.

Dr Jenner, a GP in Cullompton, Devon, who is debating whether to employ a consultant or a GPwSI, says: 'I can't see

GPwSIs expanding.

'GPs are becoming significantly more expensive whereas consultants are not. A lot of

GPwSIs need supervision from a consultant and they may have to do supervised training once a month. Acute trusts are beginning to charge for the training.'

Dr James Kingsland, chair of the National Association of Primary Care and a GP in Wallasey, Wirral, believes GPwSIs have to bring 'added value' in order to survive.

He says: 'A GPwSI who does interventions in a hospital setting is fair enough. But too many are GPs with a liking for a particular type of medicine they are interested in.'

Practice-based commissioning would identify this added value in service provision, Dr Kingsland says, and weed out those GPwSIs who still have to refer much of their caseload on anyway. He adds: 'As a PCT if GPs are sending lots of stuff in to the hospital something needs to be done.'

Dr Tony Crockett, a GP in Shrivenham, Wiltshire, and a hospital practitioner in asthma and COPD, says Payment by Results, in particular, will spell the end for GPwSIs.

He says: 'They were seen as a way of doing hospital work cheaply. Now with Payment by Results they realise it's not going to make any odds ­ it doesn't matter if a GPwSI sees a patient or not.'

GPwSIs refute the suggestion they are more expensive, arguing that the high quality of care and quicker access they offer end up cutting NHS costs.

Dr Stephen Lawrence, a

GPwSI in diabetes in Chatham, Kent, says: 'I think the costings for that assertion are erroneous. The Government's plan is to have GPs commissioning and that puts GPwSIs in the driving seat.

'In two years we have had a significant impact on delivery of diabetic care in our community. We're now seeing fewer poor-quality referrals.'

Dr Ahmet Fuat, a GPwSI in cardiology in Darlington, also warns against a 'purely monetarist' argument against GPwSIs. He says that although work will move out of hospitals, there is no guarantee consultants will want to follow it into primary care.

Professor Ram Dhillon, consultant ENT surgeon at the University of Middlesex and one of the architects of early GP ENT courses, agrees.

He says: 'I certainly wouldn't want to go into primary care ­ it's not worth my while financially and for me to see routine stuff is a waste of my expertise.'

A Government-funded evaluation of the clinical and cost-effectiveness of GPwSIs, due to report any day, will provide a strong clue to the scheme's future.

Whatever it concludes, ministers are unlikely to intervene to bring the GPSIs scheme to an end. But the market will determine what, if any, their future role will be.

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