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Should more GPSIs be encouraged?

NAPC executive member Dr Nav Chana exchanges emails with Professor Ram Dhillon of the Association of Practitioners with Special Interests on the benefits and disadvantages of GPSIs

NAPC executive member Dr Nav Chana exchanges emails with Professor Ram Dhillon of the Association of Practitioners with Special Interests on the benefits and disadvantages of GPSIs

Dear Professor Dhillon

As a national expert on this area, I would be grateful for your opinion as to whether you feel there is still value in promoting the development of GPs with special interests.

Although I appreciate the contribution individual GP colleagues have made in developing and providing specialised services, I am concerned that we could erode further the core generalist skills the health service needs.

The service redesign that is encouraged by PBC allows the rethinking of the balance between generalist skills and specialist skills, as well as who provides the specialisation. This might encourage better integration between traditional primary and secondary care colleagues, framed around the needs of patients. In such pathways, good generalist skills are paramount.

Robust evidence in terms of the effectiveness of GPSIs is limited, so perhaps it's a good time to evaluate their role robustly.

With best wishes, Dr Nav Chana

Dear Dr Chana

You raise a number of commonly held beliefs regarding the ‘loss of generalist skills', by those working as GPSIs. My view, and this aligns with that of the RCGP, is that GPSIs should continue with generalist activity as a key component of their working week. In our experience the bulk of GPSIs' activities continues to be in non-specialist general medical services.

The GPSI is akin to the hospital practitioner or clinical assistant role but for GPSIs, the training, regulation and location of delivering services is inherently different.

The DH policies of PBC, Care Closer to Home and so on cannot succeed without a major development of GPSIs. But this must be done in co-operation with secondary care colleagues.

This is happening across the country in many core specialties, ranging from ENT, cardiology through to diabetes and urology. In fact, in training GPSIs, we make working and building relationships with consultants a mandatory requirement as does the DH guidance on accreditation of GPSIs.

Thankfully the era, only four or five years ago, of PCTs encouraging GPs to run primary care services without secondary care support has ended.

PCTs, and now commissioners, demand that evidence of the effectiveness – both financial and clinical – be produced for the initiation and continuation of GPSI services.

Kind regards, Professor Ram Dhillon

Dear Professor Dhillon

Professor Barbara Starfield's research clearly demonstrates that systems of care in which primary care (generalist) skills predominate offer better access, increase the quality of care provided and are more cost effective.

In particular, her 2003 paper analysing the contribution of primary care systems in OECD countries from 1970 to 1998 (Health Serv Res 2003;38:831-65) found strong primary care systems were associated with improved population health.

All our GP-trained generalists should therefore focus on developing and honing their core generalist skills, because in many ways being a GP is the hardest specialty of all.

The recent RCGP curriculum for general practice underlines the complex attributes that are required to deliver high-quality primary care.

Demonstrating coverage of this curriculum should satisfy the professional development needs of GPs without needing to develop additional career aspirations.

If systems evolve that allow for a more sensible construction of care pathways around patient needs, why can't we have highly effective generalist GPs working with specialist colleagues in an integrated way allowing for easy access to a specialist opinion?

If such systems are governed properly, do we need another tier of GPs with specialist interest in the pathway?

Best wishes, Nav Chana

Dear Nav

Even in the secondary sector the generalist is re-emerging and increasing numbers of posts are requiring consultants, primarily as generalists but with a special interest. This shows it is quite feasible to provide both such services without undermining quality of care.

The RCGP itself has asserted, and rightly so, that GPSIs must continue with generalist provision. The question is the proportion of each. Of the hundreds of GPSIs that I know, not a single individual is doing exclusively special interest work.

The redesign of care pathways will require modification and extension of roles. We have seen this with nurses and physiotherapists in particular. GPSIs have the skills to deliver more elements in that patient care pathway.

The patient requires seamless care and GPSIs are ideally placed to take out many steps from traditional pathways, as they are likely to be delivering one- or two-stop care. GPSI is not a major upheaval of delivery of care but a small step change.

Admittedly clinical outcomes and cost-effectiveness were very poorly measured, if measured at all, six or seven years ago.

But the checks and balances of audit, clinical governance etc are crawling all over all services. The ad-hoc initiation of GPSI activity, thankfully, no longer occurs.

GPSI services do not throw the baby (generalist work) out with the bath water. They nurture the baby as well.

Kind regards, Ram

Dear Ram

It's clear that the requirements of any service should be specified at local level, and the provision should be predicated on quality, patient experience and effectiveness (including cost).

I fully endorse the training and supervision that the GPSIs under your remit have undergone. However, I have anecdotal experience of GPSIs operating at a level that quality generalists should be performing at anyway. So, in one sense if we raise the quality of primary care, the need for GPSIs might diminish.

There is clearly a strong argument for robust evaluation of all service redesign ‘in real time' to inform further redesign.

This is paramount for GPSI services as the current focus of evidence relates to the ambivalence in some of the published literature around cost-effectiveness (Coast 2005; Roland 2005), and failure to meet expectations (Gérvas, Starfield et al, 2007).

GPSI services are one option for delivery, but developments should be predicated on demonstration of ‘real' benefit.

Kind regards, Nav

Dear Nav

I apologise for the overused soundbite but we are talking about the delivery of a clinical service ‘at the right place, by the right person at the right time'.

In their areas of interest, GPSIs manage just this, at a local level. It is noticeable, however, that cost is not included specifically in this statement but I agree it is important.

It is very difficult to provide comparative evidence of cost-effectiveness in the formal sense. PCTs developing and running GPSI services have a cost-benefit modelling process, which is applied, and this will be one factor among many that goes into the mix during the decision-making process.

The obsession with cost-effectiveness, laudable as it is, can be misplaced, particularly in medicine where what matters primarily is high-quality care.

There is little chance of directing GPs not to develop special interests. They were doing so well before the term GPSI was coined. We should be concentrating on formalising the process and encouraging innovation and redesign, even if it may not be proven in monetary terms.

In the main, the conclusions of the papers you quote do not stand close scrutiny. I am happy to provide details of GPSIs who have audited their work over a number of years. Such studies must be made on an individual-service-by-individual-service basis.

The real benefits have been well demonstrated. One just needs to search out where and by whom.

Best wishes, Ram

Dr Nav Chana is a GP in Mitcham, Surrey, senior lecturer at St George's, University of London, chair of the Integrated Primary Care Commissioning LLP, associate director for postgraduate GP education, London deanery and NAPC executive member

Professor Ram Dhillon is a consultant ENT surgeon at Northwick Park Hospital, Harrow and honorary professor at Middlesex University, where he has developed a series of nationally accredited GPSI courses on such subjects as diabetes, cardiology, minor surgery and ENT

Ear examination Dr Nav Chana Dr Nav Chana

I am concerned that we could erode further the core generalist skills the NHS needs.

Professor Ram Dhillon Professor Ram Dhillon

The bulk of GPSIs' activities continue to be in non-specialist general medical services.

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