BMJ  2005;331:1448-1449 (17 December), doi:10.1136/bmj.38676.769711.7C (published 8 December 2005)

Commentary

General practitioners with special interests—not a cheap option

¹ National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL m.roland{at}man.ac.uk

General practitioners with a special interest are general practitioners with special experience or training that enables them to take referrals which would normally be seen by specialists. The training of a new cadre of general practitioners with special interest was a key part of the UK government's 2000 NHS Plan.

Are general practitioners with special interests likely to be an effective and cost effective way of providing care? A randomised controlled trial by Salisbury et al and an economic evaluation by Coast et al provide some answers.^{1 2} The results show that in dermatology a general practitioner with special interest service was effective: patients were seen more quickly, were more satisfied, and had similar clinical outcomes when compared with those seen in a specialist clinic. However, the NHS costs of referring patients to a general practitioner with special interest were 75% more than for specialist clinics. The main reason for this was that patients seen in specialist clinics could be seen by both consultants and junior hospital staff, and the junior staff had lower salaries than general practitioners with special interests. In addition, seeing outpatients in concentrated settings (for example, hospitals) provides economies of scale.

These results echo those of a previous strategy to move outpatient clinics outside the hospital setting. In the 1990s, specialist outreach clinics were established in which specialists travelled to general practitioner clinics to see patients. Again these were associated with high patient satisfaction and reduced waiting times but increased costs to the NHS.³

So from an NHS perspective, general practitioner with special interest clinics look as if they are effective mainly in providing better access but will do this in a cost effective manner only if the increased capacity cannot be provided in hospital clinics. In terms of safety and clinical effectiveness, general practitioner with special interest services need to be set up in close collaboration with local specialists, who should provide ongoing training and education. This has not always been the case, and many general practitioners with special interests are not currently receiving nationally agreed levels of training.⁴

The effect of increasing specialist capacity on general practitioners' rates of referral is another key factor that will affect the cost effectiveness of general practitioner with special interests. Several studies indicate that general practitioners with special interests are associated with an increase in number of patients referred.^5-7 Maddison et al found a doubling in the number of patients referred to a redesigned musculoskeletal service, with no change in the proportion of patients listed for surgery, implying that the increase in referrals addressed previously unmet needs.⁷ Sanderson, however, found that some of the observed increase in referrals was of patients who would not previously have been referred.⁵

The development of general practitioner with special interest services is an effective method of increasing access to specialist services when capacity cannot be increased within hospital clinics. They are unlikely, however, to be a cheap option. General practitioner with special interest clinics may cost more than the equivalent hospital based clinics and they may generate increased demand. In the context of the forthcoming white paper on care outside hospitals, general practitioners with special interests should be regarded as a positive development in improving access and patient satisfaction. Healthcare planners, however, need to understand that general practitioners with special interests will increase overall NHS costs and are probably not the most efficient way of increasing specialist capacity.

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Competing interests: None declared.

References

1. Salisbury C, Noble A, Horrocks S, Crosby Z, Harrison V, Coast J, et al. Evaluation of a general practitioner with a special interest service for dermatology: randomised controlled trial. BMJ 2005;331: 1441-4.[Abstract/Free Full Text]
2. Coast J, Noble S, Noble A, Horrocks S, Asim O, Peters TJ, et al. Economic evaluation of a general practitioner with special interest led dermatology service in primary care. BMJ 2005;331: 1444-8.[Abstract/Free Full Text]
3. Roland M, Shapiro J, eds. Specialist outreach clinics in general practice. Oxford: Radcliffe Medical Press, 1998.
4. Schofield JK, Irvine A, Jackson S, Adlard T, Gunn S, Evans N. General practitioners with a special interest in dermatology: results of an audit against Department of Health (DH) guidance. Brit J Dermatol 2005;153(suppl 1): O-1.
5. Sanderson D. Evaluation of the GPs with special interests (GPwSIs) pilot projects within the action on ENT programme. York: York Health Economics Consortium, 2002.
6. Duckett S, Casserly H. Orthopaedic GP fellowship: does it work? Ann R Coll Surg Engl 2003;85: 195-6.[CrossRef][Web of Science][Medline]
7. Maddison P, Jones J, Breslin A, Barton C, Fleur J, Lewis R, et al. Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. BMJ 2004;329: 1325-7.[Abstract/Free Full Text]

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