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Rapid Responses: Rapid Responses published:
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Special interests mean special responsibilities
- Susanne McCabe (29 August 2003)
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GPSI value
- Pawan Randev (29 August 2003)
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Experience as a GP providing a clinical service
- Edward Southall (29 August 2003)
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There is evidence for the effectiveness of GPSWIs
- David A Fitzmaurice (29 August 2003)
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But who does their work
- Mark A Smith (29 August 2003)
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Evaluating GPSIs
- Andrew N Bamji (2 September 2003)
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General Practitioner Specialists Provide Efficient Acute Care?
- Simon Collins, Sharanyaa Sivagnanapiragasam, Mohammed Baba, Nicholas Collins, Stephen Wilson. (26 September 2003)
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Susanne McCabe, retired cf24 3pf
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People are used to thinking of 'specialists' as providing a separate service where knowledge in depth has been aquired under supervision. It is to some extent putting the cart before the horse when training and qualifications for GP specialists are not established yet. Will people have a choice? How can they weigh up the skill of a GP compared with a specialist? As GPs are to do the selecting how is it going to seen to be equitable, or used to satisfy the needs of service users more than the needs for example training, or to sometimes mainly satisfy the interests of GPs, rather than the need of those who consult them ? With a shortage of GPs who will take up the general workload? GPs with 'special interests' have been practicing informally without any proper monitoring or accountability in some areas already, for example in stating that they provide ' brief psychotherapy' or 'counselling' but without appropriate qalifications. Things can go wrong in any area of practice so all need to be properly protected. It is not enough to have an interest, people who consult GPs need to know what qualifications they hold and to whom they are accountble. A practice leaflet should explain that the scheme is operating so that it is known to all 'users', can be seen to be equitable when GPs themselves are doing the selecting. Importantly if the scheme is up and running informally already, as seems the case, people need to be asked their consent to participate in the experimental stages. All too often involving and informing service users in the initial stages of a project is not thought out and loses valuable input. Competing interests: past committee member of joint health and social services cttees. |
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Pawan Randev, GP Amersham
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How much should GPSIs be paid? This is a central practical issue for them and their practices. The traditional clinical assistant rates have not kept up with locum rates. Should there be a nationally agreed scale and "merit" points? If there arent, how do you attract and retain GPSIs given the nature of the new GMS contract and the detailed nature of quality domains? Competing interests: None declared |
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Edward Southall, GP Mayfield Medical Centre, 37 Totnes road, Paignton, TQ4 5LA
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The article mentions the sparsity of evidence concerning the effectiveness of GPs in this role. In 1999 with the support of the local health authority and more recently Torbay PCT I established a Cardiac Diagnostic service based at my surgery. It provides Echocardiography, Exercise ECG testing and Ambulatory ECG monitoring. The results of the first audit were as follows. During the first 12 months 271 Echocardiograms, 95 Exercise ECGs and 125 Ambulatory ECGs were carried out. The average wait for each test was 2 weeks. Results were posted to the referring GP on the same day as the test. Referring GPs were asked to state what proportion of patients referred would have been referred to the local hospital if they had not been referred to the service and the result was 93% They were then asked how many were referred after the test was done and the result was 12%. Thus approximately 397 hospital cardiology referrals were saved in the first year. The service is continuing and we now have an average of 750 referrals per year. Competing interests: None declared |
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David A Fitzmaurice, Clinical Reader in Primary care The Department of Primary Care and General Practice, The University of Birmingham, B15 2TT
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The editorial by Rosen and colleagues states that the evidence for the effectiveness of GP specialist clinics is "almost non-existent". This ignores the literature on primary care led chronic disease management clinics such in areas such as diabetes, asthma, and hypertension. More recently there has been a growing body of evidence to support the role of primary care clinics in the management of oral anticoagulation. Indeed the evidence both in terms of clinical outocmes and and patient preference points to primary care clinics being the preferred model of service delivery (e.g.Fitzmaurice DA, Hobbs FDR, Murray ET, Holder RL, Allan TF, Rose PE. Oral Anticoagulation Management in Primary Care With the Use of Computerized Decision Support and Near-Patient Testing. Randomized, Controlled Trial. Arch Intern Med. 2000;160:2343-2348). This has been recognised within the recent GP contract with, for the first time, recognition of this service as a form of chronic disease management. Whilst I agree that minimum standards of competence need to be specified, indeed it is something I have campaigned for in anticoagulation for several years, it would be unfortunate if this potentially effective form of intervention was left stillborn due to stagnating beaurocracy when there are extant models of care which demonstrate clinical and cost- effectiveness and also are preferred by patients. Competing interests: None declared |
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Mark A Smith, GP principal Dorset BH22 0HX
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Rosen et al suggest there are 3 important questions. I venture a fourth. Who does the specialist GP's work when they are being specialists. General practice is understaffed and the new contract is stalling as I know no-one who has yet seen any sign of new money despite Chisholm's promise on the day of the contract vote result promising 14% increase to all GPs (inc. PMS) backdated to April. What the hell is going on at the DOH as our PCT simply states they await guidance. Competing interests: None declared |
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Andrew N Bamji, Consultant rheumatologist Queen Mary's Hospital, Sidcup, Kent DA14 6LT UK
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The editorial asks three questions. 1. How do we ensure quality of a GP specialist service? The answer must be that any such service is audited with (or by) the hospital specialist service. It is unreasonable to expect that a GPSI without a CCST in the specialty should be cast adrift without direct specialist support. Our solution has been to offer our GPSI space in our cottage hospital (a siting which meets the wishes of the PCT geographically) so that clinics run concurrently with the consultants. We meet on a regular basis to discuss caseload, and intend to develop a formal review process, but the setting offers the consultants the opportunity to supervise and help if necessary and the GPSI gains a sense of security, needed or not. 2. Will the service be clinically and cost effective? Clinically without a doubt; cost-wise we cannot be quite so sure. Having done outreach clinics myself I am convinced that stand-alone services, as I believe are envisaged as a general rule for GPSI posts, will be underutilised. Far better to integrate the service and gain all the advantages of cross-fertilisation of ideas. 3. What will be the impact on specialist care? In rheumatology, and in our area in particular, we will probably contain waiting times for new appointments but if a GPSI service is just confined to "simple" things such as soft tissue and joint injections then the incumbent will become bored and demoralised, and primary care physicians may use the post/clinic as an excuse not to do these things themselves. For a few years I ran a teaching clinic for injections; it was remarkable how often an attender would start referring to "The Injection Clinic", which was not the object of the exercise. In hard- pressed departments such as ours the effect of creaming off the "easy stuff" may simply be that the consultants can set more suitable (ie longer) appointment times for the connective tissue referrals, and thus there will be no impact on waiting times at all. Accordingly, although our GPSI service has been well-advertised, we are at present running a common clinic booking system. Whether a GPSI session is more useful than having extra consultant sessions may depend on the individuals involved; whether specialist services for small subgroups of GP practices in community settings can ever be a sensible use of scarce resources I doubt. Some areas have pioneered the system of booking and running outreach clinics within general practice, but I suspect that consultants will be most unhappy if they feel that someone else is prioritising the cases. An inappropriate direct referral to a GPSI might cause delay. Of course, these comments will indubitably lead someone to suggest that we are simply running a Clinical Assistant system, but I confess I am not certain why there are (or should be) differences! Competing interests: Our department has a 1 session/week GPSI |
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Simon Collins, 4th Year Medical Student - University of New South Wales Macarthur Health Service P.O. Box 149, Campbelltown 2560, Sharanyaa Sivagnanapiragasam, Mohammed Baba, Nicholas Collins, Stephen Wilson.
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Rosen, Stevens and Jones point out that there is an opportunity for improved health care should General Practitioners (GPs) expand their clinical interest (1). GPs are viewed as an important primary interface for patients (2) but it is clear that on occasion the level of medical care needed extends beyond that able to be provided by a primary care service. We would like to suggest that the specialisation of GPs should extend not only to subacute and chronic problems but also to common acute conditions such as pneumonia, cellulitis and initiation of anticoagulation. We agree that the idea of expanding the horizons of general practitioners into areas of special clinical interest may indeed improve access to appropriate care. Straightforward cases may be dealt with by a GP-specialist, thus avoiding unnecessary over-attention and waiting lists for specialist appointments. The questions regarding quality of care and cost-effectiveness are appropriate and should be studied further. The traditional model of outpatient specialist care has the obvious advantages of providing a wide range of services in close proximity to each other. These services also offer excellent access and training for medical students and young doctors. However, the distance of this setting from the primary doctor brings problems in communication, duplication, long waiting lists and high costs (3). This model is in essence system- focussed, not patient-focussed. We see no reason why GP specialisation should not extend to illnesses needing more acute medical care. Often patients found to have a simple pneumonia or cellulitis are referred by their GP to the emergency department of the local hospital. The load this places on hospitals is unnecessary. The potential for acute medical care from this setting becomes more possible as GPs tend to base themselves more and more with other GPs in medical centres. GPs pursuing their special interests have a great potential to make health care systems more efficient. It has been suggested that such alternatives exist for Ambulatory Care patients (4). Integration between primary care centres and hospital-at-home providers provide opportunities for improved care in acute conditions, simultaneously freeing hospitals to deal with more serious, resource dependant conditions. Patients have been shown to prefer this home setting for the treatment of some disorders (5). The involvement of their primary care doctor is likely to put them even further at ease. References 1. Rosen R, Stevens R and Jones R. General Practitioners with Special Clinical Interests. BMJ. 2003;327:460-2. 2. Grumbach K, Selby JV, Damberg C, Bindman AB, Quesenberry C Jr, Truman A and Uratsu C. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282(3):261 -6. 3. Orton P. Shared care. Lancet. 1994;344(8934):1413-5. 4. Wilson S and Collins N. Ambulatory Alternatives Exist [letter]. BMJ. 2002;325:390 5. Coley CM, Li YH, Medsger AR, Marrie TJ, Fine MJ, Kapoor WN, Lave JR, Detsky AS, Weinstein MC and Singer DE. Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Archives of Internal Medicine. 1996;156(14):1565-71. Competing interests: None declared |
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