Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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How Much for a Consultation?!
- John S Ashcroft (18 December 2005)
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Cost of GP Dermatologists
- Anne-Marie KILLEEN (19 December 2005)
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High costs of GPwSIs are a fallacy
- Cornelius J Crowley (19 December 2005)
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The cost of GPSI dermatology
- Simon F Cooper (19 December 2005)
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Cost of GPwSI
- Henry Mintz (19 December 2005)
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Don't Forget the Cost of the Missing GP
- Graeme M Mackenzie (20 December 2005)
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Other benefits to primary care need to be considered
- Nefyn H Williams (21 December 2005)
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GPWSI and Payment by Results
- Nicholas H Brown (24 December 2005)
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'Non referred' patients not counted
- john sharvill (4 January 2006)
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Authors' response with regard to costs of GPSI services
- Chris Salisbury, Jo Coast, Tim Peters, David de Berker (6 January 2006)
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John S Ashcroft, General practitioner Old Station Surgery,Heanor Rd, Ilkeston, DE7 8ES
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Dear sirs, Salisbury and colleagues (1), I suggest , made the front cover of the BMJ, less for proving that general practitioners with a special interest(GPSIs) in dermatology can be as effective as Hospital consultants, and prefered by patients, but that Coast and colleagues (2) found them more costly. The principal difference in cost in Coast and colleagues, appparently detailed cost analysis, appears to be the cost of the consultations conducted in a health centre by the GPSIs, and nurses. My local hospital book new outpatient dermatology patients with 10 minute appointments, with 5 minutes for "follow ups". It appears that the patients in this study had on average two appointments; an initial and a followup. The average consultation with a general practitioner is 10minutes, and the cost in 2002-3 was £16.87p (3). I would have assumed that that the two consultations with the GPSIs would have been around £30-£40 in the 2004 prices used in the study. However the pricing per consultation was £60.05p, over £120 for two. This appears excessive. The £55.28p per nurse consultation, more so. If the pricing of the GPSIs consultation were closer to that of a GP, they would, it appears, be as effective, preferred by patients and cheaper than consultant outpatient care. Yes, in Bristol, GPSIs, and even nurses, may indeed cost more than consultants but as the authors state "the study is based on one geographical area and its findings may not apply to other settings" 1 Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial Chris Salisbury, Alison Noble, Sue Horrocks, Zoe Crosby, Viv Harrison, Joanna Coast, David de Berker, and Tim Peters BMJ 2005 331: 1441-1446. 2 Economic evaluation of a general practitioner with special interests led dermatology service in primary care Joanna Coast, Sian Noble, Alison Noble, Sue Horrocks, Oya Asim, Tim J Peters, and Chris Salisbury BMJ 2005 331: 1444-1449. 3. www.bma.org.uk Competing interests: None declared |
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Anne-Marie KILLEEN, GPwSI Dermatology employed by Bradford City PCT Ashwell Medical Centre, Manningham, Bradford BD8 9DP
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The article does not take into the account the reduction in cost within the GP specialist's own general practice. My practice has about 7,000 patients and they can all access me during normal surgery time or during my in-house dermatology clinic. This has resulted in a huge reduction in secondary referrals and nearly all referrals go through me since I completed my training three years ago. The article also dose not take into account the dissemination of knowledge to other members of the general practice team which takes place, and that GP Dermatologists will often take an active part in the education of medical students and GP Registrars. Competing interests: I am a GPwSI in Dermatology |
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Cornelius J Crowley, GP Principal Queens Walk Surgery, 6 Queens Walk, Ealing, London W5 1TP
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EDITOR- The high cost of the GPSI dermatology service in the articles by Salisbury et al (1), and Coast et al (2), (BMJ of Dec 17th), was due to its failure to attract enough patients to make it economic. This was based in part on their requirement that all GP referrals were sent to hospital and the consultant deciding who could be seen by a GPSI in the community. Two doctors saw 354 new patients in 14 months, three a week each and it took 70 days for the patient to be seen. If you are looking for a service to fail then this is a good model! A proper community based skin service relies on accuracy, speed and a rapid reply to the referring GP, as well as being embedded in the community. I set up such a service in Ealing in 2000, after passing the DPD, being a clinical assistant and doing a skin surgery course. It was fully accredited by the BAD and had the support of the local dermatologists. Local GPs referred patients directly to me by fax. I did three, three hour clinics, a fortnight. In the 14 month period of the article I saw 658 new patients and 498 follow ups myself, a total of 1156 consultations. I typed the replies and faxed the letter to the GP that night. I saw patients within 2.5 weeks, had a DNA rate of 5% and referred 3% to hospital. I also did over 100 minor operations. I had no administrative or nursing support at any time, but had a typist for 6 months in the 4+ years the service ran. My costs were about £10 per patient (£155 a clinic), £80 per operation, £30 a week to type all the clinic letters (up to 25), and minimal costs to rent rooms. The total cost was about £27000 for 1156 patients, £23.35 a patient, about a tenth of the costs in the Salisbury model (£207.91) and about a fifth of the consultant costs. The articles by Salisbury and Coast paint a very different picture to the work most GPwSIs do, as well as the costs pertaining to such a service. The conclusions of the articles are suspect; the reality is entirely different. Neil Crowley MRCGP, DPD GPwSI in dermatology, Ealing 2000-2005 1. Evaluation of a general practitioner with special interest service for dermatology: randomised, controlled trial Salisbury et al BMJ 2005;331:1441-4 2. Economic evaluation of a general practitioner with special interest led dermatology service in primary care Coast et al BMJ 2005;331:1444-8 Competing interests: I was a GPwSI in Ealing until I resigned in March 2005. I am a member of the PCDS. |
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Simon F Cooper, GP principal and GPSI Dermatology Theatre Royal Surgery, Theatre Street, Dereham NR19 2QG
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EDITOR- Professor Salisbury et al have provided evidence that general practitioner with special interest (GPSI) community dermatology is accessible, well liked by patients and effective. This comes as no surprise to those of us working in the GPSI dermatology service. However, I was unable to understand how Joanna Coast et al found it to be nearly twice as expensive for the NHS as hospital outpatient care. I cannot refute the findings of this particular study, as the paper is impenetrable to all but health economists; however, I think it important to point out that GPSI dermatology posts are not all the same. I work for Norwich and South Norfolk Primary Care Trusts (PCTs) in two separate clinics. Not only do the doctors have a list, but the specialist dermatology nurse has her own clinic running concurrently. She is able to treat a number of dermatological conditions within a limited list and with the support of her medical colleagues. Norwich PCT is confident that significant savings are being made through the appropriate use of a GPSI service. My remit, apart from the clinical dermatology service, is to teach undergraduates at University of East Anglia medical school both in the university and in the community clinics and to provide feedback sessions to my general practitioner colleagues. Recently negotiations started with a nascent practice based commissioning group to provide teaching sessions directly to their general practitioners. A value added part of GPSI dermatology delivered in the community is the relationship achieved with local general practitioners and medical students. While it is too early to say whether this relationship will have a beneficial effect on inappropriate referrals, it is unreasonable to use ‘economic evaluation’ of a single GPSI model as a stick to beat us all with. Simon Cooper
Competing interests: None declared |
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Henry Mintz, GPsSI/GP Soho Centre for Health and Care W1
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I work as a freestanding GPwSI in central London with links to my local hospital dermatology clinic. Local GPs refer to me directly using a set of referral criteria. My costs are less than that of my local hospital. Clearly there are a number of different models of service provision with differing outcomes and costs. This will all be effectively thrown to the wind in 2006 with the advent of Practice Based Commissioning (PBC)where GPs or groups of GPs will be able to purchase dermatology services from within their own GP cluster or from a PCT employed GPwSIs. Under these new arrangements GPwSIs working outside the secondary sector may be able to undercut the secondary sector substantially since they will have the freedom to fix their own prices. The hospitals (somewhat unfairly in my opinion) will have their tariffs fixed nationally. Additionally GPwSI working in the community under PBC are more likely to be paid a sessional rate. Even with all the other on-costs a GPwSI working in Primary Care who sees 15 new patients and is paid (say) £300 is likely to be cheaper than an SHO who sees 15 new patients at £100 a go (approximately)I believe the argument about who is the more expensive will probably then become irrelevant. Of more concern will be what do we want GPwSIs in dermatology to do? Competing interests: I am a GPwSI in dermatology |
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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GPwSIs may be good and effective but in a full cost analysis, you also need to factor in the loss of that GP to the general practice service while he is doing his special interest. That puts more pressure on his colleagues. In addition, if the service is additional to existing services then costs soar. Competing interests: None declared |
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Nefyn H Williams, Clinical Senior Lecturer North Wales Clinical School, Department of General Practice, Cardiff University, Wrecsam
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Dear Editor The randomized controlled trial of a general practitioner with a special interest (GPwSI) for dermatology is a very thorough evaluation of the costs and benefits of a service accepting referrals from primary care.1,2 However, such trials can only measure part of the benefit. Most GPwSIs spend one or two sessions per week in their specialist clinic, but for the remainder of their time they use their skills on their own practice populations.3 Their GP partners will refer problems to them in-house, reducing the need for secondary care referrals, and also addressing unmet need. The experience of Kaiser-Permanente has taught us that to enhance care, we need to address the primary/secondary care divide, which is such a feature of the NHS in the UK.4 GPwSIs are one method of increasing the skills available for managing chronic illness within primary care. Trials which use secondary care referral as their entry criterion cannot address the appropriateness of the referral, and only measure the benefit of the special interest part of the GPwSI concept, and not its larger primary care component. Perhaps what is needed as a follow-up to such trials is a phase IV study5 across a whole primary care organization to give a comprehensive evaluation of the total care provided by GPwSIs. Nefyn H Williams
References 1 Salisbury C, Noble A, Horrocks S, Crosby Z, Harrison V, Coast J, de Berker D, Peters T. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ 2005; 331: 1441-4. 2 Coast J, Noble S, Noble A, Horrocks S, Asim O, Peters TJ, Salisbury C. Economic evaluation of a general practitioner with special interest led dermatology service in primary care. BMJ 2005; 331: 1444-8. 3 Jones R, Bartholomew J. General practitioners with a special clinical interest: a cross-sectional survey. Br J Gen Pract 2002; 52: 833-4. 4 Light D, Dixon M. Making the NHS more like Kaiser Permanente. BMJ 2004; 328: 763-5. 5 Campbell M, Fitzpatrick R, Haines A, Kinmouth AL, Sandercock P, Spieghalter D, Tyrer P. Framework for design and evaluation of complex interventions to improve health. BMJ 2000; 321: 694-6. Competing interests: I have a contract with Conwy LHB to provide an enhanced musculoskeletal & osteopathy service for patients registered in my general medical practice |
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Nicholas H Brown, GP Chippenham SN15 2SB
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The economic evaluation of a General Practitioner with Specialised Interest led Dermatology Service in Primary Care described in this paper reassures us that the clinical outcomes of and patients access to this service are equivalent or superior to a hospital based service but warns us that the costs are 75% higher primarily due to the higher salary cost of a General Practitioner compared to the mixed Consultant/Junior Staff cost. This comes of no surprise to those of us who have seen GP Clinical Assistants working in Hospital being undervalued and under-paid for many years, earning less than they are paying their locums during their absence from their practices. However what this paper fails to recognise is that in the current, politically driven, NHS framework of 'payment by results',there is an inflexible £264 cost for every NHS Hospital Dermatology Outpatient Episode, which at a Provider cost of £118 looks very poor value for money, whereas if a GPWSI can offer the equivalent or better service as an independant provider for £208, the NHS Commissioners will save money. There are plenty of GPWSIs queuing up to provide this type of service and there are plenty of Commissioners who will be wanting to save money in this way. Presumeably this will result in more NHS trusts struggling to balance their books as 'The Cherries are picked'. Competing interests: None declared |
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john sharvill, GP Deal kent ct14 7au
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In our practice the data from the pct confirm that we have below average referrals in those specialities that partners have special interests in . One could say that the nhs gets an enhanced level of care for nothing- this is exactly what the new practice based comissioning is hoping to tap into.These 'free' consultations are not included in the costings. It seems somewhat impossible to work out true marginal costs of any proceedure in the NHS when the huge infrastrucure needed for training and 24 hour care has to be paid for in some way. Competing interests: None declared |
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Chris Salisbury, Professor of Primary Health Care University of Bristol, Cotham House, Cotham Hill, Bristol BS6 6JL, Jo Coast, Tim Peters, David de Berker
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We are grateful for the responses to our randomised trial(1) and economic evaluation(2) of a general practitioner with special interest (GPSI) scheme in dermatology. Several correspondents argue that it is important not to generalise from this particular scheme in Bristol. We agree, and indeed made this point ourselves, but it is now up to others to assess whether similar findings are obtained elsewhere using similarly rigorous methods. Although some respondents believe that their own GPSI schemes are less costly, this may because some costs are not being accounted for or are being paid from other budgets. In estimating the cost of a GPSI consultation it is important to include all relevant costs as we did, such as training, salary overheads, administration, consultant support, premises costs and nurse support. Annual totals for these items should be divided by the number of consultations completed, rather than simplistic calculations which assume that clinicians spend all their time in direct patient contact. Furthermore our economic evaluation included the cost to the NHS over 9 months, including reconsultations, investigations, treatment, medication and primary care costs, not all of which are included in the Payment by Results Tariff. A national survey of GPSIs in dermatology suggests that those in Bristol are paid at the lower end of the national range, therefore GPSI schemes may be even more expensive elsewhere (Sue Jackson, Broadgreen Hospital, Liverpool, personal communication). Other correspondents discussed our choice of outcome measures for this study. We have addressed this in our rapid response to the companion paper.(1) (1) Salisbury C, Noble A, Horrocks S, Crosby Z, Harrison V, Coast C, et al. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ 2005;331: 1441-6. (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: 1444-9. Competing interests: None declared |
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