Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Why are GPsWSIs necessary?
- Lynette A Stone CBE (19 December 2005)
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GPwSIs in dermatology: perspective from the NHS Modernisation Agency Action on Dermatology work
- Julia K Schofield, Susan MacDonald Hull (Pontefract General Infirmary), Sue Jackson (Broadgreen Hospital), Nick Evans (Director Action On Programmes to April 2005) (20 December 2005)
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General practitioners with special interests - cost is not always the driver
- John S Watts (29 December 2005)
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Warfarin control: paying more for a less safe service – is this really the way forward?
- NIGEL T O'CONNOR (7 August 2007)
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Lynette A Stone CBE, Chairman, Skin Care Campaign Hill House, Highgate Hill, London N19 5NA
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Editor Martin Rowlands defines General practitioners with a special interest as being general practitioners with special experience or training that enables them to take referrals which would normally be seen by specialists. That may be technically correct but it does beg the question as to whether patients with common, mild to moderate, non-urgent skin diseases need to be seen in secondary care at all and, if so, why. The answer, of course, lies in the paucity of dermatology training received by British GPs. Although between fifteen and twenty percent of a GP’s workload has to do with skin diseases, GPs on average receive only about six days training in dermatology. There is no requirement for them to pass an examination in dermatology in order to qualify, and the dermatology component of the post-graduate GP training course is sometimes referred to as the ‘derma-holiday’. There is strong anecdotal evidence to suggest that many GPs are as dismissive of skin diseases as the public at large. Presumably, that too stems from inadequate training. The consequence of all this is two-fold. Firstly, much skin disease that could and should be being treated is not or is, at best, being treated sub-optimally. Secondly, where GPs recognise the need for medical intervention – especially where possible skin lesions are concerned – there is massive over-referral to secondary care. Since the Royal Medical Colleges seem disinclined to prioritise dermatology in undergraduate and post-graduate medical training, the National Health Service should intervene. The NHS has a perfect right and a duty to the public to require that those it employs, on whatever sort of contract, are suitably trained. Were they to do that in respect of dermatology training for GPs, the need for GPwSIs would become very much more questionable. Competing interests: None declared |
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Julia K Schofield, Consultant Dermatologist, Clinical Lead Action on Dermatology (to April 2005) West Hertfordshire NHS Hospitals Trust AL3 5PN, Susan MacDonald Hull (Pontefract General Infirmary), Sue Jackson (Broadgreen Hospital), Nick Evans (Director Action On Programmes to April 2005)
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The articles and commentary critically evaluating the clinical outcomes and cost of providing dermatology GPwSI services are welcome.1,2,3 They confirm the preliminary, less formally evaluated, findings of the NHS Modernisation Agency Action on Dermatology (AoD) pilot sites. These showed that where GPwSI services were provided by experienced suitably trained clinicians, in the context of established integrated links with the local secondary dermatology department, clinical outcomes and patient satisfaction were good. Waiting times for access to the GPwSI service were significantly reduced compared with the local dermatology department4. There were however three other important pieces of work which came out of the AoD programme which are relevant in the context of the newly published studies.1,2 Firstly the AoD evidence showed that whilst waiting times for the GPwSI clinics were short, there was little impact on overall waiting times and referral rates to secondary care dermatology departments except in pilots where significant additional capacity was created. This was demonstrated best by comparing the West Hertfordshire pilot (population 250,000) with the Eastern Wakefield pilot (population 170,000). The former with one GPwSI clinic per week showed no impact on overall secondary care waiting times throughout the pilot period4. In contrast the Eastern Wakefield model, with ten GPwSI sessions per week, showed a reduction in secondary care referrals. These data suggest that to have a significant impact on access times and referral patterns several GPwSIs, creating significant increased capacity, will probably be needed across a health community. If the cost implications of Coast’s2 paper are replicable then developing sufficient GPwSI services to provide enough capacity to impact on dermatology waiting times may prove to be an expensive option for local commissioners. Secondly a survey of Dermatology GPwSIs completed by the AoD programme in 2004 showed that many of the important recommended standards in the Department of Health document entitled ‘Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical services, Dermatology.’ (Department of Health 2003) are not being met. Only a third of GPwSIs were working within the DH framework. About a quarter of respondents had less than 12 months secondary care Dermatology experience and only 5% were being funded to complete the recommended 15 hours per year of Dermatology Clinical Governance5. The Bristol group clearly were working within the DH framework and this may be reflected in the relatively high cost of the service. High quality care does not come cheaply. Thirdly, the AoD programme started to explore other additional potential models of service delivery across the primary secondary care interface. A survey in 2004 showed that a large number of Non Consultant Career Grade doctors (e.g. Associate Specialists, Staff grades and non GP Clinical Assistants) working in secondary care dermatology departments would be interested in the development of a new role working across primary and secondary care.6 These clinicians are often very experienced and are already linked to secondary care departments thereby facilitating audit and continuing professional development needs. Unlike GPs, the problems of obtaining and funding backfill locum costs are not relevant in this group of doctors. The results of this study concluded that, in addition to developing GPwSI services, the potential of this staff group should be maximised, in particular in developing ‘intermediate’ level service provision both in primary and secondary care. As clinicians we are constantly being reminded to practice using evidence based medicine. We are pleased to see these studies published that support the lessons learnt from the AoD work and hope that commissioning organisations will take note of the findings to facilitate evidence based commissioning. 1. Salisbury et al. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ 2005;331:1441-1444 2. Coast et al. Economic evaluation of a general practitioner with a special interest led dermatology service in primary care. BMJ 2005;331:1444-8 3. Roland M. Commentary: General practitioners with special interests-not a cheap option. BMJ 2005;331:1448-9 4. Schofield et al. General practitioners with a special interest in dermatology: results of a 12-month pilot project. Br J Dermatol 2004; 151 (suppl. 68):3 5. Schofield JK, Irvine A, Jackson S, Adlard TP, Gunn S, Evans N. General Practitioners with a Special Interest (GPwSI) in Dermatology: results of an audit against Department of Health (DH) guidance. Br J Dermatol 2005;153(suppl 1):0-1 6. Schofield JK, Irvine A, Jackson S, Adlard T, Gunn S, Evans N. Non Consultant Career Grade (NCCG) Doctors in Dermatology: a hidden resource. Br J Dermatol 2005;153(suppl 1): 46 Competing interests: Julia Schofield was National Clinical Lead for Action on Dermatology and also Clinical Lead for the West Hertfordshire Action on Dermatology pilot site. Susan MacDonald Hull was Clinical Lead for the Eastern Wakefield Action on Dermatology pilot site. Nick Evans was employed by the NHS Modernisation Agency as Programme Director for Action on Dermatology and subsequently all the Action on programmes. All three have received payment for their Action on Dermatology work and for presenting the results at various educational events. Julia Schofield was Chair of the BAD NCCG sub-committee 2003-2005 Sue Jackson is a member of British Association of Dermatologists Non-Consultant Career Grade (NCCG) sub committee and a member of the RCP NCCG Standing Committee |
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John S Watts, Locum Consultant Child & Adolescent Psychiatrist Lenworth Clinic, Ashford, Kent. TN23 0QE
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EDITOR - The recent articles on General practitioners with special interests (GPSI) (1,2,3) and the associated online responses seem to focus on cost and non-equivalence with specialists. However, other factors can also be relevent to the decision to employ GPSIs. I have been involved in the development of enhancements to an ADHD service, involving the recruitment of a part-time GPSI along with other staff. The choice to employ a GPSI was made partly due to the source of the funding, and partly due to recruitment issues. The primary care trust and the clinic staff jointly developed the job description and person specification, and were actively involved in the recruitment process. The GPSI will be employed by primary care, but will be responsible clinically to the consultant psychiatrist. The GPSI will see the patients in the clinic, and not (yet) in primary care. The service is due to start in 2006, so I have no experiences to share as yet, but feedback will be sought from service users (referrers and families), and activity levels will also be measured. References: 1. Salisbury C, Noble A, Horrocks S, Crosby Z, Harrison V, Coast J, et al. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ 2005; 331:1441-4 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. Roland M. Commentary: General practitioners with special interests -not a cheap option. BMJ 2005;331:1448-9 Competing interests: None declared |
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NIGEL T O'CONNOR, Consultant Haematologist Shrewsbury and Telford Hospital SY3 8QR
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In 1974 our Hospital provided blood tests so that family doctors could advise on Warfarin dosing and date of next test. The newly appointed Haematologist was so appalled at the number of patients admitted bleeding with an unacceptably high INR he instituted a hospital-based advice service which has continued to date. Blood samples are taken in the community and sent in on a routine transport for testing, then dosage advice is posted or telephoned to the patient. There are 6,198 patients on Warfarin – from a catchment population of 500,000. Over the last 18 months Government policy has been directed to providing care away from hospital, as it is “closer to the patient”. In early July 2006, one of the general practices we serve unilaterally took back the care of ”patients who were stable on Warfarin”, although our service was asked to keep patients who were being induced or were difficult to control and to step in if a problem developed. The driver for this change was a fee to the practice of £128 per patient per year compared to the average hospital cost of £47 (7.13 INRs @ £3.79 each and dosage advice for the year @ £20). I expressed grave doubts about this change because of potential problems occurring when patients were transferred between primary and secondary care and confusion which might occur about who was responsible for providing dosage advice at a particular time. There is also the fact that Hospital laboratories are accredited, take part in frequent quality assurance schemes and that hospital “warfarin nurses” have expertise. The practice had 90 patients on Warfarin and they began to take over their care, although within 4 weeks some had requested transfer back to our service because their blood tests were being carried out more frequently than before. More worryingly by the end of 7 weeks, I had evidence of 3 clinical errors from this practice: 2 patients had an INR of >8. Since 2001 we have recorded every occasion when an INR is >8 as well as the reason for this, so we were able to compare error rates. Over the previous 20 months we logged an INR >8 on 147 occasions but only 9 of these were attributable to poor advice. Relative to patient numbers and time on treatment the practice error rate was 164 times higher. If this standard of care were rolled out across our whole Warfarin patient population, there would be 892 clinical errors per year compared to the current rate of less than 6. This error rate was difficult to defend and the practice agreed to discontinue testing. I am concerned that this transfer of service is being introduced across England with scant regard for the fact that Warfarin is a dangerous drug which kills patients and should be treated with respect. An established clinical care system should only be changed if there is a good reason to do so, and I propose a set of principles which should be followed - ranked in order of descending importance 1) Safety: a new clinical system should be at least as safe as the one it replaces 2) Quality of service: should be equivalent and not worse: for warfarin patients this would mean either better INR control or less frequent testing 3) Value for money: if there is no change to the safety or quality of service the bill for the local health economy should not increase. If all the Warfarin patients we supervise were to be transferred to the GPs, this would result in a financial penalty to our local health economy of £500,000 per year. If other hospitals across England levy similar charges, then implementing these changes nationally would divert some £50 million from patient care. Competing interests: None declared |
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