Intended for healthcare professionals

Letters

Outreach clinics in general practice

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6945.1714a (Published 25 June 1994) Cite this as: BMJ 1994;308:1714
  1. J A Dunbar,
  2. D S Vincent,
  3. J N Meikle,
  4. A P Dunbar,
  5. P A Jones

    EDITOR, - The medical press has widely reported that outreach clinics do not seem to have improved communication between general practitioners and specialists. In the case of fundholding practices this conclusion cannot be drawn from the paper by Jacqueline Bailey and colleagues, who measured only how often general practitioners attended outreach clinics.1 There are many more efficient ways of communicating and learning than attending clinics. In my practice, which has five in house clinics, specialists discuss their cases over a working lunch attended by all partners and the practice's clinic nurse. We think that communications have improved greatly.

    Bailey and colleagues state that fundholders had initiated their clinics. Presumably they arranged to communicate with specialists at other times. In the table showing the advantages to fundholders of outreach clinics, communication with specialists was mentioned most commonly and educational value was second. The outreach clinics have probably led to improved communications, but the authors' assessment based solely on general practitioners' attendance failed to show this.

    A further weakness of the paper is that it compares the incomparable. The result is meaningless. Outreach clinics set up in health centres during the 1970s largely by psychiatrists are simply collocations of services. They cannot be compared with in house clinics set up recently for other specialties in fundholding practices. In house clinics have resulted in better use of resources by improving the accuracy of referral and reducing unnecessary review. The clinics are popular with patients, who find them convenient and like the familiar setting. In our experience they lead to improved communications and better clinical management.

    Studies such as Bailey and colleagues' are of limited value. What matters are the maximum achievable benefits of outreach clinics. Once the benefits and how to achieve them are understood, outreach and in house clinics will become widespread.

    References

    Authors' reply

    1. J Bailey,
    2. M Black,
    3. D Wilkin

      EDITOR, - Though we have no doubts that some outreach clinics have resulted in improved communication between general practitioners and specialists, the findings of our national survey do not suggest that such benefits are widespread. We illustrated this by reference to the fact that general practitioners rarely attended clinics. Other evidence from our study, not included in the original paper, supports our general conclusion. Forty six (79%) fundholders and 25 (91%) non-fundholders did not have regular meetings with specialists. James A Dunbar and colleagues' observation that many fundholding practices had initiated outreach clinics has no necessary bearing on subsequent levels of communication. Though it is true that many general practitioners and specialists identified communication as a potential benefit of outreach clinics, a gap seems to exist between aims and reality.

      Dunbar and colleagues' objection to our inclusion of clinics established before 1990, on the grounds that they consisted largely of psychiatric clinics established for reasons of collocation of services, is not supported by the evidence. Firstly, many clinics in psychiatry have been established with the explicit objective of improving liaison with general practitioners.1 Secondly, we found that 21 of the 45 clinics established before 1990 were in medical and surgical specialties.

      Unfortunately, there is no evidence to support Dunbar and colleagues' assertion that outreach clinics result in better use of resources through improved referral, the reduction of unnecessary review, and better clinical management. In our study 35 (61%) fundholders and 25 (90%) non-fundholders reported that there had been no effect on numbers or types of referrals and 17 (29%) fundholders reported an increase. Only eight (11%) specialists reported that they received more appropriate referrals. Twenty six (94%) non-fundholders and 38 (65%) fundholders reported that there had been no effect on follow up.

      Dunbar and colleagues fail to acknowledge the potential problems associated with outreach clinics, including use of specialists' time, access to investigation and treatment facilities, and the provision of hospital cover.

      In the light of our results it would be unwise to emphasise the maximum achievable benefits as Dunbar and colleagues suggest. Outreach clinics are becoming widespread, but there is limited evidence of what the potential benefits are and even less of how to achieve them. Despite its limitations our study of the current spread of outreach clinics and the views of the general practitioners and specialists concerned provides a powerful case for further research to establish the clinics' cost effectiveness. Without such evidence the continuing debate between the proponents of outreach clinics and their detractors is unlikely to be resolved.

      References

      Need proper evaluation

      1. S Weich

        EDITOR, - Though highly thought provoking, the survey of specialist outreach clinics in general practice reported by Jacqueline J Bailey and colleagues was potentially misleading.1 In particular, it seems entirely wrong to conclude that “there was little direct contact between general practitioners and specialists” simply on the grounds that only 6% of general practitioners attended the specialist clinics. It was also unfortunate that different specialties were lumped together, as satisfaction with services may have varied greatly.

        The description of such services as “outreach clinics” implies a rigid and hierarchical relation between primary and secondary services and emphasises geographical rather than conceptual change. In psychiatry, where even attending an outpatient department may be stigmatising, it is recognised that the essence of any primary care attachment is liaison between professionals. While it is unlikely that a busy general practitioner would have time to attend a specialist clinic, the survey may well have overlooked the frequent but informal sort of patient centred liaison which allows general practitioners to provide continuing care for their patients, rather than handing over this responsibility to a specialist. That 40% of clinics were unknown to hospital managers suggests that many attachments may have arisen through informal negotiation between general practitioners and specialists.

        Andrew Harris is absolutely right to call for proper evaluation of specialist attachments in primary care,2 particularly in view of the resource implications of unrestrained growth.3 The introduction of fundholding means that general practitioners no longer depend on local specialists to provide services they feel their patients need. There is now an urgent need for rigorous cost effectiveness studies of specific interventions to allow general practitioners to make informed purchasing decisions.

        References

        Have educational value

        1. D MacMahon,
        2. A Roberts

          EDITOR, - We have been providing one variant of specialist outreach clinics for more than 10 years.1,2 Our joint quarterly clinic developed out of the pragmatic need to save patients (many, but not all, of whom are elderly or disabled) the need to make a 40 km round trip to use hospital services from this rural practice. The patients best served are those who need predominantly clinical skills, with only a minor technological input. We have found that patients with diabetes, Parkinson's disease, and other common medical conditions can be assessed and monitored not only at their convenience but also to the advantage of both the general practitioner and hospital staff and their systems. Duplication of investigations is avoided, and onward referral for diagnostic or therapeutic facilities is planned and selectively deployed to retain as much care and treatment within primary care as possible.

          We think that both the paper1 and the editorial2 on specialist outreach clinics underestimate the clinics' educational value, which enables trainee general practitioners, junior medical staff, and medical students to see truly shared care. The general practitioner and consultant can discuss their ideas directly, and immediately. This has proved valuable to us both. For this to be possible, however, these clinics must be jointly held, with both the general practitioner and the consultant seeing patients together. This occurred in only a small minority of the clinics described by Bailey and colleagues.1 So much change has occurred in both primary and specialist care that cross fertilisation of ideas and practice, as occurs in such joint clinics, is of benefit to everyone in training and career posts. This is a major advantage, which not only sustains but extends the vision of cooperative care.

          References