What next for accreditation of GPs with a special interest?BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1338 (Published 21 March 2013) Cite this as: BMJ 2013;346:f1338
Accreditation of GPwSI has improved services for patients, but with patchy adoption. As the bodies responsible for checking accreditation are closed down and competition among providers is opened up, Julia Schofield considers the future challenges
In 2000, the NHS Plan set out the first description of services provided by general practitioners with a special interest (GPwSI), and it provided a clear definition of the role.1 GPwSIs would be GPs who continued with their core role but with additional skills and knowledge in particular clinical areas. They would work unsupervised, usually in a community setting, and would take referrals from colleagues. Suitably trained GPwSIs, working as members of integrated consultant led clinical teams, provide services for specific patient groups, working in addition to specialists, but not replacing them.
Soon after the role was described, the Royal College of General Practitioners and the Department of Health decided that some form of accreditation would be necessary. Such accreditation was designed to ensure that the quality of care for a patient seen by a GPwSI would be the same as that provided by a specialist service.
Since 2003, generic and specialty specific guidance for GPwSIs has been published across 17 specialties.2 In 2005, an audit of the dermatology GPwSI framework showed a lack of knowledge about the Department of Health’s framework, and nearly half of the respondents had not completed the accreditation process. Around a quarter had no experience or less than one year’s experience in the specialty. Only one in 20 was meeting the required 15 hours a year continuing professional development quota, and only 25% were attending dermatology clinical governance and audit meetings.3 These results were particularly alarming for patient groups, who were concerned that GPwSIs were working beyond the scope of their expertise.
In 2007, the Department of Health published a suite of documents that outlined generic guidance for GPwSIs and were related to other reforms aiming to deliver care closer to home.45 This guidance set out clearly the requirements for accreditation by primary care trusts of GPwSIs and pharmacists with specialist interests, and of the facilities and people working within these services. The guidance was supported by a formal direction for primary care trusts to undertake this process, and this is where the current difficulty lies. Where this guidance has been implemented, it has improved the quality of GPwSI services.6
The restructuring of the NHS is now well under way, but there is no clear policy about who will manage future GPwSI accreditation when primary care trusts are dismantled in April 2013. Accreditation and three yearly reaccreditation have halted, and some GPwSIs are now practising without valid accreditation, with the obvious risks for patients and for service commissioners. There are also some specific issues relating to patients with skin cancer. Until this situation is resolved, skin cancer guidelines from the National Institute for Health and Clinical Excellence cannot be implemented and monitored where they apply to community management of skin cancers by GPwSIs.78 The lack of a rigorous framework risks a return to the situation uncovered in 2005, where patients could not be assured that GPwSIs had adequate experience to be managing their care.
Clinical commissioning groups
After April, the NHS is likely to use more GPwSI services, and so clarity about accreditation and quality assurance is important. Clinical commissioning groups are likely to commission GPwSI services, but they lack the independence of primary care trusts. There are concerns about a conflict of interest if clinical commissioning groups were responsible for accreditation, because they would be accrediting GPwSIs from whom they later buy services. Although the groups are responsible for checking that services they commission meet national quality standards, it would not be appropriate for them to accredit GPwSIs.
Logically, it would seem that responsibility for accrediting GPwSIs should sit with those responsible for ensuring the quality of primary care and the revalidation of GPs. This is something that falls to the National Commissioning Board’s 27 area teams (ATs), which have a wider focus. In the short term, a possible solution would be for the ATs to assume responsibility for accrediting GPwSIs. This would sit well with their agreed roles in providing clinical leadership, monitoring quality of services, and ensuring patient safety in primary care. It would also avoid conflicts of interest, because ATs are independent of clinical commissioning groups. There is the opportunity, in the medium to long term, for the responsibility to move to the Royal College of General Practitioners, working in partnership with specialty organisations but continuing to link to revalidation through the responsible officer of the AT.
The issue of which organisations will pick up GPwSI accreditation after primary care trusts are dismantled needs to be addressed urgently, as there will be considerable implications for patients if this is not resolved. For the first time since the role was described, there is an opportunity for accreditation to be sensibly organised with the involvement of ATs, the Royal College of General Practitioners, and specialty organisations.
Competing interests: None declared.