Re: From patient centred generalists to GPs with special interests: ‘You only live twice’ or…maybe once?
The thought-provoking editorial by Richards and colleagues1 urging us to deliver patient centred care provided the impetus for re-visiting the subject of medical specialization. Fifteen years ago, the UK government established general practitioners (GPs) with advanced training in specific health conditions such as respiratory diseases, headache, hypertension and minor surgery as GPs with special interests (GPwSIs) within the National Health System (NHS).2 Based on the premise that GPs would refer their patients to a local GPwSIs, instead of a secondary or tertiary care based specialist,3 the aim of this NHS policy was to improve management of chronic conditions and increase patients’ accessibility to specialist care 2, without tapping into more expensive and scarce secondary or tertiary resources. Other objectives included shortening long waiting-list times for consultant appointments and reducing referral costs.2 Despite justification, establishment of this new cadre of GPwSIs has been met with some skepticism in regards to individual patients and the population’s overall health improvement.4
Following implementation of this model, various studies have evaluated GPwSIs services for dermatology and neurology care.3,5 Although clinical outcomes when compared with routine outpatient care did not differ, patients with skin problems were slightly more satisfied with GpwSIs services and experienced shorter waiting times for their first consultation.3 Similarly, patients experiencing headache were more satisfied with GpwSIs service provision in terms of symptom relief.5 However, in regards to cost-effectiveness, GPwSIs were not found to be a less expensive alternative.6 Cost analysis of GPwSIs service for non-urgent dermatological problems found it to be 75% more expensive compared to care provided by a hospital clinic.7 Remarkably, GPwSIs service cost was a staggering £208 in contrast to the £118 calculated for outpatient hospital care.7 Taking into consideration the national baseline fee for dermatology outpatients, the mean cost of specialist care was calculated at £127 per patient compared with £182 for the GPwSIs.7 Differences in the provision of care as well as multiple follow-up appointments for patients attending GPwSIs could partially explain these cost variations. 3
Greece is one of the Eurozone countries that have been severely affected by the ongoing financial crisis. Since 2010, the Greek government has adopted a series of austerity measures which reduced significantly the total health and social welfare expenditures. As a result, accessibility of the general public to health care and preventive services appears to be seriously compromised.8 In this context, implementation of a fully integrated primary care system is more essential than ever to avoid further collapse of the country’s social and health service system. 9 Greece has a lot to learn from countries such as the UK that have operationalized a general practice driven system for decades.10 However, given that Greek GPs are still far out-numbered by specialists, a national GP service network is unattainable at present. Accounting for only 2.8% of the total physician workforce, there is an average rate of 0.2% primary healthcare physicians per 1000 inhabitants.11 Most often, quasi primary care services are provided by specialists such as internists, cardiologists pulmonologists, dermatologists, neurologists and others in their private practices. Thus, the viability of the GPwSIs option in the current environment is questionable.
A number of obstacles hinder implementation of the GPwSIs initiative in Greece. First, there is no nation-wide general practice population coverage. Patients in urban centers are more prone to visit emergency departments or private specialists than a GP, even for common problems. Hence, it would be unlikely to choose a GPwSIs for a more complex condition. Second, there is lack of established health system networking whereas health expenditure is severely curtailed. Third, general practice positions in academia are scarce, minimizing the potential for broad visibility and acknowledgment by the general public. Literature suggests that possession of non-specific ‘soft’ medical knowledge and generalist attitudes are elements that contribute to less prestige.12 GPs often feel the need to be recognized as experts and regain some prestige in their careers. However, given the circumstances, the Greek health system is unlikely to secure, much less certify, a systematic, comprehensive and uniformly structured educational framework for GPs desiring a special interest qualification. Fourth, funding limitations make the commissioning process of specialist services by GPs considerably less feasible and viable. All three forms of payment encountered in developed countries, namely capitation, salary and fee-of-service 4, require payment for a service that may not be the sole one in the chain of health seeking behavior and delivery care options. Last, outpatient clinics of hospitals operated by academics and specialists offer the choice of privately paid specialty care services at competitive rates. This option potentially increases access for those who can pay out-of-pocket fees and could explain Greece’s limited demand for GPwSIs services.
Establishing a fully operating primary care network is a high priority, requiring many more generalists than specialist doctors as well as doubling the number of practice nurses. Claiming one of the highest ratios of physicians per 100,000 inhabitants in the EU, combined with one of the lowest ratios of nurses, the emphasis on curative services comes as no surprise, whereas health promotion, disease prevention, rehabilitation and home care services are on the sideline.9 The rising number of patients with multi-morbidities and complex, deteriorating socio-economic circumstances makes the bio-psycho-social model of care a promising approach.13 Stepping forward to satisfy holistic health needs in conditions of limited funding capacity is a major challenge. Patient centred care has been shown to improve quality while promoting appropriate use of health care services.14 On the other hand, health care delivery by GPwSIs appears to address patient needs in a fragmented way, since this option shifts general practice’s focus from the person to the disease-stricken system, adopting a biological rather than a bio-psycho-social model of care.4,15 Under this perspective, although GPwSIs seem to have found their ‘place’ in countries with an evolved primary care system, it would be premature to invest into this model in countries undergoing extreme economic hardships with a general practice field still experiencing growing pains and no luxury of ‘living twice’.
No competing interests
“We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.”
References
1. Richards T, Coulter A, Wicks P. Time to deliver patient centred care. BMJ. 2015 Feb 10;350: h530. doi: 10.1136/bmj.h530.
2. Department of Health (2000) The NHS plan: a plan for investment, a plan for reform (HMSO, London).
3. Salisbury C, Noble A, Horrocks S et al. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ. 2005 Dec 17;331(7530):1441-6.
4. Gérvas J, Starfield B, Violán C, Minué S. GPs with special interests: unanswered questions. Br J Gen Pract. 2007 Nov;57(544):912-7.
5. Ridsdale L, Doherty J, McCrone P, Seed P; Headache Innovation and Evaluation Group. A new GP with special interest headache service: observational study. Br J Gen Pract. 2008 Jul;58(552):478-83.
6. Roland M. General practitioners with special interests--not a cheap option. BMJ. 2005 Dec 17;331(7530):1448-9.
7. Coast J, Noble S, Noble A, et al. Economic evaluation of a general practitioner with special interests led dermatology service in primary care. BMJ. 2005 Dec 17;331(7530):1444-9.
8. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011 Oct 22; 378(9801):1457-8.
9. Lionis C, Symvoulakis E, Markaki A, et al. Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. International Journal of Integrated Care 2009, 9:1-14.
10. Kousoulis AA, Symvoulakis EK, Lionis C. What Greece can learn from UK primary care experience and empirical research. Br J Gen Pract. 2012 Oct; 62 (603): 543.
11. Greek National Statistical Service. Physicians by specialty and dentists, by geographic region and prefecture: 2009. http://www.statistics.gr/portal/page/portal/ESYE/BUCKET/A2103/Other/A210...
12. Stein HF. Family medicine’s identity: being generalists in a special culture? Ann Fam Med 2006; 4 (5):455-459.
13. Eaton S, Roberts S, Turner T. Delivering person centred care in long term conditions. BMJ 2015;350:h181.
14. Stacey D, Légaré F, Col NF, Bebbett CL, Eden KB, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014 Jan 28;1:CD001431.
15. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196(4286): 129–136
.
Rapid Response:
Re: From patient centred generalists to GPs with special interests: ‘You only live twice’ or…maybe once?
The thought-provoking editorial by Richards and colleagues1 urging us to deliver patient centred care provided the impetus for re-visiting the subject of medical specialization. Fifteen years ago, the UK government established general practitioners (GPs) with advanced training in specific health conditions such as respiratory diseases, headache, hypertension and minor surgery as GPs with special interests (GPwSIs) within the National Health System (NHS).2 Based on the premise that GPs would refer their patients to a local GPwSIs, instead of a secondary or tertiary care based specialist,3 the aim of this NHS policy was to improve management of chronic conditions and increase patients’ accessibility to specialist care 2, without tapping into more expensive and scarce secondary or tertiary resources. Other objectives included shortening long waiting-list times for consultant appointments and reducing referral costs.2 Despite justification, establishment of this new cadre of GPwSIs has been met with some skepticism in regards to individual patients and the population’s overall health improvement.4
Following implementation of this model, various studies have evaluated GPwSIs services for dermatology and neurology care.3,5 Although clinical outcomes when compared with routine outpatient care did not differ, patients with skin problems were slightly more satisfied with GpwSIs services and experienced shorter waiting times for their first consultation.3 Similarly, patients experiencing headache were more satisfied with GpwSIs service provision in terms of symptom relief.5 However, in regards to cost-effectiveness, GPwSIs were not found to be a less expensive alternative.6 Cost analysis of GPwSIs service for non-urgent dermatological problems found it to be 75% more expensive compared to care provided by a hospital clinic.7 Remarkably, GPwSIs service cost was a staggering £208 in contrast to the £118 calculated for outpatient hospital care.7 Taking into consideration the national baseline fee for dermatology outpatients, the mean cost of specialist care was calculated at £127 per patient compared with £182 for the GPwSIs.7 Differences in the provision of care as well as multiple follow-up appointments for patients attending GPwSIs could partially explain these cost variations. 3
Greece is one of the Eurozone countries that have been severely affected by the ongoing financial crisis. Since 2010, the Greek government has adopted a series of austerity measures which reduced significantly the total health and social welfare expenditures. As a result, accessibility of the general public to health care and preventive services appears to be seriously compromised.8 In this context, implementation of a fully integrated primary care system is more essential than ever to avoid further collapse of the country’s social and health service system. 9 Greece has a lot to learn from countries such as the UK that have operationalized a general practice driven system for decades.10 However, given that Greek GPs are still far out-numbered by specialists, a national GP service network is unattainable at present. Accounting for only 2.8% of the total physician workforce, there is an average rate of 0.2% primary healthcare physicians per 1000 inhabitants.11 Most often, quasi primary care services are provided by specialists such as internists, cardiologists pulmonologists, dermatologists, neurologists and others in their private practices. Thus, the viability of the GPwSIs option in the current environment is questionable.
A number of obstacles hinder implementation of the GPwSIs initiative in Greece. First, there is no nation-wide general practice population coverage. Patients in urban centers are more prone to visit emergency departments or private specialists than a GP, even for common problems. Hence, it would be unlikely to choose a GPwSIs for a more complex condition. Second, there is lack of established health system networking whereas health expenditure is severely curtailed. Third, general practice positions in academia are scarce, minimizing the potential for broad visibility and acknowledgment by the general public. Literature suggests that possession of non-specific ‘soft’ medical knowledge and generalist attitudes are elements that contribute to less prestige.12 GPs often feel the need to be recognized as experts and regain some prestige in their careers. However, given the circumstances, the Greek health system is unlikely to secure, much less certify, a systematic, comprehensive and uniformly structured educational framework for GPs desiring a special interest qualification. Fourth, funding limitations make the commissioning process of specialist services by GPs considerably less feasible and viable. All three forms of payment encountered in developed countries, namely capitation, salary and fee-of-service 4, require payment for a service that may not be the sole one in the chain of health seeking behavior and delivery care options. Last, outpatient clinics of hospitals operated by academics and specialists offer the choice of privately paid specialty care services at competitive rates. This option potentially increases access for those who can pay out-of-pocket fees and could explain Greece’s limited demand for GPwSIs services.
Establishing a fully operating primary care network is a high priority, requiring many more generalists than specialist doctors as well as doubling the number of practice nurses. Claiming one of the highest ratios of physicians per 100,000 inhabitants in the EU, combined with one of the lowest ratios of nurses, the emphasis on curative services comes as no surprise, whereas health promotion, disease prevention, rehabilitation and home care services are on the sideline.9 The rising number of patients with multi-morbidities and complex, deteriorating socio-economic circumstances makes the bio-psycho-social model of care a promising approach.13 Stepping forward to satisfy holistic health needs in conditions of limited funding capacity is a major challenge. Patient centred care has been shown to improve quality while promoting appropriate use of health care services.14 On the other hand, health care delivery by GPwSIs appears to address patient needs in a fragmented way, since this option shifts general practice’s focus from the person to the disease-stricken system, adopting a biological rather than a bio-psycho-social model of care.4,15 Under this perspective, although GPwSIs seem to have found their ‘place’ in countries with an evolved primary care system, it would be premature to invest into this model in countries undergoing extreme economic hardships with a general practice field still experiencing growing pains and no luxury of ‘living twice’.
No competing interests
“We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.”
References
1. Richards T, Coulter A, Wicks P. Time to deliver patient centred care. BMJ. 2015 Feb 10;350: h530. doi: 10.1136/bmj.h530.
2. Department of Health (2000) The NHS plan: a plan for investment, a plan for reform (HMSO, London).
3. Salisbury C, Noble A, Horrocks S et al. Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial. BMJ. 2005 Dec 17;331(7530):1441-6.
4. Gérvas J, Starfield B, Violán C, Minué S. GPs with special interests: unanswered questions. Br J Gen Pract. 2007 Nov;57(544):912-7.
5. Ridsdale L, Doherty J, McCrone P, Seed P; Headache Innovation and Evaluation Group. A new GP with special interest headache service: observational study. Br J Gen Pract. 2008 Jul;58(552):478-83.
6. Roland M. General practitioners with special interests--not a cheap option. BMJ. 2005 Dec 17;331(7530):1448-9.
7. Coast J, Noble S, Noble A, et al. Economic evaluation of a general practitioner with special interests led dermatology service in primary care. BMJ. 2005 Dec 17;331(7530):1444-9.
8. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011 Oct 22; 378(9801):1457-8.
9. Lionis C, Symvoulakis E, Markaki A, et al. Integrated primary health care in Greece, a missing issue in the current health policy agenda: a systematic review. International Journal of Integrated Care 2009, 9:1-14.
10. Kousoulis AA, Symvoulakis EK, Lionis C. What Greece can learn from UK primary care experience and empirical research. Br J Gen Pract. 2012 Oct; 62 (603): 543.
11. Greek National Statistical Service. Physicians by specialty and dentists, by geographic region and prefecture: 2009.
http://www.statistics.gr/portal/page/portal/ESYE/BUCKET/A2103/Other/A210...
12. Stein HF. Family medicine’s identity: being generalists in a special culture? Ann Fam Med 2006; 4 (5):455-459.
13. Eaton S, Roberts S, Turner T. Delivering person centred care in long term conditions. BMJ 2015;350:h181.
14. Stacey D, Légaré F, Col NF, Bebbett CL, Eden KB, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014 Jan 28;1:CD001431.
15. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196(4286): 129–136
.
Competing interests: No competing interests