The Government is looking at expanding GPwSI services in its plan to move patient care closer to home. Dr Gerard Panting discusses the issues GPs need to consider
The White Paper Our Health, Our Care, Our Say: a new direction for community services, published in January 2006, outlines the Government's plans for shifting certain healthcare services into the community.1
Over the next year the Department of Health will be looking at different models for providing care closer to home in six specialties: ENT, trauma and orthopaedics, dermatology, urology, gynaecology and general surgery. One of the models of care being examined is services provided by GPs with special interests (GPwSIs).
The NHS plan, published in 2000, stated that by 2004 "...up to 1000 specialist GPs will be taking referrals in specialties such as ophthalmology, orthopaedics, dermatology and ear nose and throat surgery. They will also be able to undertake diagnostic procedures such as endoscopy."2
In fact the NHS met and exceeded the 1000 specialist GPs target a year early, with the Department of Health reporting in August 2003 that 1250 GPwSIs were in place. By 2004, that figure had risen to 4500.The DH said this meant that "more patients can be treated for complaints in specialist areas without having to visit a consultant in hospital, offering improved access and healthcare, often nearer their homes."3
The Department went on to give two examples of services that were already up and running:
- In the Bradford South and West area, where GPwSIs provided a range of services including neurology, rheumatology and ophthalmology - waiting times for all specialties were less than 13 weeks, and between 2002 and 2003 almost 11,000 patients were seen.
- At the Wallasey Heart Centre, Merseyside, a specialist GP in cardiology was performing twice-weekly patient assessments. Waiting times were reduced from 6 months to 6 weeks.
Setting up a GPwSI-led service
The Government's concept of GPwSIs is of GPs spending a couple of sessions a week providing services to meet defined specialist needs of local PCTs, but without offering a full consultant service, and therefore not interfering with access to consultants by other local GPs.
Now with more than 4500 GPwSIs offering specialist services many PCTs publish detailed requirements for GPs wanting to provide such services, setting out the aims of the service, how it will operate in practice and the conditions to be treated. They also produce an outline of what is needed, eligibility criteria, expected CPD activity, standards of equipment and premises as well as auditing and monitoring procedures.
It is up to the PCT to ensure that the GP has the necessary credentials for the role, which might include a postgraduate qualification or appropriate experience, and that the practitioner possesses the core competencies required for the role and undertakes suitable continuing training.
Guidelines for appointing GPwSIs have been developed with the RCGP for a range of conditions including coronary heart disease, child protection, dermatology, drug misuse, echocardiology, emergency care, ENT, epilepsy, headaches, intermediate and continuing care for older people, mental health, palliative care, respiratory disease and sexual health.3
And 'Practitioners with special interests. A Step by Step Guide to setting up a general practitioner with a special interest (GPwSI) service' published by the NHS Modernisation Agency,4 guides PCTs through the essential stages in establishing these services in primary care.
Standards of care
GPwSIs, just like any other GP, are accountable to their PCT, the GMC and the courts for the clinical care they provide. In responding to criticisms from any quarter, the central issue is likely to be the standard of care provided, including the systems in place to deliver care.
In clinical negligence claims it is the Bolam Test, which is used to distinguish between adequate and inadequate care: 'A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art even though a body of adverse opinion also exists amongst medical men.'5
In other words, the defence depends upon peer review and support. PCTs and the GMC will also rely heavily on expert evidence when assessing the quality of care provided.
But when it comes to GPwSIs, who do you rely on to provide that objective expert view? Should it be fellow GPs, or other GPwSIs, or consultants in the relevant specialty?
The standard required of GPs, GPwSIs and consultants is the same. All doctors must recognise the limits of their own expertise and not stray beyond them. Unless a doctor has all the necessary knowledge, expertise, facilities and assistance to complete a procedure or treatment satisfactorily (including the ability to deal with reasonably foreseeable complications), he or she should not embark upon it in the first place.
As the GMC puts it in Good Medical Practice, 'In providing care you must recognise and work within the limits of your own professional competence.' 6
And the GMC goes on to say: 'If you have good reason to think that your ability to treat patients safely is seriously compromised by inadequate premises, equipment or other resources, you should put the matter right if that is possible. In all other cases, you should draw the matter to the attention of your trust or employing or contracting body. You should record your concerns and the steps you have taken to try to resolve them.'
Making the system work
So what do GPwSIs need to do before contracting to provide specialist services?
First there must be clarity about what is required, how it will be provided, and what the GPwSI and the PCT are each responsible for. All this should be fully documented.
Second, the relationship with the local consultant service must be agreed; for example, are referrals made directly to the GPwSI with the more difficult problems then referred on to the relevant consultant, or are referrals made to the consultant, who then delegates responsibility for some patients back to the GPwSI?
Whatever plan is adopted it must be agreed at the outset, committed to writing, reviewed at regular intervals and must cater for absences, emergencies and problem cases.
Training, assessment and ongoing CPD are other prerequisites of effective care. If the system is dysfunctional, the communication inadequate, back-up non-existent and there is no induction, assessment or ongoing training, untoward events can be expected as can subsequent criticism in the local press, at the PCT and perhaps also before the courts and the GMC.
In both primary and secondary care, guidelines on how clinical conditions and situations are to be managed are now commonplace, so unless there are compelling reasons for doing something different, the idea is that the guideline will be followed.
This should not be taken to mean that other treatments are automatically indefensible but does put the onus on a defendant doctor to justify the alternative treatment provided. Guidelines should therefore be discussed and agreed locally before implementation to ensure that they address adequately all relevant local factors.
Many GPs have had special clinical interests for years, offering a more comprehensive service for their patients and have gained a great deal of job satisfaction, without the formal recognition that goes with appointment as a GPwSI.
GPwSI services have the potential to improve the lot of patients and their doctors, provided that the service is properly planned and resourced and the expectations of all concerned are realistic.
Patients benefit from ready access to local expertise, thereby removing the need for longer waits and journeys to hospital appointments; doctors gain enhanced job satisfaction and increased self-esteem from the opportunity of specialist practice.
- Department of Health. Our Health, Our Care, Our Say: a new direction for community services. London: Department of Health, 2006.
- The Secretary of State for Health by Command of Her Majesty. The NHS plan: a plan for investment, a plan for reform. London: HMSO, 2000.
- Practitioners with Special Interest Team. Practitioners with special interests: A Step by Step Guide to setting up a general practitioner with a special interest (GPwSI) service. London: NHS Modernisation Agency, 2003.
- Bolan v Friern Hospital Management Committee (1957) 1 WLR 582.
- General Medical Council. Good Medical Practice. London: GMC, 2001.