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GENERAL PRACTITIONERS WITH SPECIAL INTERESTS

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GENERAL PRACTITIONERS WITH SPECIAL INTERESTS Powered By Docstoc
					       GENERAL PRACTITIONERS WITH SPECIAL
                   INTERESTS
                                     JANUARY 2006
                        THIS REPLACES THE VERSION DATED MARCH 2004


                            RCGP INFORMATION SHEET

This Information Sheet is copyright free, copies may be made as required.

DEFINITION

A GP with additional training and experience in a specific clinical area who takes referrals for the
assessment/treatment of patients (outside GMS/PMS) that may otherwise have been referred directly to a
secondary care consultant, or who provides an enhanced service for particular conditions or patient
groups. GPwSIs are generally appointed to meet the needs of a single PCT or group of PCTs, and typically
undertake two sessions per week in their specialty.


 The art of being a generalist is the key to any GP’s work, and special interests are fundamentally there to
 complement, not replace, the core work of family doctors. But there is little doubt that enthusiasm for a special
 interest is truly beneficial to morale, recruitment and retention, and most importantly, to patient care.

 Professor David Haslam, Former RCGP Chairman of Council



I. INTRODUCTION

The introduction of the General Practitioner with a Specialist Interest (GPwSI) programme in England
formally recognises the specialist skills that exist in primary care, and the need to harness that expertise
to address the growing challenges of chronic disease management in a community setting.

In Great Britain it has been estimated that 17.5 million adults live with long-term chronic disease, such
as diabetes, asthma, arthritis, heart failure, and COPD. WHO has stated that chronic conditions will be
the leading cause of disability throughout the world by the year 20201. In England two thirds of patients
admitted to hospital as medical emergencies have chronic diseases or exacerbations of chronic disease,
and patients with a chronic disease or complications represent over 60% of hospital bed days2.
Traditionally, however, health systems have evolved around the concept of acute, infectious disease - not
the demographic transition towards chronic conditions.

The GPwSI initiative represents part of a wider governmental drive to redesign NHS care around the
treatment of chronic conditions in community, rather than acute settings. Via the development of expert
services in the community, the Government aims to prevent the complications that can lead to the
hospitalisation of patients with long-term chronic problems. The reduction of hospital waiting lists in
areas such as ophthalmology, orthopaedics, dermatology, ear nose and throat surgery, and for specific
procedures such as endoscopy, is the desired and tangible outcome of such redesign.

Around 80% of GP consultations relate to the care of chronic disease; and therefore the formal
transference of more specialist care of chronic conditions to appropriately qualified and experienced
primary care practitioners would seem a logical step – not least as it provides the potential for better
continuity in patient care.


 In a health service that offers an increasing focus on long-term medical conditions, the role of the medical
 generalist is more and more important. Co-morbidities are increasingly common and ever more important.
 Fragmentation of care leads to a greater potential for adverse medication interactions and complications, and for
 duplication of investigation and referral.

 The Future of General Practice (RCGP, 2004)




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II. THE SPECIALISM OF FAMILY MEDICINE

General practice is a specialism and therefore, in essence, all GPs are specialists in a generalist discipline.
Although the formalised concept of the GPwSI is a relatively new development, GPs specialising in a
particular area of medicine or care have existed as long as general practice itself. Indeed, a 2002 article3
by Professor David Colin-Thome, National Clinical Director of Primary Care, estimated that 16% of GPs
had a clinical special interest in addition to their general practice work.

Traditionally, GPs who provided specialist services were most commonly accredited and remunerated
through Health Circular HSG (96) 31 - A National Framework for the Provision of Secondary Care within
General Practice4. This publication expressed – as long ago as 1996 - the intention to transfer some
chronic disease management from secondary to primary care; and provided formal guidance for
appropriately qualified GPs to perform certain secondary care procedures in primary care settings. Some
PCTs are still referring to this document for the purposes of audit and the accreditation of GPwSIs, whilst
others have developed their own criteria.

III. ORIGINS OF GPWSI POLICY

The NHS Plan5 (2000) set ambitious goals for developing and formalising the role of over 1,000 Specialist
GPs. The stated intention of the initiative would be to take pressure off secondary care, by minimising
hospital referrals and carrying out one million extra outpatient appointments in primary care by 2006.
Allied to the NHS Plan was the Department of Health (DH) initiative Shifting the Balance of Power – a
programme of organisational decentralisation which encouraged provisioning solutions within the local
healthcare economy – such as specialist GPs. The commitment to GPwSI was re-emphasised in
Improvement, Expansion and Reform: Priorities and Planning Framework 2003-2006 (2002) which stated
that by 2006 there would be an increase in: “activity taking place in primary and community settings to
contribute to the national assumption that at least one million more outpatient appointments (around
10%) take place in the community rather than in hospital.”

A 2001 joint paper6 by the RCGP and Royal College of Physicians argued that the term Specialist GP – as
used in the NHS Plan - implied that GPs were not already specialists in their own discipline. The paper
suggested that General Practitioners with a Special Interest (GPwSI) was a more appropriate term - a
title that has been generally adopted henceforth. The joint paper envisaged a wide scope of specialised
functions for GPwSIs, operating both within clinical care and outside of it. This included roles in:

    •   Specific clinical areas.
    •   Education (undergraduate teaching, vocational training and postgraduate education).
    •   Leadership in service provision and representative organisations.
    •   Research and academic general practice.
    •   Quality assurance (including examiners, mentors, appraisers and assessors).
    •   Management (for example in primary care organisations or in deaneries).
    •   Public health.

Produced in conjunction with the RCGP, the 2002 DH document Implementing a Scheme for General
Practitioners with Special Interests7 introduced a framework within which GPwSI schemes could be
developed by Primary Care Trusts (PCTs). PCTs would be responsible for establishing - using a Health
Assessment Model - which areas of clinical and non-clinical care would benefit from GPwSIs.

A further DH/RCGP publication - Guidelines for the Appointment of General Practitioners with Special
Interests with the Role of Service Development: generic model8 - was also developed for use by PCTs in
the event of their being no published guidelines for the appointment of a GPwSI in a particular clinical
area. These two documents established the following principles regarding any contract between a PCO
and GPwSIs:

•   The core activities and the competencies required.
•   The types of patients suitable for the service including age range, symptoms, severity, minimum
    caseload/frequency, and reasons for referral.
•   The facilities that must be present to deliver that service.
•   The clinical governance, accountability and monitoring arrangements, including links with others
    working in the same clinical area in primary care, at PCT level and in acute trusts.
•   The level of payment should be determined through discussion with key representative bodies but as
    a guide should be sufficient to fully replace that doctors time in practice.

Originally the National Primary and Care Trust and Development Programme (NatPaCT), part of the NHS
Modernisation Agency, was appointed lead body for co-ordinating the GPwSI programme. When it’s



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Practitioners with a Special Interest (PwSI) team was disbanded at the end of March 2005, this strand of
work passed to SHAs. The DH Wider Range of Services in Primary Care (WRS) programme now oversees
top-level development of the role of practitioners with special interests in primary care, and of primary
care facilities to accommodate these additional services.


 General practitioners with special interests supplement their important generalist role by delivering a high quality,
 improved access service to meet the needs of a single PCT or group of PCTs. They may deliver a clinical service
 beyond the normal scope of general practice, undertake advanced procedures, or develop services. They will work as
 partners in a managed service not under direct supervision, keeping within their competencies. They do not offer a
 full consultant service and will not replace consultants or interfere with access to consultants by local general
 practitioners.

 Implementing a Scheme for General Practitioners with Special Interests (RCGP/DH 2002)


IV. GENERIC AND SPECIFIC GUIDANCE
The RCGP has been commissioned by the DH to produce guidelines for the appointment of GPwSIs in a
variety of specific clinical areas – based upon the generic frameworks described previously. These
frameworks include detail on the scope of the service provided; evidence of required training/experience
to deliver the appropriate competencies; clinical governance arrangements; and the necessary facilities.
Completed frameworks, with links to the online documents, are listed in the table below:

 Care for Older People           http://www.dh.gov.uk/assetRoot/04/02/04/13/04020413.pdf
 Child Protection                http://www.dh.gov.uk/assetRoot/04/06/82/22/04068222.pdf
 CHD                             http://www.dh.gov.uk/assetRoot/04/02/03/45/04020345.pdf
 Dermatology                     http://www.dh.gov.uk/assetRoot/04/02/03/48/04020348.pdf
 Diabetes                        http://www.dh.gov.uk/assetRoot/04/06/60/16/04066016.pdf
 Drug Misuse                     http://www.dh.gov.uk/assetRoot/04/02/02/91/04020291.pdf
 Echocardiography                http://www.dh.gov.uk/assetRoot/04/02/03/52/04020352.pdf
 Emergency Care                  http://www.dh.gov.uk/assetRoot/04/05/06/05/04050605.pdf
 ENT                             http://www.dh.gov.uk/assetRoot/04/02/03/54/04020354.pdf
 Epilepsy                        http://www.dh.gov.uk/assetRoot/04/02/03/55/04020355.pdf
 Headaches                       http://www.dh.gov.uk/assetRoot/04/02/04/06/04020406.pdf
 Mental Health                   http://www.dh.gov.uk/assetRoot/04/02/03/72/04020372.pdf
 Musculoskeletal Conditions      http://www.dh.gov.uk/assetRoot/04/06/60/17/04066017.pdf
 Palliative Care                 http://www.dh.gov.uk/assetRoot/04/02/03/73/04020373.pdf
 Respiratory Medicine            http://www.dh.gov.uk/assetRoot/04/02/03/86/04020386.pdf
 Sexual Health                   http://www.dh.gov.uk/assetRoot/04/02/04/27/04020427.pdf

Further areas in which GPwSI roles may be developed are continually examined, and new frameworks will
be produced where there is an identified need. The process for the appointment of GPwSIs by PCTs, and
for the development of new clinical frameworks, is briefly outlined in Figure 1 overleaf. Although usually
driven by commissioning requirements at PCT level, sometimes a more “top-down” approach to
developing GPwSI roles has occurred. For instance, the Government's 2003 Genetics White Paper9
included start-up funding for up to ten genetics GPwSIs. The NHS National Genetics Education and
Development Centre is responsible for developing these posts (http://www.geneticseducation.nhs.uk).


 Further clinical frameworks will be added at:
 http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/PrimaryCare/GPsWithSpecialInterests/fs/en




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Figure 1. Process for the Appointment of a GPwSI by a PCT




Figure from Implementing the Scheme for General Practitioners with Special Interests. (RCGP/DH 2002)

 GENERIC GUIDANCE
 A Step by Step Guide to Setting Up a GPwSI Service:
 http://www.natpact.nhs.uk/uploads/PDF%20-%20Step%20by%20Step%20Final%20pdf%20version.pdf

 Generic Model for GPwSI:
 http://www.dh.gov.uk/assetRoot/04/05/98/62/04059862.pdf

 Implementing a Scheme for GPwSIs:
 http://www.dh.gov.uk/assetRoot/04/05/98/61/04059861.pdf

 Practitioners with Special Interests: bringing services closer to patients:
 http://www.dh.gov.uk/assetRoot/04/07/23/69/04072369.pdf



V. IMPLEMENTATION
a) Coverage of GPwSI

A 2004 Audit Commission study10 identified variable degrees of service redesign at local level with only
17% of PCTs having GPwSIs in five or more areas and 36% of GPwSIs working in isolation – highlighting
a potential vulnerability where PwSI services rely upon a single practitioner for service delivery.
Nationally, only 25% of PCTs felt there were sufficient clinicians to meet their PwSI needs.

A recently published snapshot of current and planned GPwSI services11 in England (see Figure 2 below)
showed that dermatology, minor surgery, and drug misuse are the clinical areas where most GPwSI
commissioning needs have been identified by PCTs. It also found certain clinical areas – such as diabetes
and musculoskeletal medicine – where no services had been developed despite the existence of
framework guidance for GPwSI appointments.




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Figure 2. Snapshot of GPwSI Services in England




b) Local Development of GPwSI Roles

Implementation of GPs and other staff with special interests is service driven, with PCTs identifying areas
of service development in which the appointment of a GPwSI might be appropriate. Where a role is
developed locally the specifications and responsibilities of the position are determined by the PCT, based
on national standards. The example below – which is a real GPwSI Dermatology role specification from
Craven, Harrogate and Rural District PCT – illustrates how the responsibilities of GPwSIs can stretch
beyond the clinical care of patients to strategy development, teaching, and quality assurance.

 Clinical Services               Clinical work based in community clinics with regular sessions at a consultant
                                 dermatologist outpatient clinic.

 Strategic Leadership            Carrying out a baseline assessment of current dermatology provision in the
                                 PCT.

 Standards                       Raising the standards of dermatology practice in collaboration with the PCT
                                 clinical governance lead.




                                                        5
 Responsive Services            Overseeing the development of patient sampling methods e.g. questionnaire,
                                interview, focus group in relation to the use of dermatology services.

 Working Arrangements           Undertaking a work programme agreed with the PCT Medical Director,
                                including:

                                     •   8 of 10 sessions providing direct clinical dermatology services to
                                         patients, 1 of these in a consultant dermatologist clinic.
                                     •   1 of 10 sessions dedicated to CPD.
                                     •   1 of 10 sessions dedicated to strategy development, teaching, and
                                         quality assurance purposes.

 Professional Development       Remaining up-to-date professionally and pursuing a programme of CPD in
                                relevant dermatological practice, including regular attendance at
                                dermatology CME sessions.

 Logbook of                          •   Regular audit projects relevant to the clinical care provided should be
 Clinical Experience                     undertaken.
                                     •   Attendance at dermatology audit sessions is required.
                                     •   Participating in agreed research programmes.
                                     •   Participating in medical staffing appraisal, mentoring and clinical
                                         supervision arrangements.
                                     •   Contributing to the training and educational programme of other
                                         health professionals in the PCT.


With some services traditionally provided in secondary care moving into the primary sector, PCTs need to
coordinate more effectively with consultants, so as to set parameters for referral, structured training and
accreditation programmes, and co-ordination of services. Networks such the recently formed UK Primary
Care Working Group on Skin, a joint initiative by the Primary Care Dermatology Society (PCDS) and the
RCGP, are potential forums for such work. It will work closely with the British Association of
Dermatologists, the British Dermatological Nursing Group’s (BDNG) Primary Care Sub-Group, and the
Skin Care Campaign (SCC).

VI. ACCREDITATION AND DISPLAYING CORE COMPETENCIES
a) Local Accreditation


 Accreditation is a local decision for PCTs and routes to accreditation differ from practitioner to practitioner. Some
 have diplomas or similar formal qualifications, while others offer the PCT more experience-based evidence of their
 competencies. It is for the PCT, drawing on the expertise of secondary care clinicians and managers, to set the
 competencies needed to deliver the service and to ensure each practitioner meets these before accrediting them as a
 GPwSI

 Practitioners with Special Interests: bringing services closer to patients (DH 2003)

Although individual clinical frameworks suggest a broad portfolio of experiential and postgraduate training
as appropriate evidence of competence for GPwSI appointments, local PCTs are tasked with agreeing and
fleshing out the detail of such requirements, and integrating the scheme into existing services. GPs
wishing to offer a special clinical interest must make themselves known to local PCTs. The appointment of
a GPwSI should follow a review of health needs, local service provision and commissioning options.

Many local deaneries or PCTs have their own Accreditation Panel for GPwSIs, providing a standardised
and streamlined approach to the accreditation of quality services, based on national guidance where
available12. The DH does not endorse particular training courses for practitioners with special interests, as
any training should be relevant to the locally specified requirements of the GPwSI service.


 Example Accreditation Panel:
 http://www.oxford-pgmde.co.uk/gp/gpwsi/app1_cogped_gpwsi.doc




                                                           6
b) National Accreditation?

There have been increasing calls for a more formalised and systematic approach to GPwSI accreditation
at national level. Some have suggested that any national programme should be linked to vocational
training, with GPs indicating a specialty during VTS to which they could devote more time and receive an
extra qualification.

However, organisations including the RCGP and COGPED have expressed concern that the generalist role
is not undermined or diluted and that, during VTS, GPs learn the skills of a competent generalist before
applying those to a specific interest. The view of the RCGP in developing frameworks for the appointment
of GPwSIs was that most training should take place after vocational training is completed, though if there
is interest in a particular specialty, an initial diploma could be taken during the VTS. COGPED has echoed
this view in a 2004 position paper13: “GPwSI training should not compromise basic specialist training for
general practice over three years. Nonetheless, starting with the Foundation Programmes and including
innovative training posts (ITPs) as part of vocational training, there may be incidental opportunities to
develop a special clinical expertise.”

It will ultimately be the responsibility of the newly convened Postgraduate Medical Education and Training
Board (PMETB) to establish the centralised accreditation machinery around the GPwSI initiative and
delegate training responsibilities to educational institutions. The PMETB acts independently as a
professional UK competent authority, supervising postgraduate medical education and training, and
regulating specialist and general training. The Board will oversee the first GP Register, and it may follow
from this that a register of GPwSIs will also be maintained centrally.

C) Postgraduate Qualifications

The RCGP, as part of its Acquiring Specialist Skills programme, is aiming to address the issue of
educational requirements, and is in the process of developing postgraduate qualifications suitable for
GPwSIs. This may include obtaining University accreditation for such courses. A possible blueprint for
such courses is the RCGP Certificate in the Management of Drug Misuse. Although not an official
accreditation, Part Two of this highly successful certificate provides the type of competencies required of
GPs with a Special Interest in Drug Misuse (http://www.rcgp.org.uk/drug/certificate.asp). There is an
increasing – if ad hoc - array of postgraduate qualifications which provide the type of competencies
appropriate for those wishing to find GPwSI employment:

Bradford City tPCT runs the first NHS postgraduate courses for Practitioners with a Special Interest to offer
national accreditation. The part-time, work-based courses cover cardiology, gynaecology, urology and
diabetes, and run over a minimum period of 18 months part-time. Contact: psi@bradford.nhs.uk

The Diploma in Geriatric Medicine offered by the Royal College of Physicians (London) or the Royal College
of Physicians (Glasgow) is designed to assess clinical competence in the care of older people in primary
care settings. (http://www.rcplondon.ac.uk/professional/exam/exam_dip_geriatric.htm)

RILA Publications Ltd offers various postgraduate qualifications which have been accredited by the RCGP.
They cover Cardiology; Diabetes and Endocrinology; ENT; Medicine for the Older Person; Ophthalmology;
Urgent Care; and Urology. (http://www.pgdip.com/?action=overview)

VII. PRIMARY CARE REFORM AND THE GPWSI
a) The New GMS Contract

The introduction of the GMS contract in April 2004 had profound consequences for all GPs, and particular
ramifications for the GPwSI programme. Nationally Enhanced Services (NES) cover aspects of clinical care
beyond the scope of essential services and naturally provide an opportunity for more integrated use of
the extended skills of GPwSIs. The level of involvement can vary with GPwSIs leading the development of
a service, supporting other GPs, or running intermediate clinics dealing with more complex patients.

Commissioning Services under the New GMS Contract14 (2003) advised PCTs that funding for GPwSIs
would be built into enhanced services funding within the total practice budget. Other schemes supporting
the shift of services from secondary to primary care (such as Local Development Schemes (LDS), the
Improving Primary Care Incentive Scheme, services currently delivered under HSG (96) 31, and schemes
to improve patient access) would also be commissioned under enhanced services. Contracts for such
services were rationalised into a single arrangement for enhanced services under the contract between
the PCT and the practice from 2004/05. Though accreditation and remuneration of GPwSIs are both




                                                     7
generally matters for PCTs to determine locally, where the GPwSI service falls within the scope of an NES
under the GMS contract, national benchmark prices apply as a minimum price.

GPwSIs may also be commissioned to undertake the provision of Local Enhanced Services (LES) where no
service specification is defined under the new contract. LES are tailored to the specific needs of the area,
and are locally negotiated, without national pay rates. Typically GPwSIs will be paid either by an item-of-
service fee or a block payment to provide a service, irrespective of patient numbers. Below is an example
Local Enhanced ENT Service Specification which outlines: how patients are referred to the GPwSI; clinical
conditions GPwSIs should accept referrals for; and time and resources for clinics based on the total
number of new and follow-up patients to be seen.


    North Stoke PCT and South Stoke PCT Service Outline ENT LES:
    http://www.northstaffslmc.co.uk/ENT%20Final.doc


b) Practice Based Commissioning

The development of primary care commissioning via PCTs aimed to increase the range of primary and
community services available to local populations, and better manage the number of referrals into
secondary care services. Commissioning is defined as: “the process by which the health needs of a
population are assessed, the responsibility is taken for ensuring that appropriate services are available
which meet these needs (including delivery of national and local NHS planning framework targets) and
the accountability for the associated health outcomes is established.”a PbC transfers these responsibilities,
along with the associated budget, from the PCT to primary care clinicians.

GPs will determine the range of services to be provided for their population with the PCT acting as their
agent to undertake any required procurements and to carry out the administrative tasks to underpin
these processes. It is envisaged that practices could hold budgets for the full range of patient care, and
not just elective services. Although PbC is in its infancy, and the types of local commissioning solutions
that will be associated with it are as yet unknown, there would seem to be some concordance between
the role of GPwSIs and the aims of PbC.


    With the increasing transfer of responsibility for commissioning to practices under PbC in the name of greater
    patient choice, it will be vital that patients are referred to the right practitioner at the right time. PbC means that
    practices and PCTs will be required to review their approach to referral management.

    Practice Based Commissioning: promoting clinical engagement (DH 2004)


VIII. GPWSIS IN PRACTICE
a) Maintaining Professional Standards


    Practitioners need to keep their skills up to date as part of their on-going professional development. The annual
    appraisal process will be important in ensuring skills and experience continues to match the needs of the service.
    GPwSIs are also encouraged to maintain regular contact with the appropriate acute sector specialist. Many
    GPwSIs, for example, continue to undertake formal sessions in hospitals as hospital practitioners and clinical
    assistants.

    Practitioners with Special Interests: bringing services closer to patients (DH 2003)

The RCGP has recommended that each GPwSI set aside fifteen hours per year for CPD in their area of
special interest. Individual GPwSIs are expected to keep a personal development portfolio which identifies
the learning needs associated with the competencies required for the service, and evidence of how these
needs have been met and maintained.

The portfolio will serve as a training record and will be counter-signed by an educational mentor or
supervisor to confirm the satisfactory fulfilment of the required training experience and the acquisition of
the competencies deemed necessary by the employing authority. It should also form part of the GPwSI
annual appraisal. Membership of a professional society, such as the British Geriatrics Society or General
Practice Airways Group, adds value to the personal portfolio.

a
    Source: Binley’s NHS Update No.2: GP Practice Based Commissioning (September 2005).



                                                              8
b) Clinical Governance and Indemnity

PCTs are responsible for developing risk management frameworks and clear lines of accountability for the
work of GPwSIs. In this context PCTs often draw on existing protocols for shared care arrangements, such
as those for the prescribing of drug treatments15. Some GPwSIs work on a self-employed contract;
whereas others are employed by the PCT. PCTs need to clarify whose indemnity and complaints system is
covering a particular service. If the GP is employed directly by the PCT or Acute Trust, the Clinical
Negligence Scheme for Trusts run by the NHS Litigation Authority will cover them. PCTs should notify or
discuss proposed schemes with the NHS Litigation Authority and their own legal advisors. If the GP is an
independent contractor, then their own professional indemnity provider will normally cover them. In all
circumstances the GP is advised to notify their medical defence organisation.

NatPaCT, in conjunction with Keele University, published a good practice document16 to support those
involved in the development and implementation of GPwSI schemes. It highlights economic risks
associated with the impact of GPwSI services on existing patterns of working, and included insurance and
indemnity issues. It also identified significant strategic issues such as successions by a GPwSI when
another relocates or retires; adequate local training; and increased patient demand and expectation after
the introduction of GPwSI services.

The National Clinical Governance Support Team (CGST) is currently developing clinical governance
frameworks for GPwSIs.

c) Prescribing

There is specific guidance relating to GPwSI prescribing in each published clinical framework document. In
general, there should be a separate budget and prescribing code issued by the Prescription Prescribing
Authority (PPA) for prescribing within the GPwSI service. To estimate the budget, the GPwSI will analyse
the conditions to be seen, the drugs that will be prescribed, and the likely frequency of prescribing.
Prescribing costs will vary depending on the type of service offered.


 It is important for patient care that there is a clear understanding of where clinical and prescribing responsibility
 rests between Specialists and GPwSIs. When clinical and / or prescribing responsibility for a patient is transferred
 from hospital to GP, the GP should have full confidence to prescribe the necessary medicines. Therefore, it is
 essential that a transfer of care involving medicines that a GP would not normally be familiar with should not take
 place without the sharing of information with the individual GP and their mutual agreement to the transfer of
 care.
 East Lancashire Health Economy Traffic Light Prescribing Specification (2005)
 http://www.elmmb.nhs.uk/East%20Lancashire%20Traffic%20Light%20Scheme%20Definitions.pdf

d) Remuneration

Implementing a Scheme for General Practitioners with Special Interests (DH/RCGP) envisaged GPwSIs
being employed by PCTs or Acute Trusts or delivering services as independent contractors. The contract
that is used should be comparable with that of mainstream hospital practitioners, in particular around
annual and study leave entitlement, audit, clinical governance, and appraisal arrangements.

Individual PCTs have responsibility for remuneration arrangements for GPwSIs, often on a session-by-
session basis, with negotiations taking place between PCTs and LMCs for rates. GPs working as a GPwSI
will need to employ a locum GP to cover practice commitments, and payments for GPwSI sessions also
need to acknowledge follow up work required after employing a locum to cover a session, and other
expenses such as defence costs.


 GPs should be aware of the variable quality of training and contractual arrangements. We would therefore
 recommend that GPs take appropriate advice on their contractual arrangements either via their LMC or as BMA
 members from askBMA on 0870 6060 828 or email askbma@bma.org.uk

 The New General Medical Services (nGMS) Contract and Careers: a view from the Educationalists (BMA 2004)




                                                          9
IX. GPWSI ACROSS THE UK
a) Scotland

In May 2005 the Scottish Executive published its plans for renewal of the NHS in Scotland. Building a
Health Service Fit for the Future emphasised the potential for developing the role of GPwSIs, highlighting
in particular the valuable contribution that GPwSIs could make in providing services to rural communities.
Access to rural healthcare is a key issue in Scotland, and will inform GPwSI policy as much as the need to
reduce hospital waiting lists.


 A National Framework for Service Change in the NHS in Scotland: building a health service fit for the future (Scottish
 Executive 2005)
 http://www.scotland.gov.uk/Resource/Doc/924/0012113.pdf


A Workforce Numbers Group was established in 2004 to advise on the development of NHS workforce
planning. Its 2005 report17 makes recommendations on the healthcare workforce that Scotland will need
up until 2015. In light of this, the Centre for Change and Innovation (CCI) is overseeing a programme to
train up to 40 GPs across Scotland to take on GPwSI roles (http://cci.scot.nhs.uk/).

b) Wales

In May 2005 an Assembly Health Circular18 formalised the arrangements for the appointment of GPwSIs
in Wales. It superseded previous informal arrangements in defining the role of GPwSIs in the context of
overall primary care provision, and providing guidance on establishing GPwSI positions and the training,
accreditation, and service design associated with them. The circular identified the following routes to
GPwSI accreditation:

    •   GPs wishing to develop new skills in a specialist area. Qualification from an accredited specialist
        training course, and/or completion of a GPwSI training post.
    •   GPs who are currently delivering specialist services. Provide log/portfolio of experience,
        qualifications and training.
    •   GPs who have received specialist training but not currently delivering specialist services. Provide
        log/portfolio of experience, qualifications and training and undergo period of assessment by
        specialist consultant. May need period of further training to be accredited.

c) Northern Ireland

Although there are already GPwSIs already working in Northern Ireland they are not yet formally tied into
PCOs. Specialist GPs are currently working in the following areas: older people, child protection, diabetes,
drug misuse, echocardiography, emergency care, epilepsy, headaches, mental health, musculoskeletal
conditions, palliative care and respiratory medicine.

X. OTHER PWSIS
Although the Government’s initial emphasis was on developing GPs with special interests, the DH is now
exploring the potential for other staff in primary care - such as Nurses, Pharmacists and Allied Health
Professionals - to undertake outpatient appointments.

a) Nurses with Specialist Interests (NwSI)

In Implementing a Scheme for General Practitioners with Special Interests new roles were envisaged for
nurses who wished to develop a specialist interest. The 2003 DH document Liberating the Talents:
Implementing a Scheme for Nurses with Special Interests in Primary Care19 foresaw nurses in specialist
roles working across a number of practices, providing a secondary care service to patients across the
community or within one or several PCTs. Another possible scenario was specialist nurses working from a
hospital trust or a community hospital, supporting patients with chronic conditions in the home or
undertaking outpatient sessions in a community health centre or one-stop shop. Specialist nurses may
combine a more general role, for example as a district nurse or practice nurse, with expertise in a specific
clinical area.




                                                         10
b) Allied Health Professionals with a Specialist Interest (AHPwSI)

In November 2003, the DH published Implementing a Scheme for Allied Health Professionals with Special
Interests20; a document providing PCTs with guidance and good practice examples for developing the
roles of Allied Health Professionalsb. Suggested sites for AHPwSIs included GP surgeries and health
centres. AHPwSI roles currently include a dedicated Speech and Language Therapist-led service for ENT
patients at York Hospital NHS Trust, and a community OT at Cambridge City PCT.

c) Pharmacists with a Special Interest (PhwSI)

As part of the development of an integrated primary care agenda, the DH is developing a national
framework for pharmacists with special interests (PhwSIs), expected in May 2006. PhwSI is part of a
wider pharmacy workforce development programme, initiated with the publication of A Vision for
Pharmacy in the New NHS21 in 2003, and realised two years later with the publication of the contractual
framework for community pharmacy. Ultimately PhwSIs could undertake supplementary (or possibly
independent) prescribing and may operate in areas such as: dermatology; cancer care; long term
conditions such as asthma, CHD, diabetes; anticoagulation services; care of the elderly; substance
misuse; dermatology; palliative care; osteoporosis; and public health.


 Further information on PhwSIs:
 http://www.primarycarecontracting.nhs.uk/119.php



d) Practice Managers with Specialist Interests (PMwSI)

The development of this role recognises both the increasing professionalisation of practice management
as a discipline – formally acknowledged by the practice management competency framework in the new
GMS contract – and the key role that practice managers will play in realising the potential of Practice
Based Commissioning (PbC). Under PbC groups of practices within a health economy will work together to
develop new and innovative ways of developing and contracting clinical services. Developing PMwSIs will
allow health communities’ access to a core group of people with an expert and strategic level of
competence. This will be vital in developing and commissioning new services for patients across primary
and secondary care interfaces.

PMwSIs will also assist in training and developing other practice staff, enabling better staff retention, and
helping practices achieve more from the Quality and Outcomes Framework (QOF). Individual practice
managers will also know whom to contact for help in a specific area of management competence.


 Implementing a Scheme for Practice Managers with Special Interests (DH 2005)
 http://www.natpact.nhs.uk/uploads/2005_Apr/Practice_Managers_with_%20SI_Final.doc



XI. IMPACT OF GPWSIS
Recent research has questioned the cost efficiency of GPwSI services, but weighs this against improved
patient access and broadly similar health outcomes to those in secondary care.

A 2005 evidence review22 published by the National Primary Care Research and Development Centre
(NPCRDC), suggested that moving specialists out of hospitals, or having specialist services provided by
GPwSIs, is likely to increase NHS costs by removing the economies of scale existing in hospitals. In
contrast, moving services from specialists to generalists (having them provided by GPs or practice
nurses) could improve efficiency. The paper concludes that specialist care should be moved into the
community selectively – such as in rural areas where patients face difficulties in getting to hospital.

A recent study published in the BMJ23 24, which assessed the effectiveness, accessibility, and acceptability
of a Bristol GPwSI skin problems service compared with a hospital dermatology clinic, reached similar
conclusions: "The GPwSI service for dermatology is more costly than hospital outpatient care” but “it is
more accessible and preferred by patients to hospital outpatient care, achieving similar clinical
outcomes.”


b
  Art Therapists; Chiropodists/Podiatrists; Diagnostic Radiographers; Dieticians; Drama Therapists; Music Therapists;
Occupational Therapists; Orthoptists; Paramedics; Physiotherapists; Prosthetists and Orthotists; Speech and Language
Therapists, and Therapeutic Radiographers.



                                                         11
 GPWSI CASE STUDY: ENT

 Research by the York Health Economics Consortium - Evaluation of GPwSIs Pilot Projects
 within the Action on ENT Programme25 - although limited to one specialty, is a useful
 indicator of the impact on access and referral patterns of GPwSI schemes:

     •   A GPwSI can see 30% - 40% of ENT patients referred to secondary care.
     •   GPwSIs discharge about 70% - 80% of patients back to the care of their GP.
     •   Far fewer patients seen by GPwSIs have follow-up appointments than in secondary
         care.
     •   About 15% - 20% of patients are referred for a consultant opinion or directly on to
         the surgical waiting list.
     •   Did Not Attend rates at GPwSI clinics are very low (typically 1% - 2%).
     •   An established GPwSI holding one clinic per week for 9 - 10 patients will perform
         about 420 - 500 consultations per annum.
     •   One GPwSI holding a weekly clinic without audiological support can manage the
         relevant ENT workload generated by a population of about 75,000.
     •   The newly established GPwSIs did not seem to be generating any new demand, but
         the GPwSI who had been established for about 3 years was generating 33% more
         referrals (per 1,000 population) than the neighbouring PCTs without GPwSIs. Many of
         these patients benefited from receiving enhanced primary care for their ENT condition
         from the GPwSI, but would not have been referred to secondary care by their GP.
     •   Two GPwSIs each holding a weekly clinic with audiological support should cover a
         population of 120,000 - 150,000.
     •   The surgical GPwSI should usually be able to undertake four adult tonsillectomies per
         operating session (i.e. about 150 - 180 over a year).


Although evidence is sketchy it seems that patients value GPwSI services as part of a system of
integrated and enhanced care in the community. Improved access and continuity of care are key to this,
with GPwSIs providing and co-ordinating care within the familiar setting of primary care.

CONCLUSION
PWSI initiatives are now a central plank of Government policy in tackling hospital waiting lists and
admissions, and providing convenient enhanced care in the primary care sector. Although there is some
concern that the development of these roles may have preceded formal accreditation and clinical
governance arrangements, work is ongoing to integrate these roles into the educational and career routes
available to all GPs. The development of a clinical specialism can diversify and enrich the career of GPs,
and contribute to the retention of primary care professionals. The new GMS contract will also facilitate the
development of a portfolio approach to GP careers.

By providing enhanced intermediate care services as well as education and feedback to primary care
colleagues, GPwSIs can also provide the leadership required to meet major challenges in chronic disease
management in the community. These leadership roles will be particularly important in identifying
commissioning opportunities and providing a strategic overview of services at the interface of primary and
secondary sectors under new PbC arrangements.

The provision of a wider range of services in primary care is also closely linked to the expansion of
physical capacity. The development of GP premises, and the creation of One Stop Shops and enhanced GP
practices in LIFT sites, will provide more appropriate premises for outpatient appointments in primary
care.

If the GPwSI programme is to be fully effective it requires robust integration into local health networks.
The Audit Commission26 examined how PCTs were supporting service redesign of care pathways, and
highlighted obstacles to the effectiveness of the GPwSI programme. It recommended that PCTs improve
arrangements for cover so that GPs are able to develop interests that match PCT priorities. It also
encouraged PCTs to hold more up-to-date information on clinicians’ interests; and ensure GPwSIs receive
ongoing support from other specialists, through the development of more effective links with local
consultants. The support of relevant secondary care services, in accrediting and supporting GPwSIs is
crucial in determining the success of these initiatives.




                                                    12
REFERENCES
1 World Health Organisation. Innovative Care for Chronic Conditions: building blocks for action: global report. Geneva: WHO, 2002.
2 Department of Health. Supporting People with Long-term Conditions. London: DH, 2005.
3 Colin-Thome D. The NHS Plan: general practitioners with special interests. Br J Cardiology 2002; 9: 359-60.
4 NHS Executive. HSG(96)31 A National Framework for the Provision of Secondary Care within General Practice. Leeds: NHSE, 1996.
5 Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: DH, 2000.
6 Royal College of General Practitioners, Royal College of Physicians. General Practitioners with Specialist Interests. London: RCGP, 2001.
7 Department of Health, Royal College of General Practitioners. Implementing a Scheme for General Practitioners with Special Interests. London: RCGP, 2002.
8 Department of Health, Royal College of General Practitioners. Guidelines for the Appointment of General Practitioners with Special Interests with the Role of
Service Development: Generic Model. London: DH, 2002.
9 Department of Health. Our Inheritance, Our Future: realising the potential of genetics in the NHS. London: DH, 2003.
10 Audit Commission. Quicker Treatment Closer to Home. London: Audit Commission, 2004.
11 Pinnock H, Netuveli G, Price D, Sheikh A. General Practitioners with a Special Interest in Respiratory Medicine: national survey of UK primary care
organisations. BMC Health Service Res 2005; 5(1): 40.
12 Elsdon S, Noyce S, Chadwick S. How We are Accrediting PwSIs in Stoke-on-Trent. Educ for Prim Care 2005; 16: 363–6.
13 Plint S. GPs with Special Interest: what Role for GP Deaneries? COGPED Position Paper. London: COGPED, 2004.
14 National Primary and Care Trust Development Programme, NHS Confederation. Commissioning Services under the New GMS Contract: briefing. London:
NatPaCT, 2003.
15 Elsdon S, Noyce S, Chadwick S. How We are Accrediting PwSIs in Stoke-on-Trent. Educ for Prim Care 2005; 16: 363–6.
16 Birch K. Developing Practitioners with Special Interest (PwSI) Services: managing the risks. London: NatPaCT, 2003.
http://www.natpact.nhs.uk/uploads/PWSIManagingRisks.doc
17 Scottish Executive. N ational Workforce Planning Framework 2005. Edinburgh: Scottish Executive, 2005.
18 Welsh Assembly. NHS Wales Guidance For Developing GP With Special Interest Services in Wales. Cardiff: Welsh Assembly, 2005.
http://www.wales.nhs.uk/documents/WHC_2005_047.pdf
19 Department of Health. Liberating the Talents: implementing a scheme for Nurses with Special Interests in primary care. London: DH, 2003.
20 Department of Health. Implementing a Scheme for Allied Health Professionals with Special Interests. London: DH, 2003.
21 Department of Health. A Vision for Pharmacy in the New NHS. London: DH, 2003.
22 National Primary Care Research and Development Centre. Spotlight on Care Outside Hospitals. Manchester: NPCRDC, 2005.
23 Coast J, Noble S, Noble A, Horrocks S, Asim O, Peters TJ, Salisbury C. Economic Evaluation of a General Practitioner with Special Interests Led
Dermatology Service in Primary Care. BMJ 2005 (E-Pub); 331(7530): 1444-9.
24 Salisbury C, Noble A, Horrocks S, Crosby Z, Harrison V, Coast J, de Berker D, Peters T. Evaluation of a General Practitioner with Special Interest Service for
Dermatology: randomised controlled trial. BMJ 2005; 331(7530): 1441-6.
25 Sanderson D. Evaluation of the GPs with Special Interests (GPwSIs) Pilot Projects within the Action On ENT Programme. York: York Health Economics
Consortium, 2002.
26 Audit Commission. Quicker Treatment Closer to Home: Primary Care Trust's success in redesigning care pathways. London: Audit Commission, 2004.



CONTACT
 Extended Services in Primary Care                                                 RCGP Information Services
 Department of Health                                                              Royal College of General Practitioners
 Rm 4N26, Quarry House                                                             14 Princes Gate
 Quarry Hill                                                                       Hyde Park
 Leeds LS2 7UE                                                                     London SW7 1PU
 Tel: 0113 2545704                                                                 Tel: 020 7581 3232
 E-mail: GPwSI@Department of Health.gsi.gov.uk                                     E-mail: info@rcgp.org.uk


                                              Further RCGP Information Sheets:
                         http://www.rcgp.org.uk/information/publications/information/infosheets_index.asp




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