GPs with Special Interest - what Role for GP Deaneries? COGPED Position Paper

Executive Summary The GPwSI initiative offers an exciting opportunity for boosting recruitment and retention in the profession, as well as delivering improved services in primary care. Deaneries should promote the initiative to doctors in training, should engage with primary care trusts in coordinating training with service commissioning, and should support the trusts in the accreditation process. There is a continuing responsibility to support the continuing professional development of these doctors, and appraisal processes will need to be developed to address their role as specialists as well as generalists. Background The NHS Plan set the target of a million extra outpatients to take place in primary care, rather than in hospital, by 2006. The GP with Special Interest (GPwSI) initiative is a key factor in redesigning local services around the patient. The purpose is to achieve shorter waiting times, and provide a convenient community-based service, so that patients receive the necessary care in the most appropriate location. The initiative has been welcomed by the Royal College of General Practitioners, not just as an aid to delivering enhanced services within primary care, but as a way of boosting recruitment and retention into the profession. There are already 4,500 GPs with clinical special interests in England, often working as practice leads in defined clinical areas, clinical assistants or hospital practitioners. Many of these posts will continue, but some GPs will wish to enter a scheme, which offers an appropriate contract, facilities, support and professional development. This paper will examine the opportunities (and responsibilities) for COGPED to shape the future development of the initiative, and it is hoped will particularly help PCTs working with Deaneries. Definition "GPwSIs in addition to providing the full range of GMS/PMS services to their own patients, will have additional training and expertise which enables them to take referrals from colleagues for the assessment and/or treatment of patients outside GMS/PMS who might otherwise have been referred direct to a secondary care consultant, or provide an enhanced service for particular conditions or patient groups." 1 Policy guidelines thus far refer to GPwSIs in the role of providing clinical service to patients. However, this is only one aspect to the role of GPwSI. Equally important are the roles of GPwSI as a trainer, educator and coach of other healthcare professional colleagues in raising overall standards of care. The GPwSI may also play a significant part in the strategic planning of services across a health economy. The latest DOH publication2 now includes GPs as a subset of practitioners with a special interest: "Practitioners with special interests are GPs, nurses, therapists and other health professionals who develop an additional expertise which enables them to expand their clinical practice in a defined area. These areas include orthopaedics, epilepsy, diabetes, dermatology, palliative care, older people's services and mental health. Although their activities within these areas vary widely according to the needs of local patient groups, these practitioners share a common aim - to improve access to services and bring more secondary care procedures, such as diagnostic tests and minor surgical procedures, into primary care and community settings." Deaneries and PCTs should develop strategies which are based on multi-professional rather than uni-professional working. Generalist or Specialist There is consensus that GpwSIs must be generalists first and foremost, who undertake their special interests in addition; but longterm there will need to be an evidence-based justification. We don't share Cyril Chantler's vision of the future: "Perhaps the traditional distinction between the general practitioner and the consultant will disappear, to be replaced by the generalist physician based in the community but working in hospital and other settings, while the specialist, with high technical skills, will also operate in both community and hospital." 3 But we cannot rely on the circular argument that if we are not generalists we are no longer GPs. "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."2 We need instead to make the case for the GPwSI occupying an intermediate position where patients will still have more than one health problem, and are treated holistically, where the skills of the generalist in managing uncertainty and risk management will still be necessary. "Health care that is both driven and evaluated increasingly by protocols derived from studies of single disease conditions seems likely to disadvantage systematically those with complex and overlapping health problems."4 There will also need to be an evaluation of the anticipated economies of the initiative, whether shorter training and community setting translate into more efficient and still effective patient care. Deaneries together with the Royal College of General Practitioners have a key role in making the case and defining the attributes of the GPwSI. Commissioning Responsibility for analysing health need, and redesigning and increasing local capacity for provision of local services is clearly defined as belonging to PCTs. Deaneries should be involved at strategic level with PCTs identifying possible shifts in service provision, exploring whether resources for training are available, and planning coordinated training programmes. Attention needs to be paid to the risk that GpwSI numbers may be increasing too rapidly and overtaking sustainable infrastructure. Commissioning organisations must ensure that adequate facilities are in place in the primary care setting. Specification / Framework Three national development groups, chaired by the National Clinical Director for Primary Care, have overseen the development of PwSI services for GPs, nurses and, most recently, allied health professionals. These have each produced guidelines to help PCTs through the detailed process of creating PwSI services, setting out potential roles, some principles of their employment and the first steps in implementation. Guidelines for PCTs and staff have been developed with the Royal College of GPs, providing more specific recommendations for GPwSIs, for a number of clinical specialities. There is no obvious need for Deaneries to be involved in this process. The following guidelines are available from the DoH in Portable Document Format Guideline: Care for older people Guideline: Child protection Guideline: Coronary heart disease Guideline: Dermatology Guideline: Diabetes Guideline: Drug misuse Guideline: Echocardiography Guideline: Emergency care Guideline: ENT Guideline: Epilepsy Guideline: Headaches Guideline: Mental health Guideline: Musculoskeletal conditions Guideline: Palliative care Guideline: Respiratory medicine Guideline: Sexual health Training COGPED has previously stressed that 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. Extended senior registrar training and the HPE programme for all newly qualified GPs, offer Deaneries and PCTs the opportunity to develop a structured programme for individual doctors over several years to develop a special expertise. Alternatively, there are examples of Deaneries5, with the support of Workforce Development Directorates, supporting doctors with bursaries to undertake training in programmes validated by universities. There are increasing numbers of trust grade doctors who are leaving secondary care and seeking re-training in general practice. Deaneries should consider developing flexible training programmes to enable these doctors to retrain and to bring their expertise into primary care. Consideration should be given to the value added benefit of GPwSIs having teaching qualifications, to develop people and services: competence in teaching is one of the criteria for accreditation in one Deanery.6 Accreditation Although responsibility for accreditation has been assigned as a local decision for PCTs7, drawing on the expertise of "secondary care clinicians and managers", Deaneries clearly have an opportunity to be involved in this process. The process is complex, with different routes to accreditation for each practitioner, some will have diplomas or similar formal qualifications, others will offer the PCT more experienced based evidence of their competencies. In principle, accreditation should be dependent on the demonstration of prescribed competencies. One Deanery8 has already established an Accreditation Panel for GPs with Special Interests, whose purposes are defined as follows: To bring together and develop an expert group which will be professional but neutral and which will gain and share expertise in the process of accreditation (GPwSIs). To ensure a high standard of care and minimise risk to patients across the deanery. To ensure that there is uniformity and consistency in the clinical practice of GPwSIs across the deanery. To minimise risk to Primary Care Organisations and GPwSIs across the deanery. Applications for accreditation must come from the PCT and not directly from the individual. The Deanery will report back to COGPED in one year's time on the experience of the accreditation panel. Monitoring For any PCT establishing a PwSI service, measuring the improvements to accessibility, waiting times, choice and the patient experience will be a fundamental part of their on-going performance management activities. As more PwSI services come on stream across the NHS, the evidence base will strengthen and trusts will be able to benefit from a growing bedrock of good practice and examples of service redesign. There is no obvious responsibility for Deaneries to lead this process. Appraisal / CPD "Accreditation, however, is not the end of the process. 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 continue to match the needs of the service… The GPwSI should receive regular training and professional development amounting to approximately 15 hours a year."7 The training and continuing professional development of GpwSIs may need to be coordinated at a supra PCT level. Deaneries have a responsibility to advise on this work, as well as support provision of training, which GPwSIs will be appraised annually as general practitioners, and Deaneries will need to ensure that the appraisal process is robust enough to cover not only the generalist but also the specialist role of the doctor. This will involve further training of appraisers, and possibly an expert peer appraiser advising on the content of the personal development portfolio, but should still be confined to a single annual appraisal. Summary The GPwSI initiative offers an exciting opportunity for boosting recruitment and retention in the profession, as well as delivering improved services in primary care. Deaneries should promote the initiative to doctors in training, should engage with primary care trusts in coordinating training with service commissioning, and should support the trusts in the accreditation process. There is a continuing responsibility to support the continuing professional development of these doctors, and appraisal processes will need to be developed to address their role as specialists as well as generalists. References 1. Implementing a scheme for General Practitioners with Special Interests Department of Health/ Royal College of General Practitioners April 2002 2. Practitioners with special interests: bringing services closer to patients Title Practitioners with Special Interests Author DH/Access and Choice/Primary Care Publication Date 06 Nov 2003 3. Reinventing doctors Editorial Chantler C, 1998, BMJ;317:1670-1671 4. Moving beyond single and dual diagnosis in general practice Nat Wright, Liam Smeeth, and Iona Heath BMJ 2003 326: 512-514 5. Kent Surrey Sussex Deanery GP website http://www.gpkss.ac.uk/cpd/gp_speci/overview.htm 6. Accreditation of GPs with Special Interest in the North Western Deanery Sean Coughlin and David McKinlay 2004 7. Practitioners with special interests A Step by Step Guide to setting up a general practitioner with a special interest (GPwSI) service Modernisation Agency http://www.natpact.nhs.uk/ National Primary and Care Trust Development Programme Produced by Practitioners with Special Interest Team April 2003 8. Accreditation Panel for GPs with Special Interests (GpwSIs) Standing Education Conference for General Practice (SECGP) in the Northern Deanery Nov 2003 Doh Article Simon Plint July 2004

APPENDIX 1 Northern Deanery Accreditation Panel Terms of Reference APPENDIX 2 North Western Deanery Accreditation Guidance Download Acrobat Reader To read PDF files you will need this free download: Reference links Kent Surrey Sussex Deanery GP website Modernisation Agency Doh Article