General practitioners with special clinical interests

A potentially valuable asset, which requires evaluation

The NHS Plan called for the introduction of 1000 “specialist general practitioners” to establish clinics in community settings for carefully selected patients.1 A key aim is to improve access in specialties that have particularly long waiting times, such as otorhinolaryngology, dermatology, and ophthalmology. Theoretically at least, hospital consultants will then be able to offer faster access to patients with more complex problems as more straightforward cases are diverted to clinics run by general practitioners with special clinical interests.

The success of this policy will depend on recruiting and developing a cadre of general practitioners with the necessary knowledge and skills to provide specialist care. It will also depend on developing and implementing appropriate selection criteria to ensure that patients see a specialist–be it a general practitioner or a hospital consultant–who is equipped to deal with their clinical problem. This in turn raises three important questions. How do we ensure the quality of a general practitioner specialist service? Will the services be clinically effective and cost effective? What will be their impact on the dynamics of outpatient specialist care?

General practitioners with special clinical interests are not a new breed.2 Many work as clinical assistants in hospital departments, and others pursue a special interest in their own surgery, taking referrals from other partners in their practice. In general they fall into three groups–those who give opinions (by working in outpatients, for example), those who perform procedures (for example by carrying out gastrointestinal endoscopies or vasectomies), or those who lead or develop a service, drawing on education or management rather than clinical skills.3 A recent survey shows that as many as 4000 general practitioners may already participate in work of this kind.4 The range of clinics run by general practitioners with special interests that may emerge from the NHS Plan is huge, so how do we ensure their quality?

Guidance on standards for general practitioners with special interests and for accreditation, training, and revalidation is being jointly produced by the Department of Health and the Royal College of General Practitioners.5 6 However, identifying minimum standards to cover all types of clinic will not be easy. Many of the new posts will be innovative, aiming specifically to tackle identified gaps or inefficiencies in current services. They will also vary greatly. A general practitioner with a special interest in cardiology may, depending on levels of clinical skill, local need, and available equipment, establish a clinic to provide medical management for hypertension or a heart failure clinic that provides Doppler scanning. There will have to be scope for local variation, yet some essential underlying principles can be established.

A minimum level of clinical experience, necessary equipment, and specialist support should be identified for all procedural or interventional services. A system of accreditation of competence to offer a prespecified range of clinical services must be developed. General practitioners with special interests should not practice in isolation and should have easy access to advice, support, and professional development from local hospital specialists. All such general practitioners should take clinical responsibility for their work (distinguishing them from their existing counterparts holding contracts as clinical assistants or hospital practitioners with acute trusts), which will require adequate professional indemnity. As the employing body, primary care trusts should hold general practitioners with special interests to account through agreed performance indicators and compliance with local clinical governance arrangements.

In return, general practitioners with special interests can reasonably expect terms of employment that offer fair pay, continuing professional development, and support for necessary organisational changes in the practice to accommodate periods of specialist work by some general practitioners. Such arrangements could also act as a benchmark for general practitioner specialists working in other settings–particularly the clinical assistant grade, which currently provides no security and little reward.

Will such developments be clinically effective and cost effective? The evidence on this is almost non-existent. Previous initiatives to provide specialist care in generalist settings were based on the consultant outreach model. A study by Bowling and Bond concluded that the clinics were popular with patients but improved access was gained at higher overall cost to the NHS.7 They also reported that the clinics largely failed in their aim to educate general practitioners. However, extrapolating from such studies is problematic since the inputs are not comparable and the widely reported problem of time wasted as consultants drove across the country is not relevant. In addition studies comparing clinical outcomes obtained by general practitioners with special interests and hospital specialists are lacking.

Organisationally, a study of general practitioners' specialist clinics in otorhinolaryngology highlighted the extensive and detailed preparatory work required between interested general practitioners, a hospital specialist “champion,” and a committed general manager to establish the necessary relationships to support the service.8 Without such work, access to second opinions, peer review of the quality of service, and education and professional development may be denied. This risks having a knock-on effect on the quality of service. Yet the time and effort required to establish such links may be so great as to stifle change. The Royal College of General Practitioners is actively negotiating with other royal colleges to identify minimum standards of clinical skills and equipment required in different specialties and to provide shared guidance on promoting links between general practitioners and hospital specialists.

The final question about the growth in specialist clinics run by general practitioners is what impact they will have on access to outpatient specialist care. No evidence is available on the impact of such clinics on outpatient waiting times, although at least one such study is under way.9 Consultants in the United Kingdom have always resisted community based practice and have linked professional status to control of hospital beds. However, throughout Europe and the United States most specialists are based in community clinics–often providing direct access to patients without the need referral from a general practitioner They are trained and accredited as specialists (for example, in paediatrics, internal medicine, ophthalmology), and most are equipped to offer a wide range of facilities for diagnostic procedures and basic treatment to patients outside hospital settings. Many do not practice in hospitals at all.

Under the current policy, generalist general practitioners will continue to act as gatekeepers to general practitioner specialists and to fully accredited specialists in outpatient clinics in hospitals. However, we do not know whether with appropriate selection of patients and adequate education, training, and peer support, general practitioner specialists can provide a uniformly high standard of care. If not it will be interesting to see whether their introduction will pave the way for fully accredited specialists to move into community based outpatient services.