Description

The biggest issue in the medical workforce over the next 2 decades will be the
specialist-generalist debate (Wanless Report, 2001).1 Healthcare delivery in Britain
continues to change rapidly, with particular emphasis on provision of many services
moving away from secondary to primary care. The NHS Plan proposed the
establishment of 1000 GPs with special clinical interests by 2004, to reduce outpatient
waiting times. A new intermediate level of specialist care, provided by a GP, or nurse
specialty practitioner, is just one way in which the quality and accessibility of services
may be improved.

Like it or loathe it, the numbers of GPwSIs continue to expand. The Government
supports their development. PCTs like them, as they can provide needed local care at
an intermediate cost. Patients like them too as they are seen more quickly and receive
a more holistic approach. It is also reported that the GPwSIs themselves report higher
career satisfaction rates as well as raised self-esteem.

It is hoped that there will be an improvement in communication between primary
and secondary care. There is much we can learn from each other. The bridging of this
gap is already occurring at a basic training level with Modernising Medical Careers.
Foundation Programme doctors will get to experience a range of specialties, including
general practice, before entering a formal training scheme. The Royal College of
General Practitioners feel that all doctors in training should get the opportunity for a
GP placement during their Foundation Year 2, regardless of their future career
destination, as a knowledge of the patient journey and a broader approach to healthcare
is of enormous value.

The expansion of GPwSIs is not without its critics. Many consultants remain
opposed to these changing GP roles, feeling that this promotes second-class care.
There are fears that in the long term, waiting lists will continue to rise as such services
tap into previously unmet need. There are concerns about the impact on continuity of
care back at the practices, and that non-specialist GPs may feel unsupported as they
cover for their GPwSI colleagues. Others argue that we are surrendering our generalist
skills, which we all trained for in the first place.

Yet GPs have been nursing their special interests for many years, albeit in a more
informal way. Clinical Assistants and Hospital Practitioners are nothing new. It was
estimated in 2002 that 1 in 6 GPs already work 1-2 sessions/week in a specialty.2 There
are many doctors who enter general practice bringing a wealth of specialist experience
with them. It would be a waste not to maximise these skills.

What about pay? Clinical Assistant rates remain surprisingly low. Current GPwSI
rates are significantly better, in some places more than covering the cost of a session
back at the practice. One hopes as local commissioning takes off, that GPwSI rates will
remain favourable.

So, are GPwSIs a natural progression? For now, it would seem so. As nurses take
over more and more traditional roles that GPs do in practice, it would seem a natural
succession that GPs focus on the skills and knowledge in which they have more
expertise. The Wanless Report in 2001, also stated Up to 70% of work currently
done by doctors could be done by nurses or other healthcare professionals. If that is
true, then wed better make sure we are experts in the remaining 30%. GPwSIs – may
be thats what all GPs will be calling themselves in 20 years time!?

1. The Wanless Report, 2001. Securing our Future Health: Taking a Long-Term View.
2. Jones R, Bartholomew J. General Practitioners with special clinical interests: a cross-sectional survey. BJGP 2002; 52: 833-834.