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International Primary Care Association

Clinical Focus Volume 1 N1


“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 we’d better make sure we are experts in the remaining 30%. GPwSIs - may be that’s what all GPs will be calling themselves in 20 years time!?

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

Dr Alexander Watson
Professor Ram Dhillon

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Read 1803 times Last modified on Tuesday, 03 May 2016 14:29

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