ROLE OF GPWsIs IN PRIMARY CARE
General practice offers career opportunities which embrace both generalist and specialist elements and many GPs naturally develop a sub-speciality allied to primary care. The development of GPs with special interests (GPwSIs) was heralded by the publication of The NHS Plan: A Plan for Investment, A Plan for Reform.1 The key messages were the creation of 1000 specialist GPs taking referrals from GP colleagues, the transfer of hospital out-patient services to the primary care setting, and greater liaison between GPs and secondary care doctors.
The fundamental aims of developing specialist interests in general practice are to cut patient waiting lists via a service provision that increases the satisfaction and esteem of both doctor and patients.2 However, research into the success of these changes has revealed mixed results. A review commissioned by NHS Service Delivery and Organisation Research and Development Programme (SDO) in 2006 and carried out by Professor Martin Roland et al at the National Primary Care Research and Development Centre, University of Manchester found that patients treated in GPwSI clinics were provided with a high level of care, good health outcomes, greater accessibility to vital services, and a reduction in waiting times.3 In contrast, Rosen, Jones, Tomlin, and Cavanagh, revealed that GPwSI clinics had an inconclusive effect on hospital referrals, a variable effect on hospital waiting times, but agreed that there appeared to be high levels of patient and referrer satisfaction.4
In terms of the financial impact of GPwSI clinics, Coast et al found that the costs of a GP-led dermatology service to the NHS when compared with hospital-based services were almost double (£208 and £118 respectively).5 However, a response to this article by Crowley suggests that the services that were evaluated did not attract enough patients to allow them to be economically feasible, and that the reality of providing such a service was not adequately reflected in the research.6
TEACHING AND TRAINING
Despite this, little has been mentioned about the role of GPwSIs in the education and training of future GPs. With the introduction of integrated training posts (ITP) into the GP curriculum many GPs in training (AiTs) have had the opportunity to undertake GP placements that involve a portion of their time being spent in a secondary care setting. Hospital-based integrated posts offer trainees an excellent insight into secondary care services of a particular specialty and aim to expose a trainee to a wide variety of those patients. However, hospital-based placements are not always tailored to the specific needs of a future GP and AiTs can often find themselves carrying out tasks which may seem repetitive, menial, or irrelevant to general practice. Therefore, GPwSIs have a unique opportunity to share their expertise and knowledge with trainees and develop more relevant ITPs based on the specific challenges faced within primary care.
ITP schemes were first implemented in the London Deanery as part of the LIZEI scheme (1995–1998), a 3-year Department of Health funded scheme to improve innercity London GP training opportunities.7 The posts were incorporated into 3-year training schemes or as an additional 6 months for senior GP registrars, prior to gaining a JCPTGP certificate (the equivalent of the current CCT). More currently, the Northwest is one of number of deaneries that have developed their GP curriculum to incorporate ITPs during ST1 or ST2. The training is based in general practice with a significant part of the working week based in secondary care.
PERSONAL EXPERIENCE
As an ST3 GP trainee I completed a 6-month placement in an ITP in general practice/ gynaecology in Rochdale, as part of the Northwest Deanery. It was based at Castleton Health Centre, an eight partner practice with a patient list of around 11 000. This was a new and innovative post, and possibly unique across the country. They provide an allfemale staffed gynaecology and ultrasound service serving the whole practice-based commissioning cluster. The service was the brainchild of Dr Uma Marthi, a GP partner and trainer who also has over 16 years experience in gynaecology both in India and the UK, and is a Member of the Royal College of Obstetricians and Gynaecologists (MRCOG). Dr Marthi has also completed a certificate in ultrasonography run by the University of Salford and is therefore able to offer an onsite pelvic ultrasound service. In an area of high deprivation and ethnic mix such as Rochdale many women are reluctant to present to their GPs with gynaecological symptoms. The service aims to address this issue and provide a cost-effective alternative to hospital referral. The clinic now receives referrals from nurses and doctors and runs both a scanning and gynaecology clinic on a twice-weekly basis. A recent audit showed that over a 10-month period only 4% of patients who attended the clinic were referred to secondary care, with savings over the same period of around £64 000 to the Heywood, Middleton and Rochdale PCT.8 In addition, patient satisfaction surveys reveal high levels of approval and excellent feedback for the service.
The post aims to cover much of the women's health GP curriculum and as their first full-time ST2 I had the opportunity to manage many gynaecology cases in primary care that would have ordinarily been referred to hospital. A range of practical skills are taught, including coils, ultrasonography, ring pessary insertion/removal, cervical smears, implant contraception, and STI counselling and testing. There is an opportunity to attend special clinics in hospitals, such as infertility, rapid access gynaecology, urodynamics, and early pregnancy. This provides an excellent overview of various patient pathways and enables the trainee to discuss secondary care referrals with patients and prepare them for what they may expect in hospital. The placement is also an ideal opportunity to attend courses and sit examinations such as the RCGP Introductory Certificate in Sexual Health, DFSRH, and DRCOG. Overall, the post equips the trainee to deal with common gynaecological presentations in primary care, make appropriate referrals, and consult an experienced senior supervisor when necessary.
FUTURE TRAINING MODEL FUTURE TRAINING MODEL
With the movement of many secondary care services into primary care, an integrated training approach is a gateway into developing the skills and knowledge for coverage of the GP curriculum and early encouragement of special interests. GPwSIs can help in no small measure to make ITPs more relevant to general practice and inspire trainees to share their passion for specialist areas.
Acknowledgments
With thanks to Dr Barry Lewis, GP Partner, Director of Postgraduate General Practice Education (Northwest Deanery) and Professor Neil Jackson retired Dean of Postgraduate General Practice Education (London Deanery).
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2013