Taking care to the community

PCTs espouse the virtues of GPs with specialist interests (GPSI) clinics, from cutting waiting times to fewer inappropriate referrals, but are they as beneficial to patients as the DH claims? Sara Williams visits a GPSI clinic in the Wirral.

In the UK there are currently 1,700 registered GPSIs. They share a holistic generalist approach to healthcare, and use their specialist skills to offer patients quicker and easier access to treatment.

GPSIs are GPs trained in fields in which they have a special interest. They draw their skills out of the practice setting, taking it into the community through specialist clinics that take place weekly or fortnightly. Their clinics enable other GPs to refer patients to them, after triage, for diagnosis and follow-ups or for minor surgery, thus shortening waiting times. It is anticipated that, in the future, the service they provide will play a vital role in the transfer of secondary care into the community, through practice-based commissioning.

Practices looking to launch a GPSI service will need to work together and get involved from the outset. A receptionist who feeds back information from the community about their needs is just as valuable as someone who knows what medical assistance they require. Dr David Coombs found this out firsthand when he lent his skills to running a dedicated dermatology clinic at St Catherine’s Hospital, funded by Wirral PCT.

Dr David Coombs, GP and GPSI in dermatology

There has been a vast increase in the number of GPSIs in England over the last two or three years. I do one dermatology session a week in secondary care and I do one session here at St Catherine’s Hospital. The session runs from 9 to 12 every Tuesday morning. I work alongside another GPSI; this is useful because if I need to discuss anything I can chat to him. I’ve been doing dermatology clinics for 15 years and now I’m formalising my knowledge by obtaining a dermatology diploma.

The PCT was the initial driving force behind this GPSI project as it fell into its practice-based commissioning framework. The clinic was started with input from the local consultant dermatologists; we all sat down and decided what the appropriate conditions for a GPSI clinic were.

GPs see patients with initial symptoms. For example, someone with moderate to mild psoriasis may want a second opinion but it is not severe enough to send her to secondary care so she’ll be referred to me for a second opinion. It is useful for a GP to have someone else to say ‘yes, this is psoriasis’. GPSI is all about patient choice and making treatment more accessible to patients. It is in their interests because it cuts down unnecessary referrals to secondary care.

When we launched it, we had to promote the service in other practices. This was done through an advertising campaign. When we had been going for six months we did a presentation to GPs in the area about the service – what sort of cases we had seen and what sort of problems we’d encountered. One of the issues that was raised was managing actinic keratoses (sun-damaged skin). GPs can treat these themselves, but often refer the cases to me because they lack expertise. We are now in the process of organising a training session for GPs on how to manage that.

I have seen several patients referred with eczema, who in fact had tinea, a fungal infection or ringworm, which the GPs had wrongly treated as eczema.

Unless you think about this, you may miss it. Here is where a bit more experience and knowledge can save unnecessary referrals. This sort of case would not usually be referred to secondary care.

One of the risks is working in isolation, and being seen as an expert when you are not. You are a GP with a specialist interest, not a consultant dermatologist. Being aware of your limitations is the most important thing. I regularly refer more complex cases to secondary care; this is why I think mentoring and having good contacts with secondary care is important.

This will require time because some secondary care workers feel that GPSI clinics destabilise their service and draw away essential funding. But it means that more complex cases can be seen by secondary care. Patients with serious conditions such as melanoma aren’t referred to us anyway.

New guidelines came about last year giving guidance on how intermediate GPSI services should be run, and how doctors like me can be accredited to provide them. I think this will only serve to encourage more GPs to set up GPSI clinics. If this is to expand, one of the major things that we need to do is set up a mentoring system for GPSIs, with consultants working in secondary care. Those working in isolation are out on a limb. The guidance suggests that we should have one clinic a month, with a consultant who would act as a mentor. That way they can check how we are working.

Learning points

Communicate with the PCT and colleagues in secondary care.
Continue training and learning
Set up a mentoring system.
Know limits of your competence.

Michelle Grugal, patient

I’ve got white patches all over my back and arms, which I thought were from using the sunbed too much. I thought it was something really serious. I was referred here by a GP, and I got an appointment straight away, so I was seen within a week. The first GP I saw was not as useful because he did not indicate whether the patches could be serious or not. So I was a bit nervous. But Dr Coombs put my mind at rest by diagnosing a yeast infection and prescribing some tablets to clear it up. My GP had previously prescribed some cream, but Dr Coombs said this was not working so he has prescribed me oral tablets instead.

It was easy to get here on the bus; I felt only slightly anxious because it was a hospital. The GPSI service was quick and easy and got straight to the heart of the problem without much messing around and having to travel here, there and everywhere. It only took a couple of minutes because Dr Coombs knew what it was straight away. During the consultation I didn’t feel on edge; I felt that I could easily say what was wrong with me.

Future

The DH is consulting on proposals to introduce a statutory duty of partnership between the providers to work together to assess the needs of an area. Success depends on the mutual co-operation between PCTs, GP practices, local authorities and the patients.

Implementing Care Closer to Home: Convenient Quality Care for Patients, Department of Health.