GP, GPwSI, Clinical Assistants -
What's in a name?
Mark Devlin BSc MRCGP DRCOG DPCR, General Practitioner, Clinical Assistant in Rheumatology, GPwSI in Musculoskeletal Medicine
Original article: 23/06/2003
Reviewed: 08/01/2011
Next review due: 08/01/2014
The Standards of Care for People with Inflammatory Arthritis records evidence from Arthritis Research UK that in 2000 there were 1.9 million General Practice consultations for inflammatory arthritis and almost 46,000 hospital admissions. Whilst the majority of patients with rheumatoid arthritis are familiar with the role their General Practitioner plays in supporting their care within the multi-disciplinary team, they may be less familiar with the concept that a General Practitioner may reappear in another guise within the team e.g. as a clinical assistant, Hospital Practitioner, or GP with Special Interest.
The primary healthcare team includes doctors, nurses, receptionists, occupational therapists, physiotherapists and social workers. Each have overlapping roles to play in addressing the impact of a medical condition on a person's physical, social and psychological well-being, taking appropriate, supportive action to maintain optimum health and independence. The primary care,otherwise known as the general practice team, dovetails with the hospital or "secondary care" setting, where a further multi-disciplinary team of doctors, specialized nurses, radiographers, physiotherapists and occupational therapists provide support which may include the initiation of physical therapies or disease modifying anti-rheumatic drugs and assessment of the beneficial response to such manoeuvres . The responsibility of monitoring for potential adverse effects of these interventions may be shared with primary care.
Outside the traditional setting of a health centre, the individual with rheumatoid arthritis may also encounter GPs, at times unknowingly, in the guise of clinical assistants or hospital practitioners. These general practice trained doctors work within the hospital system as part of a consultant-led team either on the ward or more likely in outpatient clinics. The original premise of GPs employed as clinical assistants was to educate the local GP population in the nuances of hospital specialties, by means of weekly half-day session attendance at outpatient clinics. Similarly the hospital-based specialty service benefited from the inclusion on the team of a generalist's overall view of patient care. Clinical assistants may conduct both new and follow-up consultations, but the consultant remains available for discussion and ultimately responsible for overall management. The initial notion anticipated that GPs remain in post for a short period in one specialty before rotating to another. Thus the standard of primary and secondary care would be optimised across the local area. By contrast, Hospital Practitioners were considered a more permanent post tailored for GPs with a specialty interest, experience or ability. However, with increasing financial pressures hospital practitioner posts became rare and clinical assistants were encouraged not to rotate between specialties but become permanent Rheumatology team members at that grade.
Over the years many hospitals have become reliant on the contribution of experienced clinical assistants and other non-consultant grades to cope with increasing workload. However, with a static pay scale inadequate to offset the escalating costs of locums employed to cover a GP's absence from their practice, and a change in primary care to a target-based healthcare provision system, with consequent increasing time devoted to bureaucratic tasks, these specialty positions became increasingly difficult to fill. In 2000, the NHS proposed the creation of up to 1000 GPs with a Special Interest (GPwSI) within the NHS by 2004. There are several potential definitions of a GPwSI in musculoskeletal medicine e.g. a GP whose interest in arthritis and allied conditions supplements their generalist role, demonstrated by delivery of a high quality, and improved access service to address the patient needs within a single or group of primary care trusts. Such a service may undertake advanced procedures, such as joint injection, or instigate comprehensive assessment and appropriate investigation of those with suspected Rheumatoid Arthritis. The specifics of a service provided by a GPwSI vary throughout the country and by definition are tailored to the local community.
The intention is for the GPwSI to work as an integrated member of the Rheumatology or Orthopaedic multi-disciplinary hospital team. Although the GPwSI may take direct referrals from local GPs they do not replace consultants, nor should they interfere with access to consultants to whom patients are referred by local general practitioners. On the contrary, for the service to be successful, access by the GPwSI to consultant support is essential and in this situation competition between healthcare services would be counterproductive.
To qualify for the post of GPwSI it is likely that the GP will have completed a period of training within the specialty e.g. as a clinical assistant or by way of an accredited training post, and obtained a relevant post graduate diploma. During the tenure of the post, evidence of continuing professional development is accumulated, and a clinical audit performed to include satisfaction data obtained from patients and referring GPs. Funding is unfortunately not protected from the vagaries of unrelated financial pressures within the primary care trust. There are several models of GPwSI led services, which have been piloted across the UK. Examples include an independent service taking direct GP referrals according to a specific protocol or providing peer support to GP colleagues in management of soft tissue disease and problems encountered with diagnosed arthropathy. Alternatively, they can operate as part of a service led by secondary care which is essentially equivalent to the role of clinical assistant but providing skills with a more local patient-needs specific approach, rather than the traditional outpatient setting. The second model has the potential to provide a more concentrated exposure to patients with inflammatory arthritis, such as rheumatoid or connective tissue diseases. It is likely that in the future as more familiarity is gained with the model of GPwSI, specialist primary care teams will evolve with more specific integration of the primary healthcare multi-disciplinary team, accountable to both patient and primary care trust.
Audit data from our local GPwSI-led, community hospital-based, musculoskeletal service, demonstrated that an equal number of patients were referred with either a predominantly joint problem, or a non joint, soft tissue symptom. 25% presented with more than one problem and only 10% of the total clinic attendees required onward-referral for formal consultant review. The opinion of patients attending the clinics was sought in order to tailor the service to local needs. The majority of respondents valued the more convenient local location for appointments and found the appointments more personal, giving quicker access and flexibility with a significant improvement in the understanding of their condition. Although open to a wide array of influences, the introduction of this GPwSI-led musculoskeletal service was credited as a primary contribution to achieving a reduction in new referral appointment waiting time to see a consultant rheumatologist to a quarter of its previous level i.e. reduced to weeks rather than months. This example illustrates the potential benefits to be gained from preserved integration of specialist and generalist services provided by the NHS, served by the posts of clinical assistant, hospital practitioner and GPwSI.
References:
- Standards of Care for People with Inflammatory Arthritis. Arthritis and Musculoskeletal Alliance: November 2004 (Available at http://www.arma.uk.net/pdfs/ia06.pdf)
- The NHS Plan: a plan for investment, a plan for reform. Department of Health: July 2000
- Guidelines for the appointment of general practitioners with special interests with the role of service development: generic model. Department of Health: May 2002
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