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: 04/10/2009
Next review due: 04/10/2011

The General Household survey recorded arthritis and rheumatism as the most frequent self reported, long standing condition in Britain with a rate of 80 per 1000 females and 40 per 1000 males affected. The economic consequences attributed to arthritis and soft tissue disease is equivalent, or greater than, that of cancer. 14% - 23% of patients diagnosed with rheumatoid arthritis, cease their employment within a year. It comes as no great surprise therefore to learn that 20% of general practice consultations involve musculoskeletal disease. The majority of patients with rheumatoid arthritis are familiar with the concept of a General Practitioner's role within the primary care multi-disciplinary team approach to patient support.

The primary healthcare team comprising of doctors, nurses, receptionists, occupational therapists, physiotherapists and social workers each have overlapping roles to play in acknowledging the impact of the condition on a person's physical, social and psychological well being, taking appropriate, supportive action to maintain optimum health and independence. This dovetails with the hospital or "secondary care" setting, where a further multi-disciplinary team of doctors, specialized nurses, physiotherapists and occupational therapists provide further support which may include the initiation of physical therapies and disease modifying anti-rheumatic drugs. The responsibility for monitoring of benefits and vigilance for potential adverse effects of said intervention is 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 within the hospital system, working with 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 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 holistic view of patient care. Clinical assistants conduct both new and follow-up consultations-the consultant is available for discussion and leads overall management. GPs were supposed to remain in the post for a short period before rotating to another specialty, thus the standard of primary and secondary care would be optimised across the local area. Hospital practitioners were more permanent posts tailored for GPs with a specific specialty interest or ability. However, with financial pressures, clinical assistants have become the norm with a hospital practitioner's post becoming increasingly rare. 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 which is inadequate to cover the escalating costs of locums employed to cover a GP's absence from his practice, these positions are becoming increasingly difficult to fill. The NHS plan in 2002 proposed the creation of up to 1000 GPs with a special clinical interest (GPwSI) within the NHS by 2004. At present, one could define such a post in musculoskeletal medicine as a GP with an interest in arthritis and allied conditions which supplement their generalist role, by delivery of a high quality, improved access service to address the patient needs of a single or group of primary care trusts. The service may undertake advanced procedures, such as joint injection, or instigate a comprehensive assessment and appropriate investigation of those with musculoskeletal conditions.

The GPwSI's work as an integrated member of the rheumatology or orthopaedic hospital teams and do not replace consultants, nor should they interfere with access to consultants by local general practitioners. On the contrary, for the service to be successful, access by the GPwSI to consultants' support is essential. 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, which may be supplemented by a relevant post graduate diploma. Or as is often the case, all of the above. During the tenure of the post, evidence is accumulated of continuing professional development and clinical audit including satisfaction data obtained from patients and referring GPs. Funding is unfortunately not protected from the vagaries of financial pressures from unrelated areas within the primary care trust. There are several models of GPwSI service led service, which have been piloted across the UK.  Firstly, an autonomous service taking direct GP referrals according to a specific protocol, thus providing peer support to generalist GPs in management of soft tissue disease and problems encountered with diagnosed arthropathy. Secondly, 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 provides 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 concept of GPwSI's, 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 the initial pilot period of a local GPwSI led musculoskeletal service, demonstrated that an equal number of patients were referred with predominantly a joint problem or a soft tissue problem. 25% presented with more than one problem and 10% of the total were referred on 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. Providing primary and secondary care integration is preserved and the ever present spectre of budget cuts avoided, patients deserve the benefits to be gained from both the specialist and generalist services provided by the NHS.

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