The potential for GPSIs to improve care for patients while saving the NHS money is increasingly clear. In particular, Bradford South and West PCT's scheme for providing extensive and highly cost-effective GPSI services in the community has attracted a lot of praise and attention.
Due to become part of the new Bradford and Airedale Teaching PCT in October 2006, the PCT and the local GP community have worked together to move services into primary care. There are now 63 GPSIs in place who deal with over 50 per cent of GP referrals made in the PCT every year.
The service has been built up over several years, aided by the PCT's encouragement to GPs to develop a specialist interest.
Most services are based in Westwood Park diagnostic and treatment centre.
GPSI services provided include minor surgery, ENT, gynaecology, dermatology, neurology and cataract surgery. Diagnostic procedures undertaken by GPSIs include endoscopy, cystoscopy and hysteroscopy.
There are also four (nurse-led) practitioners with specialist interest services, including leg ulcer and abnormal uterine bleed clinics.
All 30,000 referrals generated annually by the 22 local GP practices go through the diagnostic and treatment centre, which combines a centralised Choose and Book office with a clinical assessment service. GPSIs triage and assess 18,000 referrals of which less than 10 per cent are passed to secondary care.
If other GPSIs want similar success, they need to secure the backing of relevant clinicians and managers in secondary care, says Dr Anne Connelly, a GPSI in gynaecology and rheumatology in the area: 'You must have consultants on your side. If you set up in opposition you will go nowhere.'
She says consultants in the area know GPSIs are not a threat. 'We want to work alongside them and take off some of their workload, allowing them to get on with the work that only they can do,' she says.
Local GP Dr Jan Lee, who chairs the PCT's professional executive committee, says it is important to cost the service at the planning stage.
'In Bradford South and West we can demonstrate that it has been cost-effective but you constantly have to keep modernising and reviewing the services offered to ensure that they are still cost-effective.'
Accreditation is another issue. Bradford has set up a rigorous accreditation procedure backed up by diplomas (available nationwide) developed by Bradford City Teaching PCT and Bradford University.
Dr Lee adds that GPSIs must have professional credibility. For example, this means that their training requirements for doing certain procedures are much higher than for hospital doctors. 'We have to be so careful that we can justify what we are doing,' she says.
Jan Proctor King, educational lead for practitioners with a special interest at Bradford City TPCT, says the Bradford GPSI diplomas - currently in cardiology, gynaecology, urology, diabetes, respiratory medicine and gynaecology - have generated high demand.
Dr Lee believes that the Bradford South and West set-up fits well with the vision for the NHS outlined in the 2006 care outside hospitals White Paper.
'We know from our patients that they find going to very large acute hospitals and finding their way around very difficult, particularly elderly patients,' she says. 'Delivering care locally is where the health service is going.'
Dr Connelly gains huge job satisfaction as a specialist.
'I am passionate believer in these services,' she says. 'As well as patients being seen more locally and quickly, they are seeing someone with a general practice background who can pick up on the multitude of problems they may have.'
The PCT uses different methods to pay the GPSIs. Some work as PCT staffers for one session a week, while others prefer to freelance.
Sue Nguyen, the PCT's director of diagnostic and treatment services, says: 'We pay a fairly standardised rate based on what the average GP earns.'
- Bradford TPCT's diplomas for GPSIs take about half a day a week for 18 months to complete. For details, email firstname.lastname@example.org
CHALLENGES AND BENEFITS OF GPSIs
- Winning the trust of referring GPs is vital. Bradford GP Dr Jan Lee says local GPSIs have proved their worth, although at first the driver was long hospital waiting times. She says the PCT constantly monitors GPSI waiting times to make sure they are never longer than for the equivalent waits in the hospital.
- Bradford South and West PCT director of diagnostic and treatment services Sue Nguyen says the 18-week pathway target from referral to treatment will be a key challenge as is coping with clinician turnover. 'With all the GPSIs and services we have, we need to keep a flow of GPs coming through, particularly as it can take a couple of years to train a GPSI in some specialties,' she says.
- Joint chairman of Bradford LMC Dr Andy Withers says local GPs believe the GPSIs offer a quicker, more efficient service closer to where patients live. 'But we don't know how it's going to change with practice-based commissioning. There is a feeling that all the potential savings in the system have already been made,' he says.
- The effect on the GPSI service of the merger of Bradford South and West and the three other Bradford PCTs is also a concern. However, the new PCT plans to manage commissioner and provider functions through separate departments with the GPSI services as a provider function. Ms Nguyen says: 'Our PCT commissioning team may well have an internal agreement over what they want us to provide and at what price.' There are no plans at this point to contract out the PCT's provider functions to external providers.
- In the longer term, Dr Lee, who also chairs the PCT's professional executive committee, sees huge potential for the GPSI service as part of a wider strategic plan to integrate primary and community services.
'It may be that in some areas that GPSIs form into provider units themselves but that's just one possibility,' she says.
GPSIs in Bradford South and West
GP practices 22
Total annual referrals 30,000 of which 18,000 go to
GPSIs to triage and assess.
GPSI referrals to secondary care Less than 10% of GPSI-triaged
Specialties covered by GPSI Minor surgery, ENT,
neurology and cataract surgery.
Diagnostic procedure Endoscopy, cystoscopy, and
Location of services Most GPSI services based at
Westwood Park diagnostic and
Diagnostic and treatment centre Combines centralised Choose
and Book office with a clinical