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How we specialise and keep our referral rates down

All of our GP partners have specialised in a clinical area, which has helped us improve patient care, says Dr Jonathan Heatley.

Dr Heatley: 'Our CCG does very well out of us as our referral rates are low'
Dr Heatley: 'Our CCG does very well out of us as our referral rates are low'

All six partners in our practice have an interest in at least one clinical specialty. Although our special interest areas do not make us any extra income, we have much lower referral rates to secondary care in these areas than other practices in our clinical commissioning group (CCG).

Our special interests also give us greater job satisfaction and patients get the treatment they need more quickly.

We practise from Holbrook Surgery in Horsham, West Sussex and have specialised in different clinical areas for the 15 years since I set up the practice as a solo GP. As new GP partners joined, they were all encouraged to specialise.

Specialties covered

It all started with me taking on dermatology. I had not learned any dermatology as a medical student and I was struggling when patients attended with skin problems. This led to me getting a dermatology diploma.

Between the six of us we now have expertise in dermatology, minor surgery, neurology, ENT, opthalmology, gynaecology, contraception (including fitting coils and implants), cardiology and general medicine.

Each new partner was given a morning off each week to do a clinical assistant session with a supportive consultant. They simultaneously studied for a diploma exam in the specialty concerned and after a year or two, gave up their hospital appointment to offer the service to our practice population.

Not a practice of GPSIs

To call us a practice of GPSIs is inaccurate as, with the exception of one partner, we are at an intermediate stage between GP and GPSI. Dr Hwa-Lon Liu is a qualifed GPSI in ENT, for which the practice has an enhanced service contract.  

So what has stopped the rest of us from formally becoming GPSIs? The obstacle is all the regulations and governance involved which is a headache and very time-consuming. Naturally we do keep up to date in chosen our areas by doing courses, reading journals for the specialties concerned.

Payback is in job satisfaction

Being specialists has meant investing some money and a fair bit of time, and the payback is not financial but is increased job satisfaction: we can use our knowledge to benefit patients for the rest of our working lives.

Dr Liu was one of the first people to trial the new ENT diploma. It was expensive so the costs were shared between the partners.

Then Dr Paul Woods, the first partner to join me, took on neurology. At the time there was no diploma, so he spent extra time doing hospital clinical assistant sessions. However there was such a demand for neurology that we were able to negotiate more generous clinical assistant pay.

When Dr Nadia Ziyada joined the partnership, she already had the ophthalmology diploma so we bought the necessary equipment, such as a slit lamp, to allow her to give more specialised care. Another partner, Dr Ann Williams covers gynaecology and contraception.

Later Dr Preest Singh, our cardiology expert and one of our former GP registrars became a partner.

Seeing each others' patients

We are all full-time and have personal lists of around 2,300 patients each although there is steady movement of patients between us to cover holidays.

When patients see their own GP with symptoms in an area another partner specialises in, they are given an appointment to see that partner. These patients are seen during normal surgery sessions and as we do not run clinic sessions for each speciality this adds little to the workload.

It is usually a pleasure to see a problem in one’s own field and there is no sense of being expected to do someone else’s work.

Speedier treatment

Usually the GP specialist can sort out treatment quickly as they know the local consultants and all the relevant referral protocols are second nature.

I think dermatology is particularly satisfying as it is often involves a straightforward look-and-diagnosis. Dr Woods knows how to get scans and when urgent opinions are justified. Without him neurology problems in the middle of a busy surgery would be a nightmare to sort out.

Often the relevant partner will pop into their colleague’s consulting room to give an opinion and a second appointment is not needed.

Referral rates are low

Keeping up to date with a speciality is rewarding and good for one's self esteem. We all know that medicine is so complex that no one doctor can hope to cover it all. Our hospital colleagues have been limiting themselves to ever narrower fields so it makes sense to follow their example but in a less extreme manner. It is satisfying to read a specialist journal in detail and feel in control of one clinical area.

Some might say that this de-skills a generalist but at Holbrook Surgery the feeling is that we work very much as a team and that ‘the sum is greater than the parts’.

Also our CCG does very well out of us as our referral rates are lower than other practices – as much as 70% lower in some of our special interest areas.

Six partners and nine specialties
  • Dr Jonathan Heatley - dermatology, minor surgery
  • Dr Paul Woods - neurology
  • Dr Ann Williams - gynaecology, contraception
  • Dr Nadia Ziyada - opthalmology, gynaecology, contraception
  • Dr Hwa-Lon Liu - ENT
  • Dr Preet Singh - cardiology, general medicine

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