Becoming a GP with a special interest

There are many advantages to becoming a GPSI, says Dr Lizzie Croton.

The acronym GPSI has been a buzz word in general practice for some time and regularly finds its way into MRCGP questions in some form. While there are general issues covering all GPSIs, you will find that arrangements for GPSIs vary from place to place.

GPSIs are GPs with additional experience and training in specific clinical areas. They take referrals from other clinicians within a primary care organisation (PCO) and assess or treat patients within their specialist interest. This approach is intended to free up secondary care outpatient appointments for more complex patients.

Patients usually receive an appointment with a GPSI more quickly than they would be seen at the hospital and, because many practitioners operate from GP surgeries, they are seen closer to home.

Clinicians may spend two sessions a week doing work as a GPSI and the rest of the time in general practice. GPSIs ideally work under the supervision of a local hospital consultant.

The advantages of being a GPSI include increased variety of work; an opportunity to develop an area of interest that may lead to research projects or audit; opportunities to mentor and train other potential GPSIs; and improved relationships between primary and secondary care.

We tend to think of GPSIs only as providing clinical services for patients.

However, their role can stretch to encompass education, leadership, research and management. However, this article focuses on clinical services.

Areas of specialisation
The scope is huge but, in general, you can specialise in any clinical area that interests you and in which you have appropriate experience.

In primary care, 80 per cent of consultations relate to chronic disease and this is something that GPs are very experienced at dealing with. An interest in a particular area of chronic disease management could be developed into a GPSI service. The top three GPSI services in England - in order of popularity - are dermatology, minor surgery and CHD.

How to gain the necessary experience
First, think about what clinical interests you have. We are all specialists in 'generalist medicine' but do you, for example, enjoy dealing with emergencies or treating patients with epilepsy? Have you come to general practice via another route such as surgery and have considerable operating experience?

Focus on one area only if you can. It is impossible to be a GPSI in everything.

Postgraduate membership or diploma exams in a subject, for example the diploma in practical dermatology, are useful to consolidate knowledge and gain skills.

Individual clinical frameworks state that GPSIs should have a broad portfolio of experiential and postgraduate training and this can be gained from various sources. A good place to start is to approach local secondary care consultants and arrange to sit in on outpatient clinics to learn the necessary skills. If procedures are to be a part of the GPSI service, they should be learnt and practised under supervision before becoming independent. You should keep a logbook of procedures.

There is now a national accreditation system for GPSIs in England, however, individual PCOs have their own requirements for each specialty. There are also guidelines produced by the RCGP for the appointment of GPSIs in a variety of clinical areas. These can be found on the DoH website.

Setting up the service
Generally, GPSIs are commissioned by individual PCTs in response to local needs in their area. The PCO may then provide the funding for any necessary equipment or staff needed to run the service. Interested individuals may approach the PCO directly with ideas for a service. Many practices are using GPSI services as part of practice-based commissioning.

Maintaining standards
The RCGP has recommended that GPSIs set aside 15 hours a year for continued professional development in their specialist area. They should keep a personal development portfolio linking their learning needs with the competencies required for the service and evidence that these needs have been met.

This training record should be signed by an educational supervisor and form part of the annual appraisal process. The GPSI may also want to become a member of a professional organisation relevant to the area of interest, such as the British Geriatrics Society.

Many GPSIs prescribe drugs that would usually be restricted to secondary care, for example isotretinoin for acne. This reflects their increased experience. There should be a clear understanding of where clinical and prescribing responsibility rests between GPs and GPSIs.

In cases where a patient has been started on medication that would not normally be prescribed in primary care, the patient's usual GP should be contacted by the GPSI to check that they are happy to take over prescribing responsibility for that patient.

Finally, it is important that your defence organisation is aware that you are a GPSI. If you are employed directly by the PCO or the acute trust, you will be covered by the Clinical Negligence Scheme for Trusts. However, an independent contractor may have to adjust their level of insurance to reflect the additional services they are providing.

Dr Croton is a GP registrar in Birmingham

Learning points

How to become a GPSI

  • Focus on your areas of interest, trying to concentrate on one area if you can.
  • Work out what experience you have and what you still need to do the job. Approach local secondary care consultants to learn more about your special interest.
  • Work closely with secondary care. Be aware of your limitations and refer appropriately.
  • Maintain your professional standards. Keep a personal development portfolio and join a professional organisation relevant to your area of interest.

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