Is specialisation working?

Use of GPSIs varies hugely across geographical and clinical areas. Tom Moberly reports.

Dermatology is the clinical specialism most likely to be taken up by GPSIs
Dermatology is the clinical specialism most likely to be taken up by GPSIs

Introduction of GPSI services in England has been hugely variable across different PCTs and clinical areas, a GP investigation has found.

While most PCTs have fewer than 11 GPSIs each, three have more than 50. Although GPSI services cover more than 30 clinical areas, half of all GPSIs work in just five of these.

The extent of these variations has been revealed in responses from 90 PCTs to a Freedom of Information Act request about GPSI services.

Leading the way
It is clear that a number of PCTs have led the way because of the additional resources and efforts put into organising these services, following recognition of the benefits they can bring.

NHS Bradford and Airedale, with 104 GPSIs, has almost 15 times the number most other PCTs can boast. Simon Long, head of specialist services at its community health services division, says the PCT recognised the benefits of GPSIs early and encouraged their development.

NHS Hampshire, which has 53 GPSIs, carried out an audit to identify gaps in services. The PCT then used the DoH's GPSI framework to help it commission services to fill these gaps, says its head of primary care performance and improvement Manda Copage.

But other PCTs have been less keen to develop GPSIs.

Part of the variation arose because services in some areas were already adequate, suggests Dr Brian Karet, a GPSI in diabetes in West Yorkshire.

'In many areas there may not be a lot of pressure on secondary care. In that situation, there would be little need to redesign services.

'In other areas, with more pressure on secondary care services, there may be a desire to provide more services in a community setting,' Dr Karet adds.

But differences in service need are not the only reason for the wide geographical variation in GPSI services.

Dr Paul Charlson, a GPSI in dermatology in East Yorkshire, says that although patients recognise the benefits of GPSIs, others are less enthusiastic. 'Consultants are sceptical because they do not want to have work taken away,' he says.

Dr Sarah Gray, a GPSI in women's health in Cornwall, says GPSI services need to meet two key criteria.

'GPs need to have the expertise to offer a level of service that is above the routine care offered by all GPs, at an intermediate level between primary and secondary care,' she says.

GPSIs have tended to focus on clinical areas in which there is a clear way to fit their services into this gap, she says.

But, Dr Gray adds: 'There is then the question of whether that expertise is recognised by the PCT and a service commissioned. There may be all sorts of GPs whose expertise is not being recognised.'

Dr Clare Gerada, vice-chairman of the RCGP, believes the problems stretch beyond a failure to recognise the potential of GPSIs. She argues that the development of GPSI services is 'losing momentum'.

Loss of momentum
Since the RCGP and DoH handed over the development and appraisal of GPSI roles to PCTs there has been a great deal of confusion, Dr Gerada says.

There is no agreed place for GPSI services and PCTs have been implementing accreditation schemes in completely different ways, she adds.

'There needs to be a central policy on this. The whole thing needs a re-emphasis of leadership,' she suggests. 'The programme needs a clear idea of where GPSIs fit in.'

However, Devon GPSI Dr Brian Malcolm, who was involved in developing the DoH's GPSI guidance, believes problems run deeper still.

'It was a "horse and cart" situation,' he says.

'The DoH created GPSIs - it wanted to set them up in six months - and then took a number of years to work out what they should be doing.

'The whole thing was a good idea ill thought through.'

GPSI Hotspots
Top five pcts - number of GPSIs

  • NHS Bradford and Airedale (104)
  • NHS Gloucestershire (76)
  • NHS Hampshire (53)
  • NHS Eastern and Coastal Kent (43)
  • NHS Devon (37)

Top five clinical areas in which GPs practice

  • Dermatology
  • Minor surgery
  • Substance misuse
  • Vasectomy
  • Ear, nose and throat

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