17 February 2008

The truth about GPSIs

GPs have been very effective gatekeepers between primary and secondary care. It's one of the reasons why the NHS used to be the most cost-effective healthcare system in the world. But the government thinks that GPs have been wasting taxpayers' money by sending patients to hospital unnecessarily. After all, what could the hospital possibly have to offer that a GP couldn't deliver? Plainly, so government thinking seems to go, GPs have been just a little bit idle and have been offloading their work to the hospital. Just maybe, of course, GPs are not confident in every area of medicine. But that can be dealt with by a little extra training. And then you can call the specialist GP a GPSI (general practitioner with specialist interest).

Consultants have been somewhat sceptical about the value of such an approach. But that has not stopped the training of 1000 GPs in specialties with long waiting lists. Until recently this has taken place with little scrutiny. So what is the evidence for this approach? The NHS Service Delivery Organisation Research and Development Programme has funded two separate studies which assess the cost effectiveness of GPSIs.

The results come as no surprise to Dr Grumble:

  • The introduction of GPSIs did not reduce waiting times at the hospital clinic
  • The cost of GPSI clinics was always higher than the hospital (up to twice as high)
  • GPSIs were paid more than the hospital doctors
  • One consultant saw twice as many patients as the GPSI (a chance finding when a consultant replaced a GPSI temporarily)
Dr Grumble thinks it is time for a moratorium.

This post was originally published on 28th December 2006. It was intended as a warning about the government's efforts to move specialist care into general practice. General practice is a specialty in its own right. Patients are not cases with focused conditions to be managed by specialists. They are people with a range of problems. They present with symptoms. Palpitations might be a result of anxiety, cardiac disease, asthma treatment or an endocrine disorder. Sorting these things out is what the GP is good at. Knowing the patient makes it easier for the doctor and patients certainly prefer to see a doctor they know. As patients get older (and our population is getting older) they don't come with one disease suitable for one expert, they come will multiple ills best dealt with in one sitting by a generalist. Occasionally a particular problem will need the hospital but it really is not going to be cost effective to duplicate the resources you must have in hospitals in every shopping centre in the land. The government's GPSI initiative was the beginning of this plan (which has privatisation as its goal). Evidence quickly accumulated to suggest that this really might not be a cost-effective way forward but this did not stop the move towards polyclinics. But our government is not evidence-based. If it was we wouldn't ever have gone looking for weapons of mass destruction.


Anonymous said...

Unfortunately, Doc G, the PCTs are being told to get on with these soviet-style polyclinics.

DrCrippen said...

My PCT is not currently pursuing polyclinics, but who knows what tomorrows post will bring.

GPSIs are of course complete a complete nonesense as I have been saying since I started.

Can't understand what makes some of my colleagues do it but I fear it is a combination of inferiority complex and boredom with the job for which they trained. GPSIs are of course quacktitioners (=healthcare workers doing jobs for which they are not trained.)

What no one seems to understand is that this is NOT a question of status or intelligence, it is a question of not being able to do a job for which you have not trained. A consultant has a completely different skill set to a GP and they are both equally disastrous when translocated into the other's environment. And remember, whilst the GPSI quacktitioner is seeing hospital patients, his patients are being seen by the nurse quacktitioner.

Worst of all, it is an example of the two tier medical system. Quacktitioners of for the poor folk, and appropriately trained doctors for the rich folk. You don't see quacktitioners if you go privately.

It's all crackers.


PhD scientist said...

Mrs PhD Sci is equally scornful of the GPSI idea and of Darzi's polyclinics, Dr G.

One of her major reasons for this is,as you put it, "Knowing the patient makes it easier for the doctor". It seems obvious to me how this applies in General Practise, or where she works in OH, but she says it was just as true in hospital when she was seeing repeat customers in Respiratory or Renal. The way she put this was: "when you know the patient well it only takes one look to see if their condition's changed".

Her view is that the polyclinic concept and GPSIs will lead to endless re-doing, and re-assessing, much needless, simply because all continuity of care by a particular doctor will be up the spout... if it isn't already.

Of course, one would think this was a fairly simple idea for people to get their heads round, so I am amazed it hasn't had more coverage in the press. The way that the words/concepts "access to specialised care" and "one stop shop" have dominated all the debate is quite striking

I remember reading a story (though I can't remember where) from GP that summed up the "continuity" aspect rather well. He was recounting how he had been discussing referring one of his patients to the specialists in a sort of 50:50 call, and he had said to the patient "well of course [the argument for referring is that] I'm not an expert on XYZ".

The patient's answer, he said, was "Yeah, doc, fair dos, but you are the expert on me".

The Shrink said...

What's the motivation and rationale behind this unsavoury notion?

"that has not stopped the training of 1000 GPs in specialties with long waiting lists

Waiting lists may be a fair part of it. If you refer to your local hospital and there's a huge wait for an appointment or an intervention, alternatives will be sought. Whether that's "going private" or turfing to your GP GPwSI mate, it gives an outcome now rather than waiting months.

The other element that perturbs me is that, to prevent the waiting list and solve 18 week waits, some elements of Secondary Care have embraced quactitioners.

Do you send your patient to a poorly trained Secondary Care quacktitioner or to a GPwSI quacktitioner? Those overly enarmoured with Primary Care doing everything will presumably see GPwSI as the lesser of two evils . . . at least a medic with a generalist head can focus on the problem.

They're not being entertained in my corner but how widely is this being pursued, nationally?

Anonymous said...

What's the motivation and rationale behind this unsavoury notion?
This is all about privatisation. If you can create a group of experts outside the hospital and put them together in large polyclinics you can then sell these units off to be run by Virgin or Boots or, worse, Kaiser. You won't need the expensive hospital and those expensive consultants. For example, any old doctor could claim to be an expert dermatologist and give out ointment. The punters won't be able to tell good practitioners from bad - most dermatology patient don't die. The new organisations will be shiny and new and will have thick pile carpets which cost rather little compared with expertise but impress those who know no better. That's what it's about. Where have you been if you do not realise that?

Dr Grumble said...

Don't be too harsh, anonymous. You are not supposed to understand the purpose of all this. Or does The Shrink think we are suffering from delusions. If so, I have no insight. We are not the only ones with these delusions.

cramerj said...

It is a while since I retired but was there not a range of diplomas eg DA, DCH etc to let the GP have a special interest and to help out at clinics. Seemed popular at the time.
Or do GPs know everything these days.