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)
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.