GPs with special interests fear being elbowed out as more care moves into primary settings, writes Daloni Carlisle

If you saw the GP press late last year, you might have seen the fall-out from an NHS Employers discussion paper on the future of the medical workforce.

NHS Employers had ventured unwittingly onto some sensitive ground in its discussion of GPs with a special interest - GPSIs, usually pronounced "gypsies". The paper questioned whether they would, in the long term, survive the revolution that will accompany moving care closer to home.

The "comics" (as GPs like to call the magazines Pulse, GP and Doctor) were as one on this outrage, which they reported as the imminent demise of the species, all but accusing NHS Employers of wanting to round up the GPSIs and push them over a cliff.

"We do not have a vendetta against GPSIs," says an exasperated Alastair Henderson, NHS Employers deputy director. "The issues that we raised were valid."

In future more care will be delivered in a primary care setting, he says, and probably by specialist doctors who currently work in hospitals. "On that basis, it seems likely that there will be less requirement or space for GPSIs."

A compounding factor is the development of regulation, and in particular recertification for specialists.

"At present it is not really clear what having a special interest really entails or, more importantly, what as a patient I can really expect from a GPSI," says Alastair. "There has to be clarity about the role, the training, the expertise and the regulation of GPSIs. The patient needs to know what they get when they open the tin."

And the position of NHS Employers on this? "We have been looking at scenarios," says Alastair. "We do not have a special agenda."

Scare stories aside, it is a valid question. Do GPSIs have a future?

Added value

But first a bit of history. GPSIs in their current form have been around for a decade or so, although those with a longer memory point out earlier incarnations of a similar role, the clinical specialists and physician's assistants.

In 2000 the NHS Plan called for the creation of 1,000 GPSIs by 2004. Initially they were dubbed "consultant GPs" and then GPs with specialist interest, before settling down to the current title. This apparent conformity masks a wide range of experience, expertise and assessed competence, however. The best of the GPSIs have recognised qualifications gained at master's level with a relevant medical royal college and work under the supervision of a consultant; others have simply set themselves up with a title.

That is what underlies James Kingsland's problem with GPSIs. "I was a clinical specialist for six years," says the practising GP and chair of the National Association of Primary Care. "It was hospital based and I worked alongside a consultant. I added value and increased capacity by working in the consultant team."

Then along came GPSIs. "The model when it started was to have specialist generalists who could work independently of the consultant team in the community," he says.

For James, this raises two questions. Either they are doing what generalists should be doing anyway, in which case what is the point, or they are doing interventional procedures such as endoscopy that really should be done in a unit with supervision from experienced clinicians.

"Take for example the GPSI in dermatology," he says. "It describes what I think primary care trusts should be commissioning from general practice."

Shahid Ali, a GPSI and deputy director for GP provider services at Bradford and Airedale teaching PCT (thought by many to be the birthplace of GPSIs) is very clear about the value of GPSIs. The PCT has over 100 accredited practitioners in 21 specialties including dentistry.

"They have been an enormous success," says Shahid. "If they disappeared tomorrow, it would cause enormous problems for secondary care."

Practice-based commissioning, Lord Darzi's next stage review and choice will all come to bear on how the role develops, he says, and with an eye on that, the PCT has already begun to redesign the diabetes service.

"We are moving to a tiered service," he says. "Tier one will be routine care delivered in primary care. Tier two will be an enhanced service in primary care. Then tier three will be a specialist service with GPSIs working closely with consultants in a community setting."

The PCT role in this is to provide accreditation, describe the relevant competencies clearly and set out the clinical outcomes expected for patients.

In fact, a very similar service was set up in Medway PCT in Kent seven years ago by GPSI Stephen Lawrence. It hinges on close links with the consultants who provide clinical supervision for the GPSI.

Stephen is very clear about the requirements of this kind of clinical governance. "All GPSIs should be allocated to a consultant and be accountable to them," he says. Otherwise the GPSI service risks simply becoming an irritating appendage of secondary care without doing anything to develop the patient pathway.

NHS Alliance chair Michael Dixon sees the care closer to home project strengthening not weakening the role. Working in the community requires a holistic approach as well as an understanding and links with the entire fabric of community services, he says, and that is a primary care practitioner role.

"There will be more GPs, nurses and allied health professionals with a special interest doing the work that's right for them but hopefully alongside specialists from the hospital," he says.

Teams without walls

Nevertheless, consultants (and indeed private providers) are already lining themselves up to provide services in the community.

Stephen Lawrence is sceptical about whether the sums add up. "It's not just the consultant's time in the community, it's also the cost of taking him or her out of the session at the hospital," he comments.

Clare Gerada, Royal College of GPs vice chair and lead for GPSIs, sees the role evolving over the next five years "We are now looking at teams without walls," she says. "I think we will end up with a sub-specialist working at the interface between primary and secondary care. That might be a GP or a pharmacist or physician."

It is clear that PCTs are going to need to take charge of this. James Kingsland urges them to look to the tools provided by world class commissioning to assess what is on offer and what is needed.

"Are GPSIs really adding capacity and value?" he asks. "If this is really just a form of referral management or dealing with the low-tech, low-complexity stuff that generalists should handle, it should not be commissioned."