Published: 02/12/2004, Volume II4, No. 5934 Page 33

The greatest problem for primary care trusts is a huge deficit of adequately trained healthcare professionals to deliver the government rhetoric on healthcare.

The need to invest in focused clinical activity requires PCTs to develop core special expertise. Generalist skills will become subservient to special and enhanced skills over the next 10 years.

Key to all this is the development of trained and accredited practitioners with special interests (PwSIs).

First, PwSIs are essential to the delivery of national service frameworks, which require clinical champions with the right skills to lead service development.

Second, they can provide an answer to the acute shortage of staff for the delivery of unscheduled/out-of-hours care as a result of GPs being allowed to opt out.

Thirdly, PwSIs could be among the providers that PCTs include in choice.

Without their involvement, most PCTs outside the major conurbations will have extreme difficulty in meeting choice targets.

Lastly, PwSIs could play an important role in diagnostic and treatment centres, delivering low-cost intermediate healthcare that avoids the need for hospital admissions.

PwSIs may have existed in the past as hospital practitioners or clinical assistants. Unfortunately many of the latter did not have any formal training and little or no opportunity for acquiring skills.

However, there are 35,000 GPs, together with hundreds of nurses and allied health professionals, who already have the basic expertise on which to build enhanced and specialist skills.

In many cases GPs are keen to develop new skills, and specialist nurses are ideally suited to train as PwSIs. Clinical assistants could also be provided with further training.

The value of PwSIs has been demonstrated by independent audits and a National Audit Office report earlier this year, which criticised the patchy development of trained and accredited PwSIs across PCTs.

Some PCTs have simply re-labeled some of their GPs as PwSIs to fulfil national requirements for developing more primary care services. However, this is no longer tenable.

Regulations relating to clinical governance, appraisal, revalidation and medico-legal issues require PwSIs to have formal training and qualifications to take on such enhanced roles.

In addition, PCTs will have to support and resource training and accreditation of PwSIs as the pool of clinicians with the necessary skills and experience dissipates.

There is a range of postgraduate training programmes on offer and professional bodies such as the Royal College of GPs provide guidance on appointing PwSIs and ensuring a suitable level of clinical skills.

However, ad hoc development of PwSIs will only be a waste of time and money. PCTs need to put together dedicated teams, properly resourced, and to commit to such developments for five to 10 years rather than being governed by yearly budgets.

Finally, the resources must be ringfenced or at least be an integral part of PCTs' local development plans.

Professor Ram Dhillon is consultant surgeon at North West London Hospitals trust and honorary professor, Middlesex University school of health and social sciences.