Could the roles of hospital specialists and GPs be adapted to provide closer integration, better patient care and decreased waiting times? James Ward and Romesh Gupta report

Could the divide between primary and secondary care be narrowed in the interest of patients? Current provision of services within the NHS leads to a wide segregation between the two. GPs are expected to have a broad area of knowledge encompassing all specialties. As a result, they become the gatekeepers to secondary care and specialist opinion.

At the same time the NHS suffers from lengthening waiting lists for both specialist opinion and subsequent specialist investigation. While it is difficult to interpret the significance of waiting-list numbers as a whole, the fact that by the middle of 1999 500,000 people had waited over 13 weeks for specialist opinion since original referral by their GPs suggests that as a whole patients are waiting too long.

1This wait leads to extended suffering and anxiety for those concerned. Following their consultation they may then have to wait a considerable length of time for subsequent investigation and diagnosis of their condition.

There is undoubted frustration among patients at the seemingly disjointed transfer between primary and secondary care, and a desire for a seamless transfer.

The increasing number of investigations available puts extra pressure on already stretched services. As the public become more aware of health problems there is an increasing desire for specialist opinion and higher expectations. These pressures are added to by the government's pledge to reduce waiting lists and, subsequently, waiting times. While one way of improving the service would be to increase specialist numbers, there is neither the money to create posts nor the juniors in training to fill such posts if created.

The creation of nurse practitioners within the health service has already led to a number of improvements.

Decreased waiting times within general practice, better patient care and developing nursing roles have all been a result of this process over recent years. They have also led to a closer integration between doctors and nursing staff.

Could the roles of hospital specialists and GPs be adapted to provide closer integration, better patient care and decreased patient waiting times?

The most common examples of this occur in obstetrics and diabetic care. GPs also provide some aspects of hospital-based care, such as shifts within accident and emergency departments and endoscopy lists. And it works the other way: hospital-based specialists in some areas provide some community care, such as domiciliary visits in elderly care and the use of cottage hospitals as a stepping stone between hospital and home.

Current medical training within the UK allows for two main career pathways between general practice and specialist training.

Those wishing to enter general practice are required to complete one year pre-registration followed by at least two years as a senior house officer and one year as a GP registrar.

Those planning a career in hospital medicine must complete one-year preregistration, at least two years as a SHO and then five years as a specialist registrar before becoming a consultant - if a post is available.

However, a large number of GP trainees enter vocational training with some degree of experience in other specialties. Could this experience be used by providing GPs with a specialist interest? For those wishing to go into general practice straight from pre-registration, some specialist experience could be provided with a one-year increase in training time.

Instead of four six-month slots, training could be split into three four-month slots with two years in a specialist area, or by continuing with the current training programme with the addition of an extra two years in a specialist area.

To maintain a standard of competence as well as upholding public confidence, the use of qualifications and continuing medical education is necessary.

The initial qualifications could be provided in the form of a number of diplomas already available, such as the diploma of the Royal College of Obstetricians and Gynaecologists and the diploma in cardiology. Subsequent continuing medical education and update could be provided by the local hospital and its continuing education service.

While it would be impossible for a single GP practice to provide more than a limited area of specialisation, with the advent of primary care groups such services could be divided up, with referral between GPs. The GP specialist could take part in clinics within the hospital with consultant specialist assistance.

They could, in particular, see those patients recognised by the referring GP as being in need of further tests. The GP specialists refer on to the specialist or pass back to the first GP as appropriate, thereby decreasing the time patients wait for further investigation. Such a practitioner could be helpful in an area such as cardiology. GPs often recognise the need for an exercise tolerance test in diagnosis of ischaemic heart disease. To obtain such an investigation they often have to refer through the local cardiology specialist.

The patient may then have to wait for up to two to three months for an outpatient appointment and, following this, a further two months for an exercise tolerance test, if deemed appropriate. With this new post, the GP specialist, who could decide on whether the test was appropriate, could first see the patients.

Following the test, the GP specialist could review the result and then refer back to the original GP or on to the consultant specialist as required. This would allow the number of patients requiring a consultant opinion to be determined and would not only reduce their waiting times but also reduce the time patients with other cardiology disorders requiring a consultant opinion have to wait.

Such posts could also be useful in the performance of minor surgical procedures. Many GPs have minoroperation lists within their practices, but a considerable number of minor procedures still require a general anaesthetic. A GP with specialist training in surgery could do some surgery in hospital, thereby creating more time on consultant surgical lists for more complex procedures.

Hospital doctors could also improve integration with community involvement. This could take the form of a period of time spent as a general practice registrar while on a general professional training SHO rotation. This is now included in many medical rotations throughout the country, and in our experience SHOs have found this an interesting and useful period, providing closer links with primary care.

The recurrent bed crisis over the winter months has also led to calls to reopen cottage hospitals with both GP and hospital physician input for the recuperation of elderly patients not requiring daily medical input but with nursing needs. The availability of such beds would improve the bed situation within hospitals and prevent unnecessary readmission.

The essence of general practice is its variety, close patient contact and the practitioner's ability to provide care for the whole family across a wide range of problems. It is vital that whatever changes are made within the NHS, and whatever attempts are made to provide more integration, these qualities are not altered. GPs' specialist interests must never take priority over their general practice work.

There would undoubtedly be problems attempting to initiate such a service. It would take a number of years for enough GPs to progress through a training programme to provide a service over a wide range of specialties. There may currently be difficulties in finding enough training-grade posts within the NHS. It is likely that there would also be some resistance towards such changes from within both hospital-based specialties and general practice.

Key points

Greater use of GPs, both in general practice and hospitals, could reduce waiting times for hospital services.

PCGs might consider developing some specialist services.

The development of GP specialists should be considered.

Allowing GPs with a special interest in surgery to perform some hospital surgery would reduce pressure on consultants' lists.

REFERENCES

1 Health Policy and Economic Research Unit. NHS Waiting Lists. British Medical Association Quarterly Bulletin 1999; 14 (4).