Lesley Hill On referrals management

Published: 11/11/2004, Volume II4, No. 5931 Page 29

GPs and nurses with special interests first emerged during fundholding in North Bradford primary care trust. For specialties with poor access where some referrals could be managed by an 'intermediate tier' and consultants were prepared to train GPs, specialists appeared. The first specialties in Bradford to have GPs with special interests were urology and neurology, predominantly because in these areas consultants were prepared to train GPs.

Training of GPs with special interests usually follows the 'sitting by Nellie' approach to education. The GP initially sits in with the consultant, then moves on to seeing patients as part of a consultant clinic, and finally to seeing patients in primary care. During this process, referrals are triaged so that the GP in training is seeing referrals appropriate to their skill level. In some specialties there is a diploma course the GP has to pass, as well as the local training.

Before the GP can see patients in primary care they have to be accredited. This involves a Bradford-wide panel determining whether the GP is competent to deal with certain areas of a disease. The accreditation specifies which type of patient problem the GP is qualified to see.

There has been general enthusiasm for GPs with special interests in North Bradford. Over the years, our referrals have gone down and many patients are managed successfully in primary care who would historically have needed to go to secondary care. GPs with special interests are relatively well paid and bring income to practices. They are still cheaper than secondary care outpatients. The GPs doing this role enjoy the fact they have a 'portfolio' career.

In North Bradford we now have GPs with special interests in ear, nose and throat, drugs services, mental health, urology, musculoskeletal services, neurology, plastic surgery, rheumatology and pain management.

We also have a variety of nurse specialists.We have specialist optometrists triaging ophthalmology referrals and a dentist with a special interest doing some extraction work that oral surgeons would have historically done.

The consultants are keen to train these specialist practitioners. The benefit to them is that they can concentrate on more complex referrals and their waiting times are managed. GPs with special interests are involved in hospital clinical audit sessions to ensure that high-quality care is provided. Consultants develop and retain good links with primary care. The hospital management team actively encourages this development - it helps to achieve targets.

So why are so many hospitals being so difficult about training GPs with special interests and new practitioners? As well as being better for patients (because access is easier and waiting times lower - for highquality services) it helps them achieve access targets.We aim for all GPs to have a special interest.We currently have more than 50 per cent of GPs trained and functioning as specialists. The practices backfill their primary care sessions list using nurse practitioners and salaried GPs who, as part of their contract, have a session a week to train as a GP with special interests.

It would be good to see more hospitals taking this development positively as a way of providing local, responsive care.

Lesley Hill is deputy chief executive of North Bradford PCT, winner of the prime minister's award at last year's HSJ Awards.