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Friday 30 September 2016
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The special one: the benefits of a GPwSI

Patients & Services

Mike Merriman
MRCGP DRCOG

GP with a Special Interest in Diabetes
Kirkby

GP Lead for Diabetes
Knowsley PCT

Mike graduated from Birmingham University in 1994, after which he completed vocational training in Blackpool and Lytham before attaining an MRCGP in 2000. He became a partner in Kirkby in 2002. In 2005, Mike completed training to become a GP with a Special Interest in diabetes. He is also the GP lead for diabetes in Knowsley PCT, working in a community diabetes team taking referrals across the borough

With the publication of The NHS Plan and the trend to provide care closer to patients' homes, the role of the GP with a Special Interest (GPwSI) has found fertile ground.(1,2)

A GPwSI is a GP with further training, skills and experience that enable independent clinical activity beyond the core skills of a usual GP.(3) There are many GPwSIs in different guises affecting healthcare around the country. My own area of interest is diabetes, and I work as part of a community diabetes team in Knowsley, Merseyside.

I balance my diabetes work with my main job: being a fulltime GP. I am a partner at a personal medical services (PMS) practice in Kirkby – a town in the borough of Knowsley. We have 10,800 patients over two sites, with three partners, three salaried doctors, a nurse clinician and a full complement of nursing and
ancillary staff.

To become a GPwSI, I had to complete a structured training programme under the guidance of a diabetologist at the local teaching hospital. There are five components to this training:

  • More than 40 clinic attendances at the local diabetes centre.
  • The completion of a master's module in clinical diabetes.
  • Satisfactory attendance at a programme of tutorials and workshops.
  • The completion of an education course covering educational theory.
  • Finally, a formative assessment process by a viva voce examination with two local diabetologists.(4)

Following this training, Knowsley Primary Care Trust (PCT) created a project team that developed an intermediate
diabetes service. Diabetes is about teamwork, and our team comprises a consultant-level nurse, specialist dietitian, specialist podiatrist, a healthcare assistant and a secretary.

We take referrals from across the PCT, and run clinics at four different sites in the borough. At the time of writing, we do not have any formal referral criteria, and see any patients with diabetes problems who do not require consultant care. The main body of our workload is glycaemic or blood sugar control, insulin management and advice on cardiovascular risk. I work in one diabetes clinic a week, in addition to another diabetes session that comprises PCT work.

What are the benefits of a GPwSI?
GPwSIs can benefit their practices and their patients in many ways. Below I've used my own diabetes specialism as an example of the advantages that GPwSIs in general can bring to their surgeries.

A GPwSI can affect diabetes care in several ways. A motivated and interested clinician within a practice can improve care for patients with diabetes, and a GPwSI is well suited to perform this role.(5)

There are educational benefits for the practice. A GPwSI in diabetes can coordinate workshops for the clinical team, covering areas such as diagnosis, glycaemic or sugar control, cardiovascular risk management and insulin treatment. Tutorials can be run for practice nurses to enhance their knowledge and skills. In a supportive environment, this can encourage greater autonomy from the practice nursing team when seeing patients with diabetes.

In addition, the practice team has access to specialist GP opinion on new evidence, guidance and controversies, which can then be relayed with confidence to patients.

GPwSIs can work with the nursing and management teams to improve practice systems such as register development, call recall and relevant tests at appropriate times. The use of IM&T systems to incorporate national and local guidelines can effect patient care by just a few touches of the keyboard.

Furthermore, a focus on screening the "at risk" patients and managing abnormal glucose results can improve prevalence rates closer to the predicted prevalence for the practice. With appropriately trained and confident clinicians, effective practice systems – utilising IT that enhances the use of evidence-based care – should maximise the practice score on the Quality and Outcomes Framework, and thereby increase the practice's income.

A GPwSI in diabetes also offers the opportunity to provide diabetic patients with services that have traditionally been performed by a specialist diabetes team. The initiation of insulin and insulin management can be carried out by GPwSIs or by practice nurses with the relevant training skills and confidence.

Patients then have seamless care, and only need to access hospital or consultant care when there are specific diabetes problems or complications requiring specialist opinion. Using new therapies suitable for primary care that can be managed by a GPwSI broadens patient access and reduces the need for patients to access secondary care. This may also increase income to a practice via a local enhanced services framework.

The presence of a clinician with confidence in a disease area can have a positive effect on the practice team. Providing a high-quality service for patients with a long-term condition benefits the practice's team morale and confidence, as well as its willingness to be even more innovative.

A GPwSI often has a strategic role within the PCT.6 This means that the feelings, ideas and thoughts of the practice team and its patients can influence the design and delivery of diabetes services in the local community.

The GPwSI has an important role in the delivery of services in our communities.(6) GPwSIs can work with local GPs and commissioning teams to design services that meet the local needs of patients using the appropriate skill mix. Patients who might otherwise need to travel to hospital clinics can be seen closer to home. GPwSIs are well placed to form strong links with local consultants to enable them to incorporate their services into secondary care services in an integrated way.(6)

GPwSIs can also be involved in the education of local GPs and primary care teams. This can mean speaking at events, such as PCT protected time afternoons, or locally targeted meetings with medicines management or educational groups. Practices can make use of the GPwSI by mentoring, case discussions
and co-consulting.

The GPwSI can work with the diabetes team and the PCT to respond to clinical situations or changes in drug information. For example, the team can work with medicines management to produce protocols and guidelines on home blood glucose monitoring, saving money for the PCT via the drug budgets. Sudden changes in drug information may require a prompt response from someone who understands the relevance to primary care – GPwSIs are well placed to offer sensible advice to colleagues.

The roles of GPwSIs are as diverse as their number. The dual role requires hard graft, determination and the ability to juggle two workloads and responsibilities. At times, there are conflicts and it is inevitable that the other doctors in the practice will end up working harder when the GPwSI is away even if there is backfill, since energy diverted away in the diabetes team is energy not spent in the practice. As a result, goodwill is essential.

Yet conversely, the wealth of skills, learning and business opportunities that a GPwSI can bring to a practice far outweighs the drawbacks. In the modern primary care era, every practice should have one.

References
1. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: DH; 2000. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. Department of Health. Our health, our care, our say: a new direction for community services. London: DH; 2006. Available from: http://www.dh.gov.uk/en/Healthcare/Ourhealthourcareoursay/index.htm
3. Department of Health/Royal College of General Practitioners. Implementing a scheme for general practitioners with special interests. London: DH; 2002. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
Guidance/DH_4009799
4. Department of Health. Implementing care closer to home: convenient quality care for patients. Part 3: the accreditation of GPs and pharmacists with special interests. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
Guidance/DH_074430
5. MacKinnon M. Providing diabetes care in general practice: a practical guide to integrated care. 4th ed. London: Class Publishing; 2002.
6. Department of Health. Implementing care closer to home: convenient quality care for patients. Part 2:  step-by-step guide to commissioning services using Practitioners with Special Interests. London: DH; 2007.