GPSIs in dermatology and skin surgery play an important part in the management of skin disorders. But since the release of the first guidelines in 2003, there has been significant variation in service quality, leading to the development of new guidance.
All existing GPSI services need to be reaccredited by March 2008. For those working well, this will be straightforward, but poor services may be reviewed by the Healthcare Commission .
Developing new services
The process of developing a new community service will take on a different format. First, the need for the new service has to be demonstrated. All aspects of development, including care pathways, must be multidisciplinary, with involvement from primary care, specialists and patients.
The guidance aims to promote best use of local resources, so a GPSI may not always be the most appropriate individual to provide the new service.
Guidance for commissioners
The guidance will be sent to commissioners across England and made available online, so any health professional can access it.
It has been developed at three levels. The first is a generic document, Implementing care closer to home - providing convenient quality care for patients, developed by the Practitioner with a Special Interest National Accreditation Steering Group. It comprises an introduction to commissioning more specialised care closer to home, a step-by-step guide to commissioning more specialised care delivered by accredited practitioners with special interests in community settings and national guidelines for the accreditation of GPs and pharmacists with special interests.
If a GPSI is deemed the appropriate choice for a role that is to be developed, the individual must satisfy the requirements of the generic accreditation guidance. One such requirement is the need to be on a GP performers list and hence continue their role as a GP, in addition to providing specialist work. Although attaining the MRCGP is not mandatory, it is recommended because it helps to demonstrate good generalist skills.
The other documents provide disease-specific guidance; for example, there is one for dermatology and skin surgery. The steps needed for disease-specific accreditation link up with the generic accreditation requirements.
The guidance can be found at www.pcc.nhs.uk/205.php#speciality-specific_guidance .
A GPSI's VIEW - BY DR TIM CUNLIFFE
For me, the five key areas are quality, opportunity, competition, demand management and integration. Quality is perhaps the most important, in that the quality of care provided by any new service must be at least as good as that provided by existing specialist services. The new methods of assessment allow for a more objective evaluation and are in keeping with developments in training within the NHS.
One of my concerns in the past two years has been an increasing trend for commissioners to employ GPs with an interest in minor/skin surgery, sometimes without formal accreditation.
Many of these individuals are skilful surgeons, but they do not always have the diagnostic skills needed to manage skin lesions, or the management skills needed for non-surgical treatment options for premalignant skin conditions and low-risk basal cell carcinoma. The inclusion of skin surgery and community skin cancer services in the guidance is an essential step towards improving standards.
It is more effective for a GPSI to be able to diagnose and treat appropriate skin lesions without referring. A commissioner employing one GPSI in dermatology and one in skin surgery would leave a service wide open should one practitioner leave; employing two practitioners who can diagnose and treat makes the service more sustainable.
Opportunity and competition
The training required to become a GPSI has reduced from 100 to 50 clinics.
GPSIs can manage a wide range of skin disorders, which may otherwise have been managed within secondary care.
The guidance has opened the door for a range of health professionals to develop a service in the community. This is correct and allows for best use of local resources, so the most suitable professionals can be chosen to deliver the service.
Two further points that are worthy of mention concern non-consultant career grade doctors (NCCGs) and consultants. Should a commissioner consider employing an NCCG, it is only right that the NCCG should be subject to the same accreditation process as a GPSI. With regard to consultants, I believe their place is mainly, but not always, in hospital clinics, so they have the time to deliver high quality care to patients with the most troublesome skin disease, perform research and educate specialist registrars.
Demand management and integration
The guidance makes little reference to demand management, which is a shame, given that resources are limited and the NHS needs to be made as efficient as possible.
Simply introducing new clinics (community or secondary care) has the potential to increase demand. To manage demand, commissioners need to consider the need for new services to deliver increased levels of education to GPs.
Another area needing attention is referral management, for example, schemes such as CAS/CATS (clinical advisory service/ clinical advisory treatment service). In the case of a poorly complying, poorly integrated GPSI service, such schemes can place local specialist departments under strain. On the other hand, a good referral management scheme (a well-integrated GPSI service or effective consultant-led service) can bring significant benefit by preventing low-priority framework (principally cosmetic) conditions from being referred.
It can also direct patients to the most appropriate individual at the first point of contact, reducing tertiary referrals.
Perhaps the key to success is two-way integration, which is not always easy. The advent of more multidisciplinary accreditation should make the process of integration more straightforward.
If a service is developed with the support of local consultants, patients are likely to reap the most reward.
- Dr Tim Cunliffe is a GPSI in dermatology and skin surgery at Middlesbrough PCT and a member of the GPSI in dermatology working group of the Primary Care Dermatology Society
A CONSULTANT DERMATOLOGIST'S VIEW - BY DR JULIA SCHOFIELD
The DoH considers the development of practitioners with a special interest an essential part of the strategy to meet the commitments of the February 2006 White Paper.1
The role of the GPSI was first proposed in the NHS Plan in 2000.2 A framework for the development of dermatology GPSI services was published in 2003.3 Support from consultant dermatologists has varied.
Some health communities have developed integrated models of care, including GPSIs. But concerns have been raised by many dermatologists about the training, accreditation and continuing professional development of some dermatology GPSIs. An audit against the 2003 framework showed disappointing compliance.4
Implementing care closer to home
Consultant dermatologists were delighted to be involved in the development of the new guidance documents for commissioners, launched in April 2007.
Implementing care closer to home5 was developed by a multiprofessional stakeholder group with wide representation and facilitated by the DoH.
The underpinning ethos is that wherever care is provided and whoever provides it, the quality should be the same.
There are three parts to the guidance. Part one reminds commissioners that quality care can be provided in community settings by a variety of healthcare professionals, provided they meet appropriate standards and are part of integrated models of care and clinical governance frameworks.
Part two provides excellent advice about how commissioners should assess need, review current service provision and shape the structure of supply to meet the requirements of the local health community. Accrediting the service and individuals delivering it then follows. Patient and public involvement is encouraged at all stages of development.
Part three provides the generic framework for accreditation of GPSIs and pharmacists with a special interest (PhSI). The revised definition of the GPSI is helpful, making clear that the clinician is a GP first and the special interest is second.
The document defines the accreditation process and reminds commissioners that the GPSI/PhSI must meet the requirements of the relevant specialty-specific framework. A final decision about whether part three will be mandatory is awaited.
Owing to the fact that the generic frameworks were due to be published and that there were concerns about the inadequacies of the 2003 framework, dermatology specialty-specific guidance was developed by a multidisciplinary group and released concurrently with the generic documents.
The National guidelines for the accreditation of GPSIs: dermatology and skin surgery6 offer information on a curriculum for dermatology, core competencies, teaching and learning methods, and assessment tools. This supports the accreditation process and should ensure that all dermatology GPSIs are appropriately trained to deliver the service that they have been commissioned to provide. The emphasis has moved to competency-based assessment, rather than a fixed number of sessions in dermatology. Requirements for community cancer clinicians are also clarified to meet NICE skin cancer guidance.7
Dermatologists and patients should feel reassured that there is now a robust framework to ensure the development of high quality integrated services, but there are some areas of concern.
First, the time commitment required to support the process of teaching, accreditation and reaccreditation. The documents state that these costs will need to be allowed for in the commissioning process, but nevertheless, clinicians will need to be released from other areas of responsibility to take on these roles. The time required to train and perform competency-based assessments for junior doctors is already significant.
The second concern is the more difficult issue of whether it is justifiable to engage in the process when the development of GPSI pre-choice services may result in cherry-picking of easier cases and subsequent loss of income to secondary care services through payment by results, with resultant financial instability.
The future of integrated services
The opportunities for the future of integrated services for patients with skin disease sit within parts one and two of the commissioning guidance.
Review of need and the development of service models with patients at the centre of the delivery of care should provide local solutions for local problems.
Engagement in this process will enable commissioners to identify the most cost-effective, accessible, high quality service. In some areas, this may be provided by suitably trained and accredited GPSIs, but in others, NCCGs, dermatology specialist nurses and consultant outreach may by better options for commissioners. NCCGs are usually established members of local dermatology teams and as such, have established clinical governance frameworks in place.
In areas where there are large reductions in commissioned activity, the only way to retain consultant posts may be for consultants to be available to provide outreach services. This is arguably not a good use of time, but is certainly good quality, value for money and possibly the best way to preserve the local specialist service that may otherwise be under threat.
The message is that secondary care clinicians and business teams need to look carefully at these documents, understand them fully and be proactive in implementing high quality care close to home, engaging fully with patients and commissioners.
- Dr Julia Schofield is consultant dermatologist, St Albans City Hospital, Hertfordshire, and Action on Dermatology clinical lead
1. DoH. Our health, our care, our say: a new direction for community services . Chapter 6: Care closer to home. HMSO, London, 2006.
2. DoH. The NHS Plan. A plan for investment. A plan for reform . HMSO, London, 2000.
3. DoH. Guidelines for the appointment of general practitioners with special interests in the delivery of clinical services, dermatology . HMSO, London, 2003.
4. Schofield JK, Irvine A, Jackson S et al. General practitioners with a special interest (GPwSI) in dermatology: results of an audit against Department of Health (DH) guidance. Br J Dermatol 2005;153(S1):0-1.
5. DoH. Implementing care closer to home - convenient quality care for patients. Parts 1-3. HMSO, London, 2007.
6. DoH. National guidelines for the accreditation of GPwSIs: dermatology and skin surgery . HMSO, London, 2007.
7. NICE. Improving outcomes for people with skin tumours including melanoma . NICE, London, 2006.