Primary care provision of specialist services.

Medical Association (BMA) has recently issued advice to general practitioners (GPs) on how to apply for and obtain National Health Service (NHS) contracts to deliver specialist services such as vasectomy and endoscopy.1 Recent guidance from the NHS Executive removes most of the restrictions that currently limit the range of specialist procedures that GPs may offer and obtain NHS payment for.2 But what are the likely benefits of a greater degree of specialist provision within primary care to patients or practitioners, and how does this fit in with the traditional role of the GP as generalist and gatekeeper to secondary and tertiary care services? The ideal of the generalist, concerned with whole-person medicine, has been fundamental to general practice,2 but the future may see an increasing number of GPs explicitly developing special interests. The capacity to make internal specialist referrals within a group practice has been proposed as one way of avoiding unnecessary hospital referrals.3 It has been suggested that some fundholding practices could become like small NHS provider trusts, operating within their own ‘mini health service’. 4 Defining the boundary between extended primary care and specialist care is not a simple matter, and varies between different countries; for example, in the Americas, general internists and general paediatricians are regarded as being part of the primary care team.5 For some specific surgical procedures the distinction is fairly straightforward. Minor surgery is now a standard feature in many general practices. Flexible sigmoidoscopy is not commonly carried out in general practice, but probably could be with appropriate training and equipment,6 while colonoscopy or upper gastrointestinal tract endoscopy, which requires sedation, may be better performed in hospital.7 Specialist assessment and advice of the sort that consultants provide at an outpatient clinic will be the most difficult area in which to judge when a GP is offering something that is clearly outside the normal scope of general practice. An increasing proportion of specialist services are now delivered through outreach clinics where a consultant or other hospital specialist offers a session located on practice premises. These have become rapidly abundant over the past few years and are popular with GPs, especially with fundholding practices. The potential benefits include easier access for patients, improved communication between the GP and the specialist, and educational opportunities for both GP and specialist.8 There are concerns that the burden of travelling time for hospital-based consultants may be a limiting factor, and that most outreach services operate as ‘shifted outpatient clinics’9 when a GP is not in attendance, offering little opportunity for mutual learning. Many GPs themselves have current or recent experience of practice in a hospital specialty — in 1992, some 28% of GPs held clinical assistant appointments at a hospital specialist clinic.10 In the hospital clinic, the GP working as a clinical assistant may be providing specialist assessment and opinions on the patients of other GPs under the nominal supervision of a hospital consultant. It seems logical, therefore, that a GP whose specialist experience is acceptable for a hospital-based clinic should also be able to deliver the same service on an outreach basis in practice premises. A local hospital clinician is likely to be the person in the appropriate specialty who is best placed to advise the local health authority whether an individual GP has the necessary skills and experience to provide a specialist service. But this will demand that the hospital clinician is able to exercise professional judgement free of market pressure to view the GP as a potential competitor in the provision of specialist care. With the GP acting as the specialist in such a clinic, some of its advantages could be achieved without the penalty of imposing heavy travelling commitments on a hospital-based specialist. To preserve opportunities for education and clinical audit, good working links between the specialist GP and the hospital-based consultant would be required. Also, we still do not know much about what patients think of existing consultant outreach clinics, and it would certainly be important to establish how they would view their own GP acting as both generalist and specialist. Current NHS specialist referral systems rely on the GP taking an objective view of the need for specialist referral in the first place, and maintaining a healthy scepticism on the need for continued follow-up. This gatekeeper function of general practice has been argued as being essential to the health benefits that good primary care brings, by protecting patients from unnecessary procedures and adverse events.5 Conversely, if the GP is also acting as specialist to his or her own patients, there could be an incentive to make unnecessary specialist referrals and maintain overlong specialist follow-up. In the case of fundholding practices, this would have financial implications. Until now, regulations have prevented fundholding GPs from paying themselves to deliver outpatient services,11 but recent changes in Department of Health regulations have now removed this constraint.20 Clearly agreed clinical protocols on effective patterns of care can provide both an assurance of good clinical practice and some protection against perverse financial incentives. Shared care between hospital and general practice is now a familiar way of providing obstetric services and managing chronic conditions such as diabetes. Depending on the levels of organization and training, the quality of care provided in this way has been evaluated either as inferior to, or as equal to hospital outpatient care.12,13 A number of commentators have drawn attention to the implications that increasingly shared care will have for the role of the specialist. Tudor Hart noted in 1992 that, although UK hospital specialists had been under less pressure to subspecialize than their US counterparts, this situation was beginning to change.14 One suggested response to what is seen by some as consultant over-specialization, is the creation of more ‘community’ specialists who could filter out patients suitable for treatment in the primary care setting, and work mainly in the community.15 From the ranks of hospital practice, there may be concerns that such community specialists would become sub-grade consultants and that subsequent recruitment difficulties would occur. However, GPs themselves might well be suitable recruits as ‘general physicians in the community’, and might welcome this additional career development opportunity.16 The NHS could stand to gain from such a development since GPs, by comparison to their hospital medical colleagues, have shown themselves to be more selective users of specialist investigations17,18 and more ready to identify alternatives to hospital admission.19 Increasing involvement of general practice in the delivery of more specialist services is a trend that has been evident in various ways for some time. There are potential benefits to patients, the health service and GPs themselves. However, clear safeguards will be necessary both to protect traditionally valued aspects of general practice and to ensure that new services are delivered to the standards that patients have a right to expect.