General Practitioner with a Specialist Interest (GPwSI)
– Q & A with Dr Holmes
Dr Steve Holmes is a GP, working for a group
practice in Shepton Mallet, Somerset. He is also an Associate Dean
at Severn Deanery. We asked him several questions about becoming a
GP with a Special Interest (GPwSI):
How many types of GPwSI roles are
Initially the RCGP and Department of Health
defined GPwSI as those working clinically across a PCO (Primary
Care Organisation) area or similar to help to reduce specialist
waiting times and address local health needs. However the spectrum
of GP with Specialist roles has now developed and I would say there
are three different sorts of roles.
- One type of GPwSI is appointed by the Primary Care Organisation
(PCO) or equivalent and in this role you would tend to cover a
local area or county. This is a formally appointed role and you
would be undertaking local work commissioned and funded by the PCO,
usually working in a clinical environment across the PCO area. This
may be currently at a federation or clinical commissioning group
level. You would be involved in triage and clinics aiming to avoid
unnecessary specialist care.
- A second GPwSI role works with a local commissioning group.
Here you would be expected to work outside of your own group
practice and could for example become a local or regional lead,
helping to develop local guidelines, services and pathways of
- The GPwSI lead role in a group practice. It is common for
medium to large group practices to share out the workload and look
to ensure that there are lead clinicians for many areas. This often
requires the GP to develop their skills and can open doors in area
meetings if you are interested to develop skills further and engage
at a commissioning level or as a clinical GPwSI. This is the zone
that most general practitioners move up from – they are the GP with
an interest / responsibility in for example dementia, then do work
with other practices or helping develop services – perhaps then
helping produce guidelines or doing specialist clinical work.
Which type of GPwSI are
I am a lead for several areas in the practice
I work in (asthma / COPD / dementia / GP training and
research). One of these I have been able to develop into a more
specialised role. After a period of time I started to work more
across the local area in the respiratory field (second type of
GPwSI as described above) helping to develop services, develop care
pathways and being engaged in guideline development locally. Over
time this gave me opportunities to become involved at a regional
and national level in guidelines (BTS / SIGN asthma), patient
organisations (British Lung Foundation and Asthma UK), research
with a variety of universities, teaching and working with the
primary care society for those with a respiratory interest (Primary
Care Respiratory Society – UK) as well as involvement with
colleagues in other countries such as Australia, Canada and Sweden.
I am also very much involved with Education as an
Associate Postgraduate Dean in general practice education. Since
becoming a GP trainer, I have been involved in work as a GP tutor,
training programme director, PCO education lead, clinical senior
lecturer, GP appraisal lead and clinical governance lead.
What sort of training would I need to
become a GPwSI lead in a PCO, or equivalent?
Undertaking a postgraduate qualification would
ideally be the first step. There are several diplomas around
that are designed for primary care. Examples include diplomas in
dermatology, cardiology and respiratory. Secondly you may take on a
clinical assistant role – here you would work for maybe one day a
week under a consultant. Thirdly you can study privately in your
own time, and finally you can go to update meetings, that will help
and inform you of the latest information on your specialist
What sort of training would I need to
become a GP who works with a local commissioning
The training can vary considerably – but the
GP working within a local commissioning group will need their GP
skills, some more specialised knowledge of their clinical area and
a knowledge of the processes and potential commissioning methods
that the commissioning group use. There are often both national
(strategic) and more local issues to bear in mind. For example in
some areas, especially in mining and industrial areas there is more
occupational lung disease which can influence how local services
should be developed. Other local industries (farming, fishing) have
The training should be supported by the
commissioning group – who should ensure that you are helped in your
role whatever that may be.
Would you advise taking on some of
this training while I am in GP training?
The GP curriculum is vast and it would be
difficult to fit in any further courses. I would advise you to
enjoy the diversity of GP training, take note of any particular
areas you are particularly interested in and where possible learn
in associated areas – for example if you are interested in
cardiology – you may want to learn more about lipidology or
assessment of breathlessness outside the cardiac world. With some
luck you will soon be the lead in your chosen practice and can then
devote more time to learning more.
I really like one speciality and am
interested in becoming a GP with a specialist interest, what would
It is important to note that even if you are a
GPwSI, you are primarily a generalist with some more specialist
interest. If you are considering which medical career to pursue and
are really interested in one specialist area, then you are better
putting all your effort into becoming a specialist in that area. A
good specialist and a good GPwSI have many areas of similarity but
have different skills to help in patient care. A GPwSI is bringing
the wide spectrum of their clinical expertise and understanding of
family and psychosocial issues to the clinical context.
How does working as a GPwSI differ
from being a specialist in that area?
The boundaries for this might be becoming more
blurred now – however the work undertaken by a GPwSI is likely to
be more general specialist care than a specialist. The straight
forward asthma and COPD being managed in primary care, the more
complex COPD patients and asthma patients by a GPwSI or specialist
and the rare conditions (interstitial lung disease, bronchiectasis
etc) by a specialist.
How much of an expert do you need to
be to take up any of these roles?
There is some variance in the level of
expertise required to take up the three roles mentioned above. For
the first role described, the PCT would ensure that the appointed
GP met the appropriate standards which can be in the form of either
a diploma, experience in a clinical environment (clinical assistant
role) or a portfolio demonstrating expertise in the field. If you
are planning to move down this route, check what the PCO, or
equivalent will be looking for early on and choose an area they are
likely to want to commission. Many areas may be of interest to you
and your colleagues but do not require the funded investment from
For the second type of role, you will need to
ensure that you undertake more continued professional development
in this area. You need to have developed clinical expertise
and an understanding of the patient pathway and evidence base in
order for you to help in guideline and service development. The
national primary care societies can help a huge amount in this area
with peer support, clinical and in some case leadership programmes
run by nationally known GPs with a special interest. The PCO /
commissioning group will often try to help in this area too.
For the third type of role described, i.e.
becoming the lead in the group practice. You would not be expected
to be an expert. However in most practices you will need to do some
extra learning in the area to be able to act as a resource for
other GPs and nurses and to help to improve the overall quality of
care provided. You would need to be up to date with NICE guidelines
and QOF (Quality and Outcomes Framework) and may be part of a
federation or commissioning area practice leads group which gives
you more networking and access to others with a similar
I’m interested in the role of becoming
a lead in the group practice, what sort of things would I be
As practise lead, you may be required to have
an interest in an area that does not hugely appeal to you. Most
practices would try to ensure that the less appealing roles were
shared out fairly and where possible to colleagues in areas they
had interest in.
Here is an example (not exhaustible) of the
types of areas you would be the in charge of:
- providing QOF data (i.e. quality data) and ensuring the
practice achieves targets
- informing your colleagues of new preparations and guidance
- holding in-house educational meetings on your topic area
- attending local network meetings representing the practice
- working with nurse team or other clinicians in house
- undertaking audits on quality care.
How easy is it to become a GPwSI lead
in a group practice?
Being the lead in the group practice is not
just for experienced GPs, often practices are keen for newly
qualified, enthusiastic GPs to take on this role. When you are
applying for roles, it will be important for you to find out if
there is a need for a GP with a specialist interest within the
practice. Larger practices may have more opportunities and you may
be able to find out from the GP surgeries’ website, the job
description, or by talking to someone in the practice. It will be
important to find out whether the specialist interest that you have
is desirable in that practice. If someone already has the lead
role, there may not be much scope for you to take on that
What types of areas are common for you
to be GPwSI in?
The areas could be non-clinical e.g. local
medical committee, commissioning or an interest in education
(trainer, GP Tutor, appraiser). Other common areas are:
- Woman’s health
- Musculoskeletal healthcare/ sports
- Reproductive health.
Will my employer pay for my training
and/or allow study leave?
This will be in negotiation with your
employer. Each year you will be expected to complete a certain
amount of CPD so that you are up to date with all forms of
medicine. You may be able to negotiate some study leave/finance for
courses as part of your appraisal. Some people choose to pay for
the extra courses themselves and they use their own free time to
study. Unfortunately nothing is guaranteed. It may be that your
practice will allow you some more freedom once you have established
yourself, and when they feel you are more settled in the role.
Will I get paid more for taking on any
of these GPwSI roles?
It would be great to say that we would get
paid more to undertake GPwSI roles – and this may change over
time!! At the current time working within a commissioning group or
as a GPwSI you are likely to get sufficient backfill to keep the
practice happy – though you may end up doing work in the evenings
and at other times. The payments are better than working as a
clinical assistantship – but the majority of those undertaking
GPwSI roles do this for the interest, challenge and job
satisfaction rather than money. There is probably better paid
(though less professionally stimulating) work in other parts of the
Many of my colleagues really enjoy the GPwSI
work even though it doesn’t make them any more money – as it can
open doors to other opportunities. (This year I have been
fortunate to visit Glasgow, Edinburgh, Vienna, San Franscisco and
many other parts of the UK with my respiratory work – and have
turned down invitations to Spain and Zimbabwe – next year I am
looking forward to doing some work in Bangladesh).
Our thanks go to Dr Steve Holmes for
agreeing to be interviewed for this article. Thanks also go to
doctors Vivak Hansrani, Nilima Shah and Ying Teo for reviewing the
article and for their suggestions.