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GPwSI article


General Practitioner with a Specialist Interest (GPwSI) article

– Q & A with Dr Holmes

Steve Holmes

Dr Steve Holmes is a GP, working for a group practice in Shepton Mallet, Somerset. He is also an Associate Dean at Health Education South West, Severn. We asked him several questions about becoming a GP with a Special Interest (GPwSI):

How many types of GPwSI roles are there?

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.

  1. 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.  
  2. 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 care.
  3. 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 you?

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 interest.

What sort of training would I need to become a GP who works with a local commissioning group?

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 risks.

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 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 you advise?

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 the PCO.

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 interest.

I’m interested in the role of becoming a lead in the group practice, what sort of things would I be accountable for?

As practice 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 position.

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:

  • Dermatology
  • COPD
  • Cardiology
  • Woman’s health
  • Musculoskeletal healthcare/ sports injuries
  • 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 NHS.

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.