DEVELOPMENT OF GENERAL PRACTITIONERS WITH SPECIALIST INTEREST (GPwSI) IN CARDIOLOGY

POSITIONING DOCUMENT

The purpose of this document is provide clarity within the Grampian Managed Clinical Network (CHD) on the evolving role of General Practitioner with Special Interest in Cardiology. Existent guidance from national bodies (which is recent and may evolve further) and agreed position within the MCN have been taken into account.

Introduction:

There are several forces and drivers leading towards the inception and development of a comprehensive intermediate care system for patients with cardiovascular disease. These include political will, patient preference, ever increasing referrals to secondary care, better use of available resources and in the private sector, a desire to reduce costs. However, if this is to be successful then a balance has to be struck between ensuring that only the most appropriate patients are managed within general practice and, that if GPs are to look after these patients, robust support mechanisms, appropriate training and resources are freely available. Some models of GPs working in this way have not been deemed to be successful purely as they do not seem as cost-effective as traditional models but this is to ignore the other potential benefits. However it would be naïve to ignore cost-effectiveness when the health service is chronically under funded.

The Grampian model:

Preliminary assessment by a panel of GPs, cardiologists and managers found that up to 40% of current referrals could be potentially managed initially in general practice thus avoiding the traditional approach of early cardiology referral. This has also been termed as ‘refining the referral.’ This assumed that appropriate investigations (for example, exercise testing, echocardiography and Holter ECG recording) were available. It also assumes that GPs have the necessary skills to interpret and apply the resultant data to this refining process.

In Grampian it has therefore been decided that intermediate care has a great deal of potential but will need to be introduced carefully. Existing practices may also need to be modified. There is potential for clinically useful intermediate care clinics in a variety of areas including atrial fibrillation, palpitations, chronic heart failure/breathlessness and perhaps chest pain assessment, although the latter may be hampered by the poor diagnostic and prognostic capabilities of exercise electrocardiography. The relative merits and limitations of various community clinic models will be assessed by the community cardiology subgroup of the MCN over the coming months.

Thus themodel can be summarised as follows:

  • Develop increased general cardiology skills (encouraged via participation in formal recognised dedicated courses, “road shows”, general education events, guidelines, annual cardiac symposium etc)
  • Provide 1:1 teaching for these GPs with a Consultant Cardiologist, adapting the available national recommendations/curricula.
  • Develop further enhanced skills forGPs prepared to take the ‘lead’ role in cardiology in their locality (via the Cardiology Fellowship programme)
  • When deemed “competent” by the paired consultant to start operating back to back with the community cardiology consultant.
  • When resources allow to provide additional technician/nurse/administrative time to allow GPwSI to run own formal clinics but meantime to take lead in provision of intermediate cardiology care in their practice.
  • To extend this role beyond their own surgery by providing an on going knowledge interface to other surgeries in the area.
  • Appointment of 4 additional GpwSI to be based in centres being developed for community cardiology (Elgin, Peterhead, (Inverurie), (Turriff), Stonehaven and Aberdeen). 1 already existing providing a rapid access chest pain clinic in Aberdeen.
  • Endeavour to bring the current service provision in Inverurie and Turriff into line with above for good practice and clinical governance reasons.

Clinical Governance issues:

It is important that both GPwSI and the Consultant Cardiologists are not exposed from the medico-legal point of view with respect to this development. This has been a particular issue in England although no know cases of issues of either direct of vicarious responsibility are known.

In Grampian the situation has been clarified and lines of responsibility are as follows:

  1. A GP with Special Interest (GPwSI) is not a ‘junior doctor’ to the Consultant Cardiologist. He/she is deemed as an independent, fully registered General Physician working as a ‘partner’ on the basis of his/her special interest. He/she is therefore primarily responsible for his or her clinical decisions as would be in his/her normal General Practice. They (the GPwSI’s) should therefore be covered by their own medico-legal insurance as there are no special circumstances in their role.
  2. A GPwSI is also covered by the CHP clinical governance arrangements.
  3. Both NHS and private insurance arrangements cover a consultant cardiologist.
  4. Whereas, in practical terms, the situation of teaching/training a GPwSI is no different to supervision of a ‘junior doctor’, for clinical decisions made by the GPwSI independently, ‘1’ shall apply.

The MCN on behalf of NHS Grampian endorses the above arrangements.

Reimbursement:

GPs will be paid a standard NHSG sessional payment for their GPwSI services. This will usually be used for backfill arrangements.

Progress to date:

Progress with the Intermediate care project has been very satisfactory and we are now, for example, on the second cycle of 12 GPs in the Fellowship Programme. The four GPwSI are in post and are steadily progressing their own skills and undertaking more complex assessments in the community cardiac clinics. Hopefully they are also improving the care of their own and partner’s cardiology patients. This is difficult to measure but we would hope that despite discharge of many traditional review patients the number of referrals will level off. There is also conclusive evidence of fewer referrals from Aberdeenshire where intermediate care provision, by virtue open access services, has been established for several years. However, these data also point to an excessive degree of investigation in order to achieve this, which reinforces the need for excellent quality education in the appropriateness of investigation.