Five steps to becoming a GPwSI and running a service in diabetes

The General Practitioner with a Special Interest (GPwSI) role is a relatively new one (see Table 1 for a description). Although there are GPwSIs working in a variety of specialities, the requirements of a GPwSI in diabetes are generally more complex than in some other areas (see Table 1 for an explanation of the rationale for having GPwSIs in diabetes). One reason for this is that diabetes covers several specialist areas. Thus, not only does it require expert care from health professionals, but the varied professionals need to work together effectively as well.

Importantly, the nature of the condition also means that empowerment enables patients to look after many aspects of their condition themselves (Meetoo and Gopaul, 2005). The result is that the GPwSI must work with the patient and a range of other health professionals in a collaborative and productive manner. 

The five steps
The process of becoming a GPwSI and running a service in diabetes can be seen as one involving five steps.

Step 1: Be an experienced generalist with knowledge of working in diabetes in a practice that is supportive
The GPwSI must be currently working as a GP (Department of Health [DoH], 2003). The DoH guidelines (DoH, 2003) suggest that GPwSIs should work at least one session a week in the GPwSI role. However, in reality, there is a lot of variability in the hours that GPwSIs work. The author believes that working two sessions as a GPwSI is ideal in giving good exposure, with minimal encroachment on everyday GP work.

The GP’s practice needs to be supportive of the extra role being taking on. Thus, the role must be negotiated with the practice. On a day-to-day basis, GPwSI work may take time from other duties in the practice. For example, meetings and phone calls may occur during practice time, when the GPwSI is not actually timetabled to do a GPwSI session. This is one reason why the support of GP colleagues within the practice is so important.

GPwSI payment tends to be more than usual locum rates (Hadley-Brown, 2004), so the practice may, as a result, feel that this gives some compensation for this inconvenience. However, it may be preferable to organise GPwSI hours and payment completely separately from practice work. In this case, the author believes, the practice must still give overall support for the GPwSI work, in order for the GPwSI post to be sustainable in the long term.

The aspiring GPwSI is likely to have a particular interest in diabetes issues and this may well be demonstrated in his or her practice commitments. This special interest is obviously a prerequisite to becoming a GPwSI!

There are several paths a GP could take before becoming a GPwSI. For instance, a GP who has been running a diabetes clinic in primary care might want to develop his or her interest in diabetes by becoming a GPwSI. Working in hospital as a clinical assistant would be another route to becoming a GPwSI. Sometimes, in the author’s experience, GPs have been primary care trust (PCT) leads in diabetes and progressed to a GPwSI from this post. 

Step 2: Organise accreditation, accountability, clinical governance and monitoring
There is not, at present, a centrally agreed accreditation for GPwSIs. This is an area of current debate (Karet, 2005; see Table 2).

In practice, the GPwSI needs to have completed defined core training (Stoke-on-Trent Teaching PCT, 2005). This training can be negotiated with the local diabetes consultant. It is likely to include completion of higher medical training in diabetes: a certificate, diploma or master’s degree. It will also include satisfactory completion of a learning contract. The clinical accreditation panel of the PCT can then grant approval as a GPwSI.

The GPwSI is accountable to the PCT but clinical responsibility rests with the GPwSI (DoH, 2003). The GPwSI follows PCT clinical governance arrangements and must organise supervision from the diabetes specialist (DoH, 2003). GPwSIs need to inform their medical defence organisation that they are undertaking this work, but there is not currently an extra fee with the Medical Defence Union or the Medical Protection Society for the work of GPwSIs in diabetes. 

Step 3: Explore what service is needed and its scope
In the author’s experience, GPwSIs have developed their own service in most cases. Common scenarios include GPwSIs or diabetes specialists seeing a need and then proceeding to develop it with support from their PCT. However, GPwSIs will be increasingly employed to continue or develop services that are already running, the author believes.

The proposed ‘GPwSI’ service should cover an area that is needed, rather than one that the GPwSI is interested in. (The two may often fortuitously go together, the author has found.) It is important to have clarity on this when exploring the need for a service. The service needs to function and be sustainable, whoever the providers are.

It is important to keep patient need at the centre of the design (Gerada, 2005). It is also important to network with key stakeholders to ensure that the service is appropriate for the locality, the author feels. Meeting with local patient groups will give an idea of what resources patients would welcome access to. Liaising with colleagues, in both primary care and secondary care, can highlight areas in which the GPwSI could usefully work.

Communicating with the PCT and GP commissioning bodies is also vital. With the advent of practice-based commissioning, it is important, in the author’s opinion, to develop a service that is likely to be commissioned and is cost-effective in the long term. Commissioning is currently in a state of reorganisation (DoH, 2005a), which leads to uncertainty in this area. Although, in the author’s experience, GPwSIs are typically employed by PCTs, it is conceivable that in the future they may become independent contractors, offering services to commissioning bodies.

There are many components of the service that GPwSIs can offer. For example, by looking at shared care of patients with diabetes, different models can be developed. Some patients have their care unsatisfactorily shared between primary and secondary care (DoH, 2005b). It is clearly important that care is well coordinated and patient centred. Different models of care may lead to working in a more joined-up way.

There are some patients whose needs are not best suited to primary or secondary care. Developing a clinic for some of these patients in an intermediate care setting is a possible solution. Looking for ways to improve communication between primary care, secondary care and the patient is another. With a GPwSI leading a multidisciplinary team, a different style of care can be given to patients (Hadley-Brown, 2004).

Setting up a new service requires planning on many levels. Because the service is being designed to run in a different way and often in a different setting, this may exclude it from usual operating procedures. Thus, it is vital that the setting-up is planned thoroughly.

The GPwSI service may have particular needs in terms of infrastructure and IT. For instance, if a multidisciplinary team is envisaged, space and confidentiality for all members of the team is necessary. And if the service is being offered outside secondary care, patient records may need to be accessed via the internet, requiring IT expertise and resources.

The development of multidisciplinary teams may also require the employment of new staff. The appointment of and funding for staff needs to be organised. Prescribing and administration also need to be budgeted for and planned. It should be noted that changing existing services – particularly moving services from secondary to intermediate care – may not always reduce costs in the short term. 

Step 4: Enrol a team and design the service
A crucial part of working in diabetes is the team approach. There is a variety of health professionals that can be part of the intermediate care team, such as diabetes specialist nurses (DSNs), dietitians, chiropodists and psychologists. There is also a variety of ways of working together. It is useful (as described below) not only for the health professionals to work as a team, but also for the patient to be involved with the team arrangement. In the author’s opinion, the GPwSI is often in a good position to lead the team. The author also feels that the ideal situation is for the team planning to work within the proposed service to include the people that develop it.

In an intermediate care service, the GPwSI and DSN may see patients together. If this is done, a person with complicated type 2 diabetes who is considering starting insulin, for instance, is able to explore this with both the GPwSI and DSN. The patient has access to a breadth of knowledge, which is helpful at this crucial time. If the decision to start insulin is made, the DSN and the patient have the advantage that they were both part of the decision-making process. They may then find that they work together more effectively in the initiation of insulin therapy.

On the other hand, the dietitian may wish to see the patient separately, since it is often more useful for a patient to have a one-to-one discussion of dietary habits. The dietitian would, in this case, benefit from meeting with the whole team to discuss a plan for the patient after his or her consultation. The patient would also gain from being present and contributing at this time. In addition, the GP letter could be written at this time, with all professionals having an input. Ideally, the patient would also receive a copy of this letter.

The location for the service should be convenient for patients, and transport should be provided for patients with mobility problems. The location will often be a medical centre or GP practice; it is useful if the service can be offered outside hospital premises, as this may be more acceptable to patients who find hospitals distressing. These premises are also often a cheaper option, in the author’s experience.

Referral and care pathways need to be considered and specified. The author feels that it is an advantage if local stakeholders are involved with this process. It is also an opportunity to consider less traditional referral pathways. For an intermediate care service, it may be appropriate to have referrals from GPs, practice nurses, DSNs, dietitians and consultants. The service would then be truly bridging gaps between primary and secondary care. Being a multidisciplinary organisation with lay members who have diabetes, the local diabetes network can have a particularly valuable input into the development of these referral and care pathways.

It is also vital to organise the administrative systems – in a new service, the administrative infrastructure is often not present. This may be a complicated issue in intermediate care, where existing systems are often not useful. In the author’s experience, when working in intermediate care, it was not possible to access hospital records and there was no secretarial support on site. Thus, it may be necessary to set up new systems for accessing patient records and communicating with patients and health professionals. 

Step 5: Pilot, run, audit and evaluate the service
A pilot is useful when starting a new service. Both the patients and the service providers can give feedback on the process. This helps to refine and improve the service.

Running the service is not an end point. The GPwSI should ensure that the service is not only sustainable but also dynamic. In this way, the GPwSI needs to constantly review the service and consider different, improved ways of delivering care. The original vision for GPwSIs was for them to improve patient care by ‘improving skills and links, etc. across the NHS’ (Gerada, 2005).

The GPwSI needs to look at the impact that the service is having. Meetings with GP and consultant colleagues will provide some of this information. The GPwSI needs to have regular meetings with the commissioning body to look at the caseload and design, as the service develops. Feedback from patients can also be useful.

Evaluation of the service needs to be a regular process. For an intermediate care service, this might include review of correspondence with the diabetes specialist.

Other considerations
Barriers
The author understands from communication with other healthcare professionals that the common blocks to GPwSI posts being developed are lack of resources from PCTs, lack of interest among local GPs and reluctance to change established services. 

Education
Updating skills
GPwSIs need to have an ongoing relationship with the local diabetes consultant. This should involve a joint partnership with the consultant that includes a supervisory component (DoH, 2003). 

NICE guidance
Another possible area of activity for a GPwSI is structured patient education. This is of particularly relevance as the DoH has recently announced that all PCTs will need to implement guidance from the National Institute for Health and Clinical Excellence (NICE) on structured education from January 2006 (http://www.nice.org.uk/page.aspx?o=68326; accessed 17.11.2005). 

Other roles
GPwSIs are also likely to have a role in local professional education and be a member of the local diabetes network. 

Conclusion
Becoming a GPwSI in diabetes and proceeding to run a service is a natural progression for many GPs who are interested in diabetes. It requires good networking skills and the ability to work within a multidisciplinary team. As with any innovation, it will be necessary to overcome unforeseen problems and to learn new skills. With the advent of practice-based commissioning it is not entirely clear at present how GPwSI posts will develop in the future.

Becoming a GPwSI can enhance a GP’s job satisfaction both clinically and through contributing to an innovative way of developing patient-centred care.