In this edition of Diabetes & Primary Care, Dr Brian Karet presents the results of a survey that provides the first comprehensive dataset on the demographics, clinical practice, education and accreditation of GPs with a special interest (GPwSIs) in diabetes (starting on page 298). This interesting work is a valuable and timely piece of research coming at a time when the management of people with diabetes (among other long-term conditions) now falls very much within the sphere of primary and integrated care services. In respect of diabetes, this transition was triggered via the National Service Framework for Diabetes (Department of Health, 2003), as well as the new General Medical Services contract and the inception of the Quality and Outcomes Framework.
One way of managing the demands of increasing numbers of people with long-term conditions is, as Dr Karet details, through the use of accredited GPwSIs, often working alongside secondary care specialists; this is really the essence of a truly integrated service. As long ago as the year 2000, GPwSIs were identified as a means of delivering such integrated care, and there are several well-documented examples of where this works well (Department of Health, 2000). However, in turn, the additional financial resources that have followed the transition of conditions such as diabetes into community management is associated with increased accountability and a need to provide clear evidence of improved clinical outcomes.
As a general principle, ensuring that care takes place closer to home in the community, often via local practitioners, has a huge number of very tangible benefits for people with diabetes and the clinicians involved in providing care. When structured correctly, this can clearly lead to efficiencies and reduce duplication of work across both primary and secondary care services. I think few involved in community-based or integrated care services would deny the obvious advantages. Furthermore, a key element of the role of GPwSIs is also in the organisation and planning of services and in the provision of patient and professional education. Given the recent introduction of clinical commissioning groups, this now provides a platform for the role of the GPwSI to come to the fore. Furthermore, GPs in general are being forced into a position of increased workload and increased expectations, but at a time when resources are increasingly stretched. For many of us, developing an additional role as a GPwSI is one way of managing and coping with the rigours of the increased demands we face through the acquisition of increased knowledge and skills.
The survey described in this issue of the Journal provide an extremely useful snapshot of the current state of play. But with all of the above discussion in mind, for me there is a certain unease and frustration regarding the results. The design of, and working arrangements for, GPwSI provisions also differ, but it probably goes without saying that the individual structure and nature of integrated services need to be pertinent to the demands of the particular locality, and variances in this regard are understandable.
However, in my view, the most pertinent issue is the fact that only a third of respondents in the survey had been through a process of formal accreditation. I believe that GPwSIs must be supported (and support themselves) in the acquisition of core competencies, which should lead to formal accreditation. The fact that there isn’t a more well-defined means of obtaining formal accreditation strikes me as unsatisfactory and, moreover, is an untenable situation that should not be allowed to continue.
Clinical experience is the most valuable asset anyone can possess. However, each of us faces increased scrutiny and, now more than ever, we need to be able to display demonstrable enhanced skills and improved outcomes for our patients. One way of supporting GPwSIs is through a process of formal accreditation. I find it bizarre that in an NHS where so much attention is focused on ensuring the quality of healthcare services (but often when the areas of focus are of seemingly dubious value), a clear process of formal accreditation for GPwSIs is still not in place.
GPwSIs (and indeed any individual working in such settings) fulfil an important and valuable economical role in the health service that goes largely unrecognised. Developing guidance and a process through which we can obtain formal accreditation is, I imagine, going to take time but I see it as essential.