Haywood Hospital, Stoke on Trent and Primary Care Sciences Research Centre, Keele University and 1 Department of Rheumatology, Barnsley District General Hospital, Barnsley, UK
Correspondence to: E. M. Hay, Primary Care Sciences Research Centre, Keele University, Newcastle under Lyme ST5 5BG, UK. E-mail: e.m.hay{at}keele.ac.uk
Rheumatology seems peculiar amongst all the medical specialities in having an ongoing identity crisis about what the speciality represents. An often-heated debate, which started many decades ago, continues to address such fundamental issues as how best to diagnose (lump or split); which patients to treat (are we really inflammationologists?); who should treat the patients (doctors versus nurses); and where they should be treated (primary or secondary care). Although understandable, such debates can draw attention away from our united goal: to improve the care of patients with musculoskeletal pain across diagnostic categories, across organizational boundaries and across professions.
What needs no debate is the fact that musculoskeletal problems are common, are a major reason for pain and disability at the individual level, and have a major impact on society in terms of health service utilization and payments for incapacity benefit. It is also clear that hospital services in the UK are running at full (or over) capacity, with their agenda firmly set on delivering emergency medicine and meeting government-enforced targets. In a nutshell, secondary care has no foreseeable hope of delivering an adequate service to meet the increasing demands and needs of patients with musculoskeletal problems. However, the alternative of simply transferring the workload from secondary to primary care will not work, as this will just turn our problem into their problem. We need to work together to develop new ways of working that ensure patients with musculoskeletal problems receive timely, appropriate care within the limits imposed by limited resources. This is clearly a tall order!
General practitioners (GPs) with special clinical interests in rheumatology/orthopaedics are nothing new. Many rheumatology centres have relied heavily on GP clinical assistants for years. What is new is the notion of GPs with special interests (GPwSIs) as a recognized breedbut what are they, who are they, who are they answerable to, what do they do, who do they treat, how much do they earn? The short answer to all these questions is that nobody knows. GPwSIs emerged from the UK's Department of Health (DOH) in a mist of confusion, suspicion and distrust from both primary and secondary care sectors [1].
A recent survey of GPs carried out by the Arthritis Research Campaign (ARC), the Primary Care Rheumatology Society (PCR) and Keele University confirmed that there is wide variation across the country in what GPwSIs do, their working relationships with secondary care and their contractual arrangements. Only 34% of respondents who considered themselves to be GPwSIs had a contract and only 17% had a GPwSI-specific annual appraisal. In total, 139 GPs identified themselves as GPwSIs, and we suspect that the true number exceeds this. Despite these problems, it is now obvious that GPwSIs are here to stay as part of the National Health Service (NHS) workforce [2, 3], and we need to try to draw order out of the chaos.
The first bit of potential good news is that musculoskeletal conditions was one of the ten condition-specific frameworks for which the DOH commissioned the Royal College of General Practitioners (RCGP) to draw up a GPwSI framework. In taking this remit forward, the RCGP has endeavoured to have representation from a wide range of stakeholders. This has included input from the British Society for Rheumatology (BSR). This framework (www.doh.gov.uk/pricare/gp-specialinterests) sets out the rationale for a GPwSI service and the core activities a musculoskeletal GPwSI might undertake. It makes explicit that a GPwSI service should not operate in isolation but should rather be part of an integrated service across primary and secondary care. The framework also acknowledges that the exact makeup of the service will vary from place to place and will need to be responsive to local needs. The strong steer from the framework is that the bulk of a musculoskeletal GPwSI's workload will be concerned with diagnosing and treating common non-inflammatory problems, such as regional pain and osteoarthritis. Furthermore, and perhaps even more importantly, the enhanced diagnostic skills of a GPwSI will facilitate the recognizing and fast-tracking of inflammatory arthritis and other red flags. One thing that is very clear from this document and from subsequent statements from the RCGP is that GPwSIs are to remain very much general practitioners. There is no intention, from the GP community at least, for these individuals to become specialists or mini-consultants.
The framework acknowledges that there are a number of issues still to be worked through with respect to GPwSIs. One is ensuring that GPwSIs have access to adequate and appropriate facilities and investigations, such as magnetic resonance imaging, electrophysiology and orthotics. The prevailing view is that such facilities should be available, but usage should be consistent with the relevant national and local protocols. Questions also arise about the accountability, monitoring and clinical governance arrangements for musculoskeletal GPwSIs. Again, the emphasis in the framework is on flexibility whilst maintaining a credible robustness, the precise arrangements to be sorted out at the local level. Consequently, accountability and monitoring could be either with the Primary Care Trust (PCT) Board or with a local NHS Hospital Trust, depending upon the configuration of the service. Regardless of the geographical and organizational location of the service, the importance of good mechanisms for joint working, communication and training between primary and secondary care is highlighted. We are encouraged by this.
The second reassuring piece of news is that, following a period of lengthy consultation with a number of groups, the DOH has agreed that a process of standard-setting for expected competencies for GPwSIs is crucial. These competencies will, broadly speaking, fall into two categories: general competencies relevant for GPwSIs from all specialities, and specific competencies relevant to the given clinical interest. The RCGP has a working party addressing the issue of general competencies. This working party is also addressing how the attainment of both general and specialist competencies should be assessed. Once again, the aim is to seek a degree of flexibility whilst ensuring that there is confidence by all stakeholders in the competency assessments themselves.
With respect to the speciality competencies, the RCGP have made it clear that the remit for this lies with relevant primary care societies in close liaison with the RCGP and secondary care speciality organizations. Happily, we are ahead of the game here. A working party with representation from a number of relevant groups, including the RCGP, PCR, ARC, the British Institute for Musculoskeletal Medicine (BIMM) and the BSR, have already held a meeting to drive forward this process. During a weekend workshop, progress was made in terms of agreeing core competencies for musculoskeletal GPwSIs and detailing the appropriate knowledge, skills and attitudes required. A draft document setting out the recommendations of the working party is now being put out for consultation with various stakeholders, including patient representatives.
There are a lot of unanswered questions remaining about the contribution that GPwSIs, and other extended scope practitioners, might make to innovative musculoskeletal services. Robust evaluation will be required to assess the clinical effectiveness, cost-effectiveness, acceptability and sustainability of such services [4, 5]. Overall, it is time for the rheumatology profession to adopt a united and optimistic approach with respect to the future of our important speciality. The key to improving the management of common musculoskeletal problems is to ensure that the appropriate patients are seen by an appropriate person in an appropriate setting. There is no shortage of work for all in the diagnosis and management of patients with musculoskeletal conditions. The advent of interface services, spanning the boundary between primary and secondary care, provides a unique opportunity to expand, strengthen and secure the future of rheumatology. Such services are a key feature of the DOH's forthcoming Strategy for Musculoskeletal Services, and GPwSIs and other trained musculoskeletal team members from primary care can make important contributions to their success. These initiatives complement rather than compete with hospital-based rheumatology services, which will clearly continue to play a crucial role in the management of patients with complex rheumatic disorders.
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