Twenty five stakeholders in total took part, encompassing patients with asthma and/or Chronic Obstructive Pulmonary Disease (COPD) (n = 7), secondary care nurses and allied health professionals (n = 6) primary care nurses (n = 4), general practitioners (n = 3), secondary care doctors (n = 3), a PCT manager and a non-Leicester respiratory GPwSI. One of the Leicester GPs was also a GPwSI (non-respiratory). Four focus groups, three face-to-face interviews and four telephone interviews were used to collect data (see Table 1). The key themes were fed back by e-mail to all the GP practices (n = 28) in one of the PCTs: no dissenting responses were received.
Can a generalist be a specialist?
There was some ambivalence within the different focus groups and interviews as to whether a GP could also be a specialist. Even the title 'GP with a Special Interest' was challenged.
"You'd have to do away with the title GP for a start. If you're talking about a specialist then he's a specialist" (Patient)
"The word 'specialist interest' will disappear, because it is not the right word, just because you have got an interest, but some of them they are going to be a specialist in time, the interest will vanish and they become a specialist in that arena" (GP)
At a theoretical level, it was suggested by some participants that generalist skills could usefully broaden the perspective of specialist consultations, especially in patients with co-morbidity.
".they [GPs] understand where the patient is going through all sorts .., how their heart failure is getting on, how their diabetes is being managed, and take the patients who may have 3 or 4 illnesses. We don't often see the whole picture purely because we can't." (Respiratory physician)
"... if everybody specialises ... you would go to the diabetic GP, the heart GP, the respiratory GP, and who is left to know the patient as a whole?" (Primary care nurse)
Some nurses, however, disputed the holistic role of GPs and thought that this should be the role of nurses, though nurse specialisation (e.g. in the UK, nurses are increasingly providing chronic disease management in both primary and secondary care ) was seen as a threat to that important role.
"Maybe that's quite a key point actually isn't it, that a GP because of their training is probably not capable of looking at them holistically and with chronic disease such as this they need holistic care to keep them out of that revolving door syndrome" (Secondary care nurse)
"And it maybe that the nurses are asking to do that, but a lot of nurses are specialised now and do respiratory and all that..." (Primary care nurse)
Both patients and professionals expressed concern about the potential adverse effect specialism might have both on the individual's generalist skills and on the future of general practice.
"If Dr [GP], we'll say for arguments sake he was an, if he was upgraded to a specialist in asthma or breathing problems wouldn't that then diminish the GP side of this practice?" (Patient)
"deskilling from a GP" (Secondary care allied health professional)
"GP's will have portfolios in the future, I do not, I cannot foresee a generic GP, as we know them, carrying on delivering the NHS Plan" (GP)
The roles of a GPwSI
A variety of possible roles were suggested as being appropriate for a GPwSI to deliver. For example:
Providing a clinical service for patients, that would be "local, and easily accessible" with a familiar doctor in whom patients felt they could "have more confidence"
Providing education and support, as a clinician who was "respected of his colleagues, and would oversee and would be approachable and helpful, a trainer and co-ordinator." 'Bridging the gap' between primary and secondary care was specifically highlighted: "to set, you know minimum standards of what GP's can and can't manage..., and to also say to the hospital doctors, 'look this is what we would like you to do with these patients."
Co-ordinating services: "a specialist team, working in the community"
Developing new services: e.g. pulmonary rehabilitation, intermediate care. a point of referral midway between primary and secondary care
Opinions were divided on the potential contribution GPs could make to specialist care. One healthcare professional felt that a respiratory GPwSI role would not be as large as in other clinical areas because it was well supported by guidelines and was either very routine (and therefore easily delegated to nurses) or very complicated (and therefore should be in the hospital). By contrast, others identified a 'referral hierarchy' which could include GPwSIs.
"Medicine has become [a] very protocol [driven], and what you actually need is someone who can follow the guidelines accurately and occasionally think outside that particular box you know without having to refer up, I am confident that GP's can do that." (Respiratory physician)
"I would sooner see someone that knows a little bit more because [GP] doesn't specialise in asthma. She refers you to [Practice Nurse] but I, you know, I mean very, I think [PN]'s wonderful as well, but if I was having more problems then perhaps I would like to see someone that a doctor that, you know, is just that little bit more advanced than what the nurse is" (Patient)
"Well I still see the very severe and complicated ones coming in to the secondary care, whereas the bulk of the, that middle stage would go to a specialist GP, or a specialist clinic, that would have specialist nurses..." (Primary care nurse)
The local needs of the area were seen as paramount, with general agreement that the role should be clear and avoid duplication of already existing services. Secondary care participants thought that although gaps were still evident, in comparison to some areas of the UK, Leicester was fortunate to have relatively few gaps.
The effect on workload was debated both by patients, who were concerned that their GP was already too busy, and professionals who raised concerns that offering a GPwSI service might not just meet existing need but actually create demand.
"There's certainly a role but would he be able to cope with his normal influx of patients who keep him busy all week now anyway..." (Patient)
"The workload might increase, because if the patients realise that there is more contact available, they might ask for this contact." (Respiratory physician)
The right person for the job?
GPs (or medical doctors generally) were thought to have more power compared to other healthcare professionals when it came to influence over and education of other doctors as well as being able to influence decisions at PCT level. Doctors' ability to prescribe was also seen as an important and powerful lever. This was highlighted several times in the context of comparing the roles of specialist nurses versus GPwSI. For example:
"...if they are going to be a champion, politically, the more clout they carry, the better really" (Secondary care allied health professional)
"...you need a doctor's voice as well.....that is why a lot of initiatives have failed in primary care because there hadn't been that ground swell from within. You can talk until you are blue in the face as a nurse....<snip> sometimes you need to have that label" (Primary care nurse)
"it could be a GP not convinced it has to be a GP...<snip> need to make sure [whoever does it] has the appropriate training, backing and empowerment to provide that service and not have to stand in the corridor saying can you sign this prescription for beclomethasone or whatever." (GP)
Throughout the interviews and focus groups the fact was highlighted that whoever takes on the role of a GPwSI needs to have the trust of their primary and secondary care colleagues as well as the patients, if the role is to succeed. Some of the personal qualities thought to be important for a GPwSI can be seen in Text Box 1.
Making it work: possible issues and pitfalls
Highlighted in the majority of focus groups and interviews is that a GPwSI service should be a multidisciplinary team effort. A GPwSI working on their own was thought unlikely to succeed e.g. "extremely difficult for any one person these days to have all the knowledge" (GP). As well as teamwork ("the GPwSI cannot work without a team of nurses with them" -GP), good links, support and communication with secondary care, primary care and PCTs was seen as pivotal with regards to the success of a GPwSI service.
Taking the wider context into account, another participant pointed out that what was needed was a:
"...general buy-in from the whole health community, for that particular initiative, so that they become part of the wider team of professionals, in helping to tackle the problem of respiratory disease." (PCT manager)
Several stakeholders suggested that emergency cover out of normal clinic hours would be a positive addition to the role of a respiratory GPwSI respiratory care. However, in the light of the new General Medical Services contract in the UK which has allowed GPs to 'opt out' of providing out-of hours care, views were mixed as to whether this would acceptable to potential GPwSIs:
"Well, the role that they could play is there is enough of them to be on call, it is a hospital admission avoidance, and particularly if they are in areas where there is intermediate beds." (GP)
"it [GPwSI service] would probably need to be 24 hrs, and all the other bits that go with it" (Primary care nurse)
"if you are going to take some of that responsibility away from secondary care, em, I don't think it would hurt [being on call], but obviously the GP culture now..." (Respiratory physician)
Another key point, made by both patients and professionals, was the need for a respiratory GPwSI to have access to appropriate equipment and facilities (e.g. radiology, lung function testing) to enable them to undertake a specialist role.