BGS policy is quite clear that this should not mean a move away from our standard: all older people who are ill are entitled to appropriate specialist care irrespective of whether this is provided in a district general hospital, a rehabilitation setting or in their own home. This is to ensure that reversible medical conditions can be identified and treated, and the patient’s optimum function restored. This has led to ongoing work by the BGS Policy Committee in conjunction with the British Association of Emergency Medicine to develop a statement proposing the presence of older people’s specialists in emergency departments, to support decisions about admission or transfer to intermediate care.

Indeed our recent updated statement, Developing Intermediate Care (BGS Policy Committee 2003), about intermediate care itself applies. The recent report from the Federation of Royal Colleges of Physicians (Working Party on Medical Aspects of Intermediate Care. Royal College of Physicians, London 2003), explores in detail the need to ensure the appropriateness of medical cover for intermediate care, particularly for older people.

However there is an increasing tension for all specialists in older people’s services, who face growing demands for specialist expertise outside the traditional hospital setting, whilst also trying to ensure that the standards in acute hospitals continue to improve.

The GP’s Perspective
From a General Practitioner’s (GP’s) point of view, initiatives to devolve the care of older people may be perceived as an ill-considered transfer of clinical responsibilities from hospitals out to the ‘community’, with little or no resource to support them. GP’s, who provide the bulk of services for older people in such circumstances, find themselves increasingly bereft of time, money and support staff which they need to do it well.

General Practitioners with Special Interest
We may now have a new opportunity to address some of these issues. One of the strategic ‘thrusts’ of a primary care led NHS (through PCT’s in England ) is the concept of general practitioners with a special interest (GPwSIs). A far cry from the established ‘clinical assistant’, these GP’s will have developed appropriate professional portfolios demonstrating their competence in the clinical care of older people and, where relevant, in allied skills such as service development or education. Crucially, whereas the work of clinical assistants is subordinate to consultants, GPwSIs will work as independent clinicians.

The RCGP and BGS, in consultation with the DoH, have agreed a professional framework for a GP with Special Interest in Older People’s services (GPwSI-OP). These will be active and experienced GPs who may work as principals or in salaried posts. They may be expected to have a strong local knowledge and local ties. They will be able to work in a complementary manner with existing geriatric and old age psychiatry services, to augment and develop the services locally. Many will be primarily involved in the non- hospital or community aspects of the service (for example intermediate care) – but they will be no less specialist for that.

The framework – some of which is printed here - can be downloaded in full from here
Its provisions include:

• The GPwSI-OP should work cohesively with local consultant led services
• Most should work closely with their local Department of Geriatric Medicine
• Clinical governance, appraisal and other professional development, may be shared
  between GPswSIs and consultant led services.

Although they will be independent practitioners in their own right, they will be providing services which form part of the overall district wide specialist service for older people. Care needs to be taken to ensure that these services integrate effectively (see below).

For new GP’s, an attractive way to prove competency to take on the role of a GPwSI-OP will be by a diploma of geriatric medicine. This has already been recognised by the RCP in London, who are discussing an extensive review of their exam in partnership with the RCGP, and the relaunch of a joint diploma, better suited to the needs of GPwSIs should follow. The Royal College of Physicians and Surgeons in Glasgow are also concerned to ensure that their Diploma remains relevant to GPwSI roles.

Diploma exams are by no means the only route into the system, as many older GPs have established skills developed through clinical assistantships, or by independently developed innovative community roles. Whatever evidence is advanced for initial accreditation, GPwSIs will have to demonstrate ongoing competency in the care of older people though appraisal, as they will for all other aspects of their practice.

Links with the new GP contract
The new GP contract may also offer opportunities for improving standards for services for older people. For the first time, this contract offers incentives for all practices to provide evidence of quality in the care they provide for their older patients.

Enhanced Services
National Enhanced Services are to be defined for a range of community services considered to be beyond the normal remit of general practice, and will be offered by some practices only. One of these will define standards of care for care home residents. Resources will be attached to these standards, hopefully at a level commensurate with the work involved.

Finally, primary care organisations (PCT’s in England) will have the option of specifying Locally Enhanced Services. These will enable service specifications to be drawn up to meet the particular needs of local communities. Like National Enhanced Services, these will be provided by GPs under the terms of extended practice contracts, usually to patients on their registered practice list.

There will inevitably be some cross over between services provided by Departments of Geriatric Medicine, the GPwSI-OP, and National or Locally Enhanced Services under the new GP contract. Such diversity could lead to confusion, which in the worst case could threaten the integrity of existing services, rather than improving care through the introduction of new services. Handled well, however, there may be a real opportunity here for GPs, consultant geriatricians and primary care organisations to review their services and to define a blueprint for comprehensive services for older people.

Who will employ GPwSIs?
GPwSI’s-OP will be employed largely by the primary care organisations(PCT’s in England). Typically they will work two to three sessions a week and will also work regularly in general practice under their practice contracts. Some PCTs are employing salaried GP’s to work in a practice and to work part time as GPwSIs.

Currently there is no absolute requirement on PCTs to ensure that the GPs they employ as GPwSI’s-OP are appropriately trained to work with older people. Given the complex demands that could be placed on GPwSIs working in newly developed services, and the lack of a formal professional qualification, this could lead to risks for patients, practitioners and PCTs alike.

Concern has been raised on this matter by the BGS, and is being relayed by the RCGP to senior levels of government, though as yet without any firm reassurance that our concerns are being addressed. While further formal guidance is awaited, any PCT which is considering employing GPwSIs who are not appropriately trained using the framework described, would be advised to read the CHI report into the Gosport War Memorial Hospital.

The remuneration and terms and conditions of employment for GPwSIs are all still under consideration. However, the sessional salary for GP’s is likely to be considerably in excess of the clinical assistant sessional commitment. Typical rates being paid currently, are around £7,500 per annum for doing weekly sessions, comparing favourably with consultant sessional rates.

Responsibilities of Departments of Geriatric Medicine
Although PCT’s exist in England only, all UK Departments of Geriatric Medicine will find the concept of the GPwSI framework of interest and of potential value in considering ways to provide a comprehensive service for older people.

Geriatricians will be aware that the best service for older people is likely to be provided when the component parts ‘match up’. Geriatricians are advised therefore, to involve themselves with PCT’s and be receptive to discussions about GPwSIs. They should try to ensure that the PCT’s problems being addressed are clearly defined, that GPwSI led services are an appropriate solution, and that effective evaluation forms an integral part of the service specification.

Geriatricians may be approached to provide or organise training placements or appraisal sessions. Integrating these new specialist services with acute specialist departments, and recognising the unique contribution they can make, has the potential to provide benefits for older people. GP’s who take on these roles will be valuable allies, supporting the clinical care of older people, and acting as local champions for old age services – nurture them!!
For further information see the NatPact website www.gpwsi.org/subindex.shtml

The full framework may be downloaded from either here or the RCGP site www.gpwsi.org

We would welcome comments and reports of experiences by both our geriatrician and GP members in the implementation of this new stream of service.

Gill Turner
Chairman : BGS Policy Committee
Joe Neary
representing the RCGP