GPwER vs GPwSI - A call to action

Specialist GPs provide holistic physical, mental, spiritual and social care, within communities, for whānau usually as part of a team. 

A GPwER brings additional insight, knowledge, and skill of their extended specialty to further improve care for their patients. 

A GPwER undertakes an extended role within a contract or setting that distinguishes it from standard general practice, and/or is an activity offered for a fee outside of care to the registered practice population. 

“A GPwER receives referrals for assessment and treatment from outside their immediate practice.” (1)

“A GPwER undertakes work that currently attracts an additional or separate medical indemnity fee." (1)

Some examples of such roles are leadership and liaison roles, teaching, training, research, occupational medicine, minor surgery, cosmetic procedures, and assisted dying.  

In the UK GPwER includes doctors previously working as GPs with Special Interest, or GPwSI/GPSI.

• Firstly – it sounds cool!
• Language is important – having "power" is uplifting to the person, and is much more active than having a "special interest."
• The word "Gypsy" carries a troubled history. It has offensive connotations to some Roma people. The largest ethnic minority across Europe, Roma have a long history and rich culture but they were targeted in the holocaust, and continue to suffer discrimination, hate and the disparities common to the marginalised across the globe. 
• Moving day - June 1 in Aotearoa New Zealand is the day when dairy farming families, contract milkers, sharemilkers, and employees move to new farms, it is no longer called "Gypsy Day" because of it's potential for offense.
• It's time we dropped the term "GPwSI" just as we have changed the name of reactive arthritis, autism spectrum disorder and granulomatosis with polyangitis. 

If you have a role that has required additional training over and above the RNZCGP Fellowship, how is this reflected in your CV or job description? 

Claiming your GPwER is not diminishing the concept of Specialist General Practice as a broad scope generalist profession. It does not stop people from having specialist interests within their general practitioner work. 

Formally describing the scope of an extended role and the training required to work in it safely and effectively does not lead to "micro-credentialing" of tasks in general practice, as scope of an extended role is, by definition, over and above that performed by a general practitioner. 

GPwER in Assisted Dying

The role is contracted for separately to general practice, requires specific training, and has a separate clinical governance structure outside of the RNZCGP. 

GPwER in Sports Medicine

GPs working as sports doctors for a local team are contracted separately to general practice, have usually undertaken a diploma or other sports medicine qualification, vocational registration with the Australasian College of Sport and Exercise Physicians is available but onerous for someone not choosing to sub-specialise.   

GPwER in Women's Health 

Women's health is "bread and butter" to all specialist General Practitioners, but some extended roles are developing. Extra training, and extra contractual arrangements are made to provide long-acting reversible contraceptives and medical abortions. Having specific standards, quality assurance, and quality improvement around these procedures will provide the public with more confidence and care more effectively and safely.

GPwER in Minor Surgery

The role is contracted for in addition to the usual PSAAP "back-to-back" GP contract, requires additional training, and often has a separate clinical governance structure within the practice. 

GPwER in Community Infusion Medicine

Oncology, immunology, rheumatology gastroenterology are all expanding rapidly in demand and interventions are more frequently through IV infusions. 

It does not take a lot of training to insert an IV and run a bag of fluids, but the management of each medicine, side effects during and after administration are complex. 

More and more opportunities will arise for community-based infusion services and a GPwER as part of a multidisciplinary team will keep patients closer to their homes. 

Name it, claim it, and get paid for it. 

Having a specific role description, with training requirements, clinical governance including quality assurance, quality improvement and standards that is outside of the PSAAP back-to back contract should be paid work. 

If it isn’t then you are doing it for love, which is wonderful, often because an amateur does love what they do and they do it well, but one of the intended consequences of formally describing a GPwER is to ensure the system can SEE the role, can MEASURE the outcome, have CONFIDENCE in the quality of care, and REMUNERATE accordingly. 

If we just keep adding more and more roles into the "general practice" bucket, without specific intent and structures, we will continue to be asked to do more and more with the funds we are given.  

RNZCGP wero ​/ challenge​

The Royal College of General Practice in the UK has developed resources that support GPs with Extended Roles in the UK. 

They have defined the role and its limitations as follows.​

"For a GP to describe themselves as a GPwER, their clinical activity in general practice should be maintained, and GPwER is not simply a ‘mini-secondary care specialist’ who has taken a different route to specialty practice."​

"One key distinction is that a GPwER’s management of the patient extends beyond the medical model, and as a GP they bring important additional skills in practising holistically and dealing with complexity and uncertainty to these roles." (2)​

They have clearly laid out what GPwER need to do to demonstrate competence in their role. 

The Royal Australian College of General Practice has reviewed the literature and shown that GPwERs provide care across very diverse clinical ad geographical settings, patients are highly satisfied with their work, which is often faster and closer to home with equivalent outcomes to traditional services. (3)​

The Royal New Zealand College of General Practitioners is the standard setting body for general practice and has the role to train for and support the specialist general practitioner profession in New Zealand. ​

The RNZCGP could provide the framework for training, quality assurance, quality improvement, mentorship, and review of the generic GP with an Extended Role. ​

The RNZCGP could describe the specific pathways to achieve each extended role and describe the scope of that role and ensure that these roles do not become sub-specialties. ​

By taking up this wero the RNZCGP would prevent further fragmentation of the generalist medical role in community care and support the expansion of our profession. 

References

(1) GPwER framework published by Royal College of General Practitioners.

(2) RCGP guide to GP Clinical Extended Roles, Royal College of General Practitioners 2021.

(3) ​General Practitioners with Special Interests: An integrative review of their role, impact and future. Yellamaty et al. AJGP: vol 48, issue 9, Sept 2019.

RCGP General Practitioners with Extended Roles website accessed 29/6/23. 

General Practitioners with Special Interests: An integrative review of their role, impact and future. Yellamaty et al. AJGP: vol 48, issue 9, Sept 2019.