Specialist outreach clinics

On p 1083 Jacqueline Bailey and colleagues confirm the rapid growth in specialist outreach clinics in general practice.1 Should this trend be encouraged or opposed? Until such clinics have been properly evaluated the authors recommend that we suspend our judgment.

Like every other intervention, such clinics should fulfil Brook's definition of appropriate care - “that for which the benefits exceed the risks by a wide enough margin to make it worth providing.”2 Neither expanding the range of services available in primary care nor addressing some of the in- efficiencies of the secondary sector is sufficient justification for their existence. (It is not for general practitioners to become Don Quixotes, righting the wrongs of the NHS.) The piecemeal provision of consultant outreach clinics is also likely to widen further the divisions that currently exist within general practice.

Bailey et al's survey shows that doctors prize efficiency and accessibility over equity or appropriateness.2 Although gains in efficiency were reported - such as fewer non-attenders and referrals to hospital- these may be offset by the inefficient use of consultants' time (resulting from inadequate surgery accommodation or equipment) and difficulties with subsequent follow up at hospital. Extending outreach clinics may complicate, if not damage, specialist care, training, and research.3 In a 10 year survey of paediatric outreach clinics Spencer identified several inefficiencies, including problems with medical records and substantially shorter consultation times between patients and consultants. 4

Decisions on acceptable levels of efficiency depend on the appropriateness of the care. Inappropriate recycling of follow up patients may lead to the overuse of outpatient departments5; Roland et al have shown that nearly half of general practitioners' referrals to an orthopaedic clinic were inappropriate, despite long waiting times.6 Shifting these services into primary care may seem like an attractive solution, but the appropriateness of the service and the site need to be considered separately.

For example, Millac developed a “one stop shop” hospital neurology outpatient clinic, where selected new referrals were seen and completely investigated during one attendance, which reduced non-attendance and follow up visits.7 Street et al determined that most pregnant women at low risk could receive their entire antenatal care in the community; the consultant service could be restructured to offer a same day specialist opinion.8

Hughes and Gordon have shown how shared care schemes are paving the way for primary care teams to form quite different relationships with consultants and hospitals.9 They report developments in the specialist functions of consultation, advice, and feedback to general practitioners, leading, for example, in a Dutch diagnostic centre, to fewer inappropriate tests.

Will bolting on specialist run outreach clinics enhance the core strengths, values, and skills of general practice? The current survey's finding that only six out of 112 outreach clinics were attended by a general practitioner is alarming1 and reinforces the view that the current proliferation of these clinics results from perverse incentives of the NHS internal market to extend inappropriate care. The lack of joint working between general practitioners and specialists is all the more surprising because the successes of psychiatric shared care have been the mutual education, the increase in appropriate care by the general practitioner, and the progressive reduction in the power and authority of the expert.10

Spencer found that about one third of outreach clinics are eventually stopped.4 Innovating fundholders are doing the same and are using the specialist as a liaison consultant to develop protocols such as the diagnostic work up for prostatism (E Brown, personal communication) and to train general practitioners to run specialist clinics.11

Consultant outreach clinics may be appropriate if accessibility overrides all other criteria, as it may in the treatment of some elderly people. But, on the whole, consultants' time in primary care would be better spent providing training and support for professional development rather than direct services to patients.

Developing specialist services, which involve other disciplines, and integrating them into primary care is the preferable option. Primary care risks becoming an aggregation of fundholders, polyclinics, specialists, and generalists united by no more than geography; far better if its diverse providers could share a common vision of appropriateness.