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General practitioners are learning vital new skills and supporting hospitals in the General Practitioners with a Special Interest program, which has been running for five years across Queensland.
In the past, it was not unusual for GPs to work across both community and hospital settings. This model is still used in rural areas, where it strengthens collaboration and continuity of care; however, most Australian general practice work is now limited to office-based community care with little connection to the hospital system.
The General Practitioner with Special Interest (GPSI) model originated in the United Kingdom in 2000. Since then, many countries, including Australia, have introduced GPSIs into hospital and community health services.
The model of care is still developing in Australia and there are no agreed skills or qualifications that define a GPSI. On the Sunshine Coast, GPSIs are considered GPs with extra experience, interest or qualifications within a specific field of practice. They develop those skills within a consultant-led specialty team.
The GPSI pilot began at five hospitals and health services in south-east Queensland, including the Sunshine Coast, in 2018. We found it demonstrated benefits for patients and the health service. Two of the important benefits were i) a reduction of long wait lists in two-thirds of the specialties with a GPSI clinic, and ii) the discharge rates from GPSI clinics were higher on average than regular outpatient clinics.
Of all the health services in south-east Queensland that have a GPSI program, Sunshine Coast Hospital and Health Service has by far the largest number of GPSIs and specialties. Indeed, the GPSI model has been incorporated as business as usual in several public hospitals on the Sunshine Coast. In 2019, we wrote in InSight+ about the results of the pilot.
There are currently 20 specialty areas in which hospital GPSI clinics have been established. The total full-time equivalent (FTE) occupancy has grown from 3.0 FTE in 2018 to 6.6 FTE in 2023 (approximately 25 part-time GPSIs)
| The Sunshine Coast Hospital and Health Service employs GPSIs within the following disciplines:
Cardiology |
The model in practice
GPSIs are employed as senior medical officers and become part of consultant-led clinical teams. They work in one or more hospital outpatient clinic sessions per week, in addition to their work as community GPs. At present, GPSIs are required to hold vocational registration with the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM) and a minimum of five years of general practice experience is preferred.
One of the goals of the Sunshine Coast GPSI model is to better connect primary and secondary care. Therefore, it is a requirement that GPs continue working in the community. The Sunshine Coast GPSI model does not accommodate career hospital doctors who do not actively work in general practice.
All GPSIs must have access to clinical supervision by consultants (in clinic or remotely if appropriate). GPSIs often manage a particular subset of patients (eg, post-operative breast cancer or skin cancer surgery). The scope of work is determined based on the requirements set by the specialty teams, local health needs, and the confidence and skills of the GPSIs.
GPSIs report to the general practice liaison officer as their line manager, and clinically to their specialty director. Role-planning, selection and interviews are done collaboratively between the hospital General Practice Liaison Unit and the medical directors of each specialty. This provides a collaborative structure to support the GPSI within the role. We believe it is a success factor for the Sunshine Coast GPSI program.
GPSIs are funded through hospital activity-based funding. The Primary Health Network has also cofunded several GPSI positions.
Surveys during the pilot, and repeated in 2022, demonstrated a high degree of satisfaction among patients, GPSIs and consultants.
| Benefits of the Sunshine Coast GPSI program:
Improved patient access to timely, safe hospital outpatient care |
Breaking down silos
It is generally accepted that parts of the health care system are siloed and that the current system of care is fragmented. Therefore, many have highlighted the need for better integrated solutions.
Building trust between providers is a key step in better connecting care, and GPSIs can contribute towards this goal.
Our experiences with the GPSI hospital outpatient model confirm the added value of the model as mentioned in the literature, including benefits with regards to hospital access and waiting lists, workforce, reduced costs, and satisfaction.
This is partly the result of applying generalist expertise in managing, personalising and coordinating care in patients living with multiple complex chronic conditions. The holistic knowledge and broad skillset of GPSIs working as part of hospital specialty teams is complementary to hospital specialist expertise.
Patients understandably want access to clinicians with expertise in their particular condition but at the same time appreciate the benefits of generalist approaches to improve oversight and connect the different parts of the health system involved in their care.
Feedback we received from GPSIs, both informally and via our survey, indicates that their hospital work increases job satisfaction, which is confirmed in the literature. GPSIs value the opportunity to improve their skills or apply their skills and knowledge in specific areas, while continuing their work in the community as GPs.
The benefits of upskilling
Upskilling GPs while they are working in their GPSI positions is cost-effective because, since they are learning, they are simultaneously assisting with reducing waitlists and generating activity.
Hospital teams working with a GPSI gain better understanding of the scope of general practice and often improve their clinical handover procedures. This results in an increased discharge rate in most specialties with a GPSI.
Discharging patients to primary care when their condition has stabilised and no longer needs input from the hospital specialty team is essential to avoid outpatient departments becoming congested. The higher discharge rates demonstrated in GPSI clinics help to improve the hospital’s capacity to see new patients in a timely fashion.
Before recruitment, some of the GPSIs have extra knowledge and training in a specific area, which enables them to work at a high level from the outset. Others are employed with the aim of upskilling on the job, and then continue working in the team. Many GPSIs continue working in their chosen specialty for a substantial amount of time (eg, one to five years). However, in some specialties, the intention is that GPSIs rotate for a set amount of time and then return to the community. The relatively shorter amount of time spent in the rotations enables more GPs to gain experience in those specialties, increasing the broader skills base in the community.
Some studies estimate that 25–50% of referrals to hospital outpatient clinics could be dealt with in a community-based GPSI clinic. The literature suggests that, for example, community GPSI otolaryngology and headache clinics have benefits for patients at costs that are lower than those for secondary care services.
A look ahead
Future models may include horizontal referrals from regular GPs to GPSIs within the community, potentially reducing hospital referrals and demand for specialist outpatient services for conditions that can be managed locally. In this scenario, it is envisaged that hospital-trained GPSIs would function as an additional port of call for peer support and advice in the community, strengthening resources in primary care.
This potential community GPSI model would require agreed pathways for referral and discharge back to the regular GP and would likely benefit from the support provided by both Primary Health Networks and hospitals. In the Sunshine Coast, GPSIs who have capacity to receive referrals in general practice are listed on HealthPathways, although a formal governance model is not (yet) in place.
Another future variant of the model could include upskilling of GPs or GP registrars, who have recently obtained their Fellowship, within hospital clinics that have already established GPSI clinics.
In our experience, the coordinating role of the hospital General Practice Liaison Unit is fundamental to the success of the GPSI Program. We have found this provides structure and strategic oversight across the program, which may not occur if the GPSI positions were managed by each specialty department. General practice liaison officers can assist with any issues experienced by the GPSIs, including matters that may arise across specialties. It also keeps the focus of the model on care integration and not just workforce.
Potential disadvantages to the model, such as taking GPs out of the community, have not been observed in the Sunshine Coast. As the model appears to increase job satisfaction of participating GPs, it may play a role in retainment of community GPs. Further research is required to better answer this question.
Conclusion
The GPSI model has been successfully implemented in the public Sunshine Coast Hospital and Health Service since 2018 and continues to evolve. The model has demonstrated benefits for patients, hospitals and the GPs who work in the GPSI positions.
We believe it remains essential that hospital GPSIs are also actively working as GPs in the community. The link with community general practice is a fundamental part of our philosophy to improve the connection between primary care and the hospital sector, resulting in more efficient health services. Future models may include community-based GPSI clinics to facilitate more patients being treated in the community, rather than the hospital.
Dr Michelle Johnston is a general practitioner, General Practitioner with Special Interest (GPSI) program clinical lead, and general practice liaison officer (GPLO) in the Sunshine Coast Hospital and Health Service.
Peta-Maree Willett is GPSI program manager in the Sunshine Coast Hospital and Health Service.
Dr Edwin Kruys is general practitioner, GPLO in the Sunshine Coast Hospital and Health Service, and cochair of the Queensland General Practice Liaison network.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thanks for your comment Chris, it is great to hear of examples where this model has worked well!
We have three procedural Gynae GPSIs in the SCHHS program and the feedback from the Consultants, GPs and patients have been very positive.
For almost 40 years prior to 2016 retiring, I worked as a Specialist O&G in Western NSW. During these years I worked alongside many very capable procedural GPs. Their impact on improving my ability to work to full specialist capacity was enormous, making better our team surgical and obstetric medical management and providing skilled anaesthetic and emergency support. So this team practice has been present in some fashion for many years in Western NSW and has only been limited by the occasionally inappropriate disenfranchising of GP ‘special interest’ practice by ill-advised non-medical management by Area administrators. Greater involvement of Medical Administrators may help here.