Primary care Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial

Objective To assess the effectiveness, accessibility, and acceptability of a general practitioner with special interest service for skin problems compared with a hospital dermatology clinic. Design Randomised controlled trial. Setting General practitioner with special interest dermatology service and hospital dermatology clinic. Participants Adults referred to a hospital dermatology clinic and assessed by a consultant or the general practitioner with special interest service,. Suitable patients had non-urgent skin problems and had been identified from the referral letter as suitable for management by a general practitioner with special interest. Interventions Participants were randomised in 2:1 ratio to receive management by a general practitioner with special interest or usual hospital outpatient care. Main outcome measures Primary outcomes were disease related quality of life (dermatology life quality index) and improvement in patients’ perception of access to services, assessed nine months after randomisation. Secondary outcomes were patient satisfaction, preference for site of care, proportion of failed appointments, and waiting times to first appointment. Results 49% of the participants were judged suitable for care by the general practitioner with special interest service. Of 768 patients eligible, 556 (72.4%) were randomised (354 to general practitioner with special interest, 202 to hospital outpatient care). After nine months, 422 (76%) were followed up. No noticeable differences were found between the groups in clinical outcome (median dermatology life quality index score = 1 both arms, ratio of geometric means 0.99, 95% confidence interval 0.85 to 1.15). The general practitioner with special interest service was more accessible (difference between means on access scale 14, 11 to 19) and waited a mean of 40 (35 to 46) days less. Patients expressed slightly greater satisfaction with consultations with a general practitioner with special interest (difference in mean satisfaction score 4, 1 to 7), and at baseline and after nine months 61% said they preferred care at the service. Conclusions The general practitioner with special interest service for dermatology was more accessible and preferred by patients than hospital outpatient care, achieving similar clinical outcomes. Trial registration ISRCTN31962758. Introduction The concept of the general practitioner with special interests was promoted in the NHS Plan. In this model general practitioners refer patients to a local general practitioner with special interest rather than to a hospital based specialist. Factors driving this initiative include the need to increase service capacity in the face of rising demand for specialist advice, to reduce excessive waiting lists for outpatient appointments, and to improve the accessibility and convenience of care. Diversion of appropriate cases to general practitioners with special interests may also allow consultants to concentrate onmore complex cases. Although not providing the full breadth of services provided by consultants, within their defined role general practitioner with special interests should offer care with an equally high quality of process and outcomes. 4 Many schemes for general practitioners with special interests have been established by primary care trusts in several clinical disciplines, but evidence is lacking on their costs and benefits. A general practitioner with special interest service for dermatology was established in Bristol in 2001. Dermatology represents one of the most common causes for consultation in primary care and for referral to secondary care. More general practitioners with special interests are operating in dermatology than in any other clinical specialty, with the exception of diabetes. We investigated the effectiveness, cost effectiveness, accessibility, and acceptability of the Bristol general practitioner with special interest dermatology service compared with usual hospital outpatient care. The findings from the economic evaluation are presented in an accompanying paper.