Table A.2 Developments in service delivery: summary of articles examined for primary care.

ID and authors	Research setting and year of study	Study design	Sample size	Topic of document	Key results and conclusions	Level of evidence	Quality score (AGREE) (%)
Rubin et al136	Northern England; UK (2000)	Survey of clinical records	135 723 Patients	Epidemiology of IBD	GPs have expressed interest in shared care with gastroenterologists; need for GP training in the management of IBD in primary care	2−	73
Jones and Bartholomew701	UK (2002)	Survey of clinicians	398 Responses	Survey to elicit views on GPwSI	This survey indicates that substantially more GPs than are required in the NHS plan are already providing clinical specialist sessions. There is, however, something of a mismatch between the clinical topics listed in the plan and those in which GPwSI are currently delivering their services. Strategic thinking at regional and PCG/T level is patchy, making the recent policy initiatives of the RCGP and the RCP of London particularly timely. Many GPwSI are likely to have developed a particular skill or expertise during hospital training, others after vocational training. These activities provide an important source of variety and stimulation, and there is evidence that recruitment and retention of GPs is enhanced by offering “mixed portfolio” job descriptions, and that patient outcomes may be improved. For example, the Primary Care Society for Gastroenterology has demonstrated a level of safety comparable to hospital endoscopy, associated with better access and very high levels of patient satisfaction	2−	70
Littlewood et al700	UK (2000)	Survey of GPs	153 Survey responses	Study of GPs' research interests	GPs show interest in updating their practice and carrying out research; there is a difference in emphasis on health issues and research interests between GPs in different inner city trusts	2−	64
Nocon and Leese699	UK (2004)	Commentary and recommendations	NA	The role of GPwSI	It is not clear that GpwSIs are cost effective. What is clear is that they are additional to, rather than a substitute for, secondary care; allocations to secondary care can rarely be reduced as a result of GPwSI provision. Were any such reductions to be considered, the objections raised by hospital consultants would probably be so strong as to jeopardise their support for GPwSI schemes. In any case, a key driving force behind GPwSI policy is the reduction of waiting times. Evidence of cost effectiveness may be less important than policy objectives and professional interests	3	73
Kernick693	UK (2003)	Commentary and recommendations	NA	Developing intermediate care with GPwSI	Although the development of GPwSI services is being encompassed within formal governance and professional development frameworks, and 16% of GPs are already providing services outside their core commitments, there is currently no evidence to support the effectiveness or cost effectiveness of these changes. In many areas, GPwSI development will build on existing historical services that may have actually encouraged inefficient use of resources. Developing GPwSI services is one of a range of options open to PCOs for developing the NHS modernisation agenda. This initiative forms part of an overall process of healthcare integration that sees the patient at the centre of a pathway of care. Although the move towards unified PCO budgets may facilitate this development, GPwSI service shifts may have a better chance of success when additional resources are available, rather than financing them from the removal of existing resources	3	73
Gerada and Limber703	UK (2003)	Commentary and recommendations	NA	The role of GPwSI	The development of GPwSI is an exciting opportunity for GPs to develop their interests and widen their clinical horizons. However, it is important that PCOs and clinicians understand that if patient safety is not to be jeopardised, these services should be underpinned by robust clinical governance frameworks. The RCGP together with the NHS Modernisation Agency is currently developing frameworks in a number of clinical areas together with guidance for PCOs in developing this service further	3	66
PCSG698	UK (2001)	Survey, commentary, and recommendations	27 Primary care units	Endoscopy in primary care	The data suggest a very high level of patient satisfaction' the overall assessment of 98% was very good or excellent. This also highlights how sensitive patients are about waiting for appointments or waiting within the unit as their answers here are clearly at variance with the rest of their assessments. No official body has yet pronounced on the thorny issue of the maintenance of endoscopy skills, and knowledge. Three areas need to be examined: (a) number of endoscopies performed each year; (b) supervision of practical skill level; (c) maintenance of knowledge base. Although an endoscopist may make the actual examination, the nursing team resource the process from beginning to end. This ensures continuity and support for the patient, a safe and efficient endoscopy room, and well cared for and reliable equipment	3	55
Gerada and Harris702	UK (2003)	Commentary and recommendations	NA	GPwSI	The development of GPwSI requires clear clinical governance, which includes appraisal and revalidation criteria, in order to maintain a good standard of care	3	53
NHS690	UK (2003)	National guidelines, commentary, and recommendations	NA	Setting up GPwSI services	This guide focuses on the provision of a clinical service to patients by GPwSI. However, we acknowledge that this is only one aspect of the role of GPwSI. Equally important are the roles of GPwSI as a trainer, educator, and coach of other healthcare professional colleagues in raising overall standards of care. The GPwSI may also play a significant part in the strategic planning of services across a health economy	Guideline	59
DoH and RCGP691	UK (2002)	Commentary and recommendations	NA	Implementing GPwSI	Progress to date suggests the introduction of GpwSI brings real and sustainable benefits for patients and the NHS. They are providing localised services, in familiar surroundings, with easier access and speedier care for patients. In addition, this role will help support GPs in their professional development and allow GPs with specialist experience and expertise to apply their skills and knowledge to best effect for the benefit of patients and local services. It will also improve management of workload between primary and secondary care and enhance the quality of referrals to consultants	Guideline	45