In January 2006 a White Paper, Our health, our care, our say: a new direction in community services,1 looked at the options for bringing patient care closer to home.
Since then, with the arrival of practice-based commissioning (PBC), many GPs have been considering this issue, especially in dermatology and minor surgery.
The media have recently reported that patients will be treated closer to home, keeping them in familiar surroundings and reducing the need to travel and the risk of hospital-acquired infections. But hundreds of secondary care jobs will be lost as primary care takes over these roles in future.
Minor surgery in primary care offers GPs the opportunity to save money, although some are concerned that they will receive no further funding to pay for procedures carried out locally. Here in Leicestershire, we already have a list of conditions, including benign skin conditions, which we are unable to refer.
Many GPs currently treat benign skin conditions in primary care, but prefer to refer basal cell carcinomas (BCCs), squamous cell carcinomas and melanomas. In February 2006 NICE issued guidance2 recommending the establishment of two levels of care: local hospital skin cancer multidisciplinary teams (LSMDTs) and specialist skin cancer multidisciplinary teams (SSMDTs).
Any doctor treating patients with skin cancer should be a member of one of these teams, regardless of whether they are based in primary or secondary care. If there is diagnostic doubt, referral to somebody in one of these teams is also recommended, with GP follow-up if appropriate. It is recommended that LSMDTs and SSMDTs work to agreed protocols for referral, review, management and audit.
The guidance goes on to state that precancerous skin lesions can be safely managed in primary care by appropriately trained GPs. Low-grade BCCs should be restricted to approved doctors working in the community, usually a GPSI or the LSMDT, while all other skin cancers should be referred to the LSMDT.
Treatment in primary care
When considering the provision of minor dermatological surgery in the community, this advice should be followed, but the majority of lesions are benign. This leaves GPs a lot of scope, although they may wish to use the restricted list criteria and simply tell patients that NHS treatment is unavailable.
Once decisions have been made regarding what can and cannot be treated in primary care, the next consideration is the provision of the service.
Before any actual surgery can be performed, the establishment and management of waiting lists will need to be considered, as will details of how the surgery will be recorded and transferred to the patient’s notes. This will include information on batch number for anaesthesia, sterilisation cycles and so on. Consent is another important issue; for example, there must be clear procedures covering verbal or written consent and the use of locally or nationally agreed consent forms.
Whether surgery takes place in the practice or a community hospital, the room will need to reach certain standards regarding hygiene, lighting, size, changing facilities and so on. Equipment will have to be adequate and sterilised to a recognised standard. Nurses must be trained to assist and safeguards must be in place to cover unexpected events which might require resuscitation and recovery. The theatre area will need to be maintained, as will stock control, cleaning and staffing. After surgery, follow-up will need to be organised, including provisions for dealing with complications, both immediate (haemorrhage, dehiscence and so on) and delayed (infection), as well as the removal of sutures.
Histology will have be considered and may add significantly to the financial burden of minor surgery. For the majority of skin lesions, histological examination is recommended, but costs
per lesion vary. Again, this information will need to noted in the patient’s records and any conditions requiring referral to secondary care managed appropriately. This is especially important for diagnostic biopsies.
Advantages and disadvantages
In general, patients prefer to be treated locally, in familiar surroundings, with less distance to travel. As fears of hospital-acquired infection increase, they feel safer when treated close to home.3 Waiting lists may be shorter and follow-up better.
One disadvantage is that secondary care may be better placed to cope with unforeseen emergencies, although these are rare. Demand will have to be high enough to make local provision viable; for example, in my practice of 9,000 patients, there is more than enough to fill a monthly afternoon list.
The new GMS contract divided minor surgery into three groups – cryotherapy, electrocautery and curettage. These are provided for under additional services, so do not attract an additional fee. Injections, aspirations and cutting surgery are classed as directed enhanced services, so do attract a fee.4 This, along with PBC, offers GPs many opportunities for saving money when considering dermatology and minor surgery, but there is clear need for careful planning beforehand.
- Dr Nigel Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary
1. DoH. Our health, our care, our say: a new direction in community services. January 2006. www.dh.gov.uk/ourhealthourcareoursay
2. NICE. Improving Outcomes for People with Skin Tumours including Melanoma . February 2006.
3. Godfrey E, Watkiss M, Schnieden H. Initiation and evaluation of a pilot scheme for minor surgery in general practice. Health Trends 1990; 22(2): 57-9.
4. DoH. Standard General Medical Services Contract. www.dh.gov.uk/assetRoot/04/10/84/58/04108458.pdf