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Can GPs carry out minor surgery safely?

The fastest way to treat almost any lesion is GP excision followed by histology and referral if necessary, says Dr John Adams, but Professor John Primrose argues the quality of surgery done by GPs is poor, too often unsafe and usually unnecessary

The fastest way to treat almost any lesion is GP excision followed by histology and referral if necessary, says Dr John Adams, but Professor John Primrose argues the quality of surgery done by GPs is poor, too often unsafe and usually unnecessary

Yes

The answer to this question is a very simple 'yes'. GPs have been doing minor surgery for many years, very successfully, safely and with good results.

The real debate is about what constitutes minor surgery, and which procedures should be done where. Extreme cases are easy. GPs should obviously not be doing procedures requiring general anaesthesia. The days of an appendicectomy on the kitchen table under a whiff of chloroform are long gone. Equally I'm sure surgeons don't want their theatre lists deluged with skin tags and seborrhoeic warts. The question is about where to draw the line.

To a degree this depends on the skill and experience of the GP surgeon. All doctors should be aware of the limits of their own abilities and refer when these are exceeded. GPs undertaking minor surgery should be properly trained and perform enough procedures to maintain their skills.

Given that, most GP surgeons are happy tackling reasonably small benign lesions, provided they are not in surgically risky or cosmetically sensitive areas such as the face. Most would also agree with NICE guidelines that frankly malignant lesions should be referred to a consultant. There may be a little argument about whether small basal cell carcinomas can safely be removed by GPs.

The problem is that many lesions do not arrive in the surgery clearly labelled with a diagnosis. Take the case of slightly dodgy moles. These range from the barn-door malignant melanoma to the freckle with slightly variable pigmentation or irregular border, with all shades in between.

Ideally, perhaps all of these should be seen by a consultant dermatologist, and if adjudged suspicious, removed by a plastic surgeon. But this has massive resource implications. Also, nobody is 100% perfect at spotting melanomas. Practice helps, as do technical aids such as dermoscopes and computerised imaging systems, but very innocuous-looking lesions are occasionally reported as malignant by the pathologists.

In a secondary care environment it is likely that these would have been given a low priority, and had to wait the full 18 weeks before removal, if not longer.

In general practice they could have been removed within days and referred for definitive treatment on the day the histology report is received. In fact, for almost any lesion, the fastest route to final treatment is GP excision followed by appropriate referral with histology. There are some essential safeguards here. If there is any suspicion, lesions must be removed completely with an adequate margin, and everything must go for histology.

It must be stressed that there is no place for incisional biopsy in the diagnosis of melanoma, as it makes staging the lesion difficult or impossible, and failing to send tissue removed during any procedure for histology is medicolegally indefensible.

Finally, there is the issue of patient choice. The GP surgery is usually more accessible and more familiar, for an experience that most patients do not regard as 'minor'. It is usually easier for them to be accompanied by a friend or relative, and time off work is minimised.

Going to hospital involves a longer journey, often difficult by public transport, impossible parking, and an entry into a strange world of operating theatres and clinics. It also usually involves taking time off for pre- and post-operative outpatient clinics as well as the day-case surgery.

If asked, most patients express a preference to be treated at the surgery, and are often disappointed if referred to hospital, even if advised that this is to produce a better result.

Dr John Adams is a dermatology GPSI in Cheadle, Cheshire

No

In 1991 the GP contract changed to allow a service fee for minor surgery, replacing part of capitation funding. GPs were permitted 60 such cases a year and almost all have since claimed the full number - about 1.8 million procedures per year in England.

This was part of a naive and misguided attempt by the Department of Health to move surgery away from secondary care.

In fact it had no impact on this whatsoever and the surgery carried out in primary care was simply additional activity.

Although the intention might have been to try to get surgery such as hernias and varicose veins performed outside secondary care, this failed completely. Analyses carried out in our department show that the largest rises are in joint injections, for which there are few data on efficacy within primary care, and cryotherapy for warts, which a Cochrane review does not support.

In order to establish the utility of minor surgery in primary care, the Health Technology Assessment Programme funded the MiSTIC trial, a randomised trial of minor surgery in primary and secondary care, which is to be to be published shortly.

These are the key findings:

  • The quality of the wound, as determined by two blinded observers, was worse in primary care, with only 13% of wounds being graded optimum compared with 20% of hospital cases.
  • Significantly fewer excisional specimens could be found from the patients treated in primary care - with 30% missing from general practice versus 16% missing from hospital practice.
  • In malignant lesions, 56% of incisions were incomplete when performed in primary care compared with 25% in hospital practice. Indeed the GP sensitivity for the diagnosis of malignancy was only 67% and all of the malignant melanomas in the study were missed.

Interestingly, although the outcomes were worse, patients preferred being treated in primary care - this being related mainly to issues such as waiting time and ease of parking.

A full health economic assessment was carried out in association with the trial. The results of this are complex but they suggest that although treatment in hospital is more expensive, treatment in primary care is not cost effective due to the smaller numbers of optimal procedures.

The other qualitative finding was that most of the skin lesions randomised in primary care to be operated on in hospital were small and most wouldn't have been treated surgically if the patient had been seen in hospital.

So the evidence does not support the current system of performing minor surgery in primary care. Much of the surgery does not need to be done at all.

The quality of the surgery is poor and in some cases frankly dangerous, as shown by the higher rate of positive excision margins when malignancy is treated.

Bearing in mind the recognition of malignant melanomas was so poor among GPs in this study it is especially worrying that so many excision specimens are clearly not being sent for histological evaluation. This may lead to a patient losing their life and must not be allowed to continue.

What should be done in the future? It is not the geographical site at which surgery is performed, but the experience, training and skill of the surgeon, that matters. It does not matter from which discipline such expertise is drawn, whether it be primary care, dermatology or surgery.

What matters is that the practitioner is fully trained in the diagnosis of surgical conditions, including skin lesions, and has the judgement to know where such procedures should be performed and the skill to achieve a good technical result, a safe result and cost-effectiveness for the health service.

Professor John Primrose is professor of surgery

Can GPs carry out minor surgery safely? yes quote

The real debate is about which procedures should be done where

no quote

It is very worrying so many excisions are not being sent off for evaluation

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