Delivering day-case surgery in primary care
Cornwall’s Probus Surgical Centre has been providing procedures in primary care for more than a decade. Dr John Tisdale offers some lessons to other GPs looking to follow in his practice’s footsteps
Cornwall's Probus Surgical Centre has been providing procedures in primary care for more than a decade. Dr John Tisdale offers some lessons to other GPs looking to follow in his practice's footsteps
PBC offers a unique opportunity to improve local medical services and make financial savings by redesigning services and fostering innovation. The decision for commissioners is whether to use traditional providers or to look at alternatives, which may include private providers or NHS-based primary care sources.
The concept of primary care surgery is new and the definition somewhat arbitrary. Here it is used to describe surgical services traditionally provided in secondary care, now performed in the community setting. This concept has found favour with the Department of Health under its Care Closer to Home initiative.
However, primary care surgery is not without controversy. Articles have appeared in the medical press citing evidence against it, on the basis of small-scale studies, anecdotes and hearsay.
I believe much of this rhetoric is based on fear of change and an unwillingness to evaluate new models of care that threaten the position of established providers. Equally, we need to look critically at these new models of care to ensure they deliver improvements in service, are cost-effective and above all do not compromise on quality or safety.
Probus Surgical Centre is based in a rural general practice in Cornwall that is part of Mid Cornwall commissioning group.
The centre has provided surgical services since 1995 and its activities are now commissioned by practices throughout Cornwall, Plymouth and West Devon. The service is well-received by local practices, patients and commissioning authorities and has received recognition by the DH as a demonstration site for the movement of secondary to primary care.
Activity has increased year on year and more than 2,000 surgical procedures are performed annually (see box below). The service is managed and delivered by three GP partners and a staff-grade plastic surgeon.
Roots in fundholding
The service began with fundholding. At that time there was a perception some surgical services were unsatisfactory, with waiting times of up to two years, poor patient experience and excessive costs. Having identified the problems we developed a strategy to solve them and this involved starting our own surgical service. Initially this was restricted to our own patients and was later offered to other practices.
After a period of training in the surgical techniques required and investment in infrastructure and staff, we were able to demonstrate improvements in all aspects of care, with reduced waiting times and increased patient satisfaction levels. Most importantly, careful audit has repeatedly shown no reduction in standards of care, with the emphasis on quality and safety.
Confidence in the service was boosted when the local hospitals in Cornwall and Devon, who were required to reduce waiting lists, commissioned work from us.
Start-up costs were relatively low and easily absorbed by the practice. As pioneers, we set our own agenda on training and contractual issues, and learned from experience. Before long, national commissioning groups were seeking advice from us on redesigning their own services. Now, there is interest in replicating our model nationally, and a new national and local agenda of addressing accreditation and accountability issues.
Current service provision
Probus is now a provider of much of the surgical day-case work in Cornwall, particularly abdominal hernia repair (400 a year), carpal tunnel release and vasectomy. Other urological procedures currently offered are frenuloplasty, circumcision and hydrocoele repair, all performed under local anaesthetic.
About 70 or 80 practices now use the service. Patients are either referred directly or through Choose and Book. Referral guidelines have been issued to practices, with whom we keep in touch by regular newsletters.
We have developed the service to be patient-centred, focusing on accessibility, flexibility, information and, where possible, one-stop surgery. Although all consultations and surgical procedures are carried out by the GP surgeons, the effectiveness of the service depends on the input of well-trained, skilled and dedicated nursing and administrative staff.
The use of local anaesthetic techniques makes it possible to perform quite complex hernia surgery on elderly, infirm patients with significant comorbid conditions.
Patients are usually discharged from the unit 15-30 minutes postoperatively. Current waiting times from referral to completion of treatment are about 12-16 weeks, depending on the procedure.
Probus is an SPMS practice and surgical services are currently commissioned by three PCTs. Contracts are based on one-year rolling service level agreements and although for planning reasons we would prefer three-year contracts – given the vagaries of the health service – it is unlikely that any commissioning group will give such an undertaking.
Our fixed costs include salaries for the surgical team and administration staff, capital expenditure on equipment and infrastructure, sterilisation costs, disposables such as gowns, drapes, meshes and sutures, and increased costs associated with the running of the building.
We discount the national tariff rates by up to 30%, offering significant savings to commissioners of between £200,000-£400,000 a year, all of which is recycled into the local health community.
All Probus activity is subject to rigorous clinical governance, as agreed with the PCTs, and is regularly audited for outcomes and patient satisfaction.
Benefits of a community service
When the Probus surgical service began in 1995, it was easy to demonstrate the advantage of reducing waiting times from 100 weeks down to eight.
However, as waiting times in general are reducing, it is more difficult to identify improvements, so the focus is on other quality indicators.
Planning for the future
Building on the success of the surgical service, we have identified other areas where a primary care service is ripe for development. In particular, we have looked at general urology and urological investigations such as flexible cystoscopy.
In order to offer the service, we plan to engage specialist expertise, one urologist and another GPSI. We would also require the services of an ultrasonographer. There are infrastructure implications and considerable costs associated with capital equipment. A clinical care pathway has been developed and a business plan submitted to the PCT for consideration. Our locality group is supportive of the plan and we await a response from the PCT.
The key to success is commitment to delivering a first-class, sustainable, patient-centred service. There is no room for short-term, personal profit motives.
Practices wishing to become involved in providing new services must have a clear idea of why they feel a change in provision is desirable. What is the clinical problem to be solved? Having identified it, a clear alternative clinical pathway must be developed. Consideration of the impact of the proposed change on the partnership is vital, as is the effect on traditional providers.
The next step is to consider the human and infrastructure resources needed. What is available and what must be acquired? Consider sustainability, as commissioners are unlikely to offer contracts unless this is assured. Succession planning is also a must.
Consideration about what happens if things go wrong is crucial. How will you manage complications? Who bears clinical responsibility? Are you indemnified?
Also, a strong business plan is required. What are the costs of providing the service? How much work is available and how much can you attract? Where is the competition? What happens when tariffs reduce?
Only when these issues have been considered will you be ready to approach the commissioners – and don't forget your contracts will have as robust governance arrangements as other major providers.
As yet, there are no agreed standards for qualifications, training, accreditation or revalidation, and these are the most important issues to deal with if this new model of care is to be valid.
Various professional bodies – including the royal colleges of surgeons and GPs – are examining these issues, but there is urgent need for unanimity.
There is also a need for primary care surgical practitioners to be represented at these negotiations and anyone wishing to provide these services would be well advised to join the Association of Surgeons in Primary Care. This group was formed to promote the vision of primary care surgery and assist practitioners wanting to get started.
The ASPC is linked to other organisations involved in primary and secondary care surgery and is actively seeking to agree standards for accreditation and appraisal. Further details can be found on the ASPC website.
Dr John Tisdale is a full-time primary care surgeon at Probus Surgical Centre in Cornwall and a council member of the Association of Surgeons in Primary Care. You can email him at firstname.lastname@example.org to success
is a first-class, patient-centred service. there is no room for personal profit motives key to success
key to success
is a first-class, patient-centred service. there is no room for personal profit motives
focus is now on other quality indicators with secondary care waiting times coming down, the
with secondary care waiting times coming down, the
focus is now on other quality indicators
Excisions of benign skin lesions, sebaceous cysts, small lipomas, chalazions
Vasectomy, carpal tunnel and trigger finger release, haemorrhoids, frenuloplasty, skin malignancy, lesions requiring flaps and grafts, large lipomas
Advantages of primary care surgery for patients
Dupuytren's fasciectomy, various types of hernia repair, adult circumcision, hydrocoele procedures
Advantages of primary care surgery for patients
• Reduced waiting times
• Easier access
• One-stop management
• Low incidence of infection or complications
• Less intimidating, a more personal service
• Happy clients
• Efficient service
• Cost efficiency
• Financial savings
• Obligations met
• Increased job satisfaction
• Financial incentives for the practice
• Alternative career path as primary