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How we set up a skin cancer surgery service

A community dermatological surgical service has just been launched in Nottingham. Dr Neil Shroff and Dr Jim Hamilton explain how they set it up.

A community dermatological surgical service has just been launched in Nottingham. Dr Neil Shroff and Dr Jim Hamilton explain how they set it up.

In response to practice-based commissioning, practices in the former Rushcliffe PCT have joined together to develop a social enterprise called Principia (as outlined in an article in the September 2007 issue of Practical Commissioning).

One of Principia's goals is to achieve financial balance, in part through new care pathways. One of these is a community surgical dermatology service launched at Keyworth Medical Practice two months ago. It aims to complement the existing community medical dermatology service.

Traditionally in Rushcliffe, GPs carried out minor skin surgery on their own patients and referred more complex surgery and suspected skin cancers to secondary care. Analysis of day-case surgery data, along with a review of GP referral letters, revealed a significant proportion were being sent to secondary care when they could be managed in primary care.

Fortuitous factors

The idea for the service was conceived in December 2006 and several factors facilitated its development.

In April last year our practice moved into LIFT-funded purpose-built premises that were well-equipped with minor surgery facilities and equipment that would meet disinfection and sterilisation rules and reduce the need for disposable instruments.

The practice wanted to take full advantage of the new facilities. One of us, Dr Jim Hamilton, was a keen minor surgeon and wanted to develop the service and hone his skills. Dr Shroff had joined the practice as partner in April 2007, with a background in plastic and reconstructive surgery and ongoing experience in part-time work for an acute trust carrying out 12 to 15 skin cancer operations every fortnight. We also had enthusiastic backing from Principia and PCT managers.

Initial plans

Initially we envisaged the service as a ‘spoke' to the hub of the dermatology department at Queen's Medical Centre (part of Nottingham University Hospitals NHS Trust) and used the 2006 NICE guidelines on improving outcomes for people with skin cancer as our starting point.

Patients with basal cell carcinomas (BCC) had been traditionally referred on a two-week wait for a first outpatients appointment but could then wait up to four months for surgery – and even longer if they needed a specialised procedure known as Mohs surgery. In our new service we planned to assist secondary care by taking away some of the BCC work, ensuring the dermatology department could concentrate on more complex cases.

Regular meetings took place with Principia's clinical reference group, which comprised a patient representative, GPs, a public health doctor, allied health professionals and health service managers from the newly formed Nottinghamshire County Teaching PCT (into which the former Rushcliffe PCT was subsumed). The business plan was thoroughly worked up to ensure a smooth passage through the approvals process at the PCT.

Despite aiming to work closely with the acute trust's dermatology department at all times, it became apparent this would not be an easy relationship and numerous delays ensued. We also felt in limbo while awaiting Department of Health guidance on competencies expected of GPSIs providing dermatology and skin surgery services (published in April 2007).

Eventually we sought clarification from the PBC division at the DH about moving the project forward. We were told that although we should work closely with secondary care colleagues wherever possible, we should not delay or postpone the plans, so long as the PCT, as commissioner of the service, was satisfied with the clinical and administrative governance.

Pilot phase

Before the PCT's approval process, we operated on our own practice population to iron out any unforeseeable problems.

The other GPs referred patients by filling in a form that was passed to the practice secretary. Patients were to be seen by us within two weeks and the operation would take place within six weeks. With our own patient population we easily met this target.

We carried out clinics from 8.30-11am and surgery from 2-6pm. We chose Tuesdays as ‘derm surgery day' as this was a day when there were a large number of doctors working at the practice, we would not be on call and we could follow up any complications later in the week. No complications occurred during the pilot.

PCT approval and funding

After piloting, the PCT approved the service but our caseload was restricted to 220 procedures a year on a running three-year contract, to ensure the PCT could evaluate the service and increase capacity when resources permitted. It would also allow our practice to see how we would balance the work with our GMS duties.

The PCT would pay us on a cost-per-case basis, including the cost for consumables, administration, service audit and analysis. This cost is substantially cheaper than the first outpatient, follow-up and procedure costs payable to acute trusts under the national Payment by Results tariff.

Start-up costs were also released by the PCT. These were minimal, given the existing facilities, and were used to purchase a good quality bipolar machine, an operating table, fine surgical instruments, drapes, scrub suits, sutures, dressings, face masks and two state-of-the-art dermoscopes.

We were fortunate to have an experienced nursing team in the practice who could assist in the operations and do the dressings. One of our practice nurses has trained one of our healthcare assistants to carry out sterilising and disinfection as well as helping with the dressings and laying out of the equipment.

This nurse works part-time as a tissue-viability sister and can do leg Doppler assessments – useful for assessing the level of compression for large defects on the lower leg that we leave to heal by secondary intention following excisional surgery.

Rapid rollout

After the approvals process we started accepting referrals from three neighbouring practices. We invited the GPs to view our facilities, discuss referral pathways and allay any fears. We impressed on them that we were not here to do cosmetic surgery or carry out standard GP minor surgery that was part of their GMS or PMS contracts.

Once we established we could cope with the additional workload, we rapidly moved on to referrals from practices further afield and also received patients via the community medical dermatology service.

In December we opened up the service to 18 practices, covering 115,000 patients.

How it runs

Referrals normally arrive by fax, which we acknowledge within 24 hours. In the clinic we assess the suspected lesion and also thoroughly inspect the rest of the patient's body in case they have any further lesions that warrant treatment. Consent for surgery and photography for educational purposes occurs at this encounter.

If surgery is needed, our administrator contacts the patient with a list of suitable times. Dr Hamilton assists and carries out operations under Dr Shroff's supervision. We do the complicated cases first.

Our case mix is mainly BCCs, but we also treat precancerous lesions and examine any pigmented lesions that GPs are unsure of. We refer on to secondary care all malignant melanomas, squamous cell carcinomas and high-risk BCCs – ill-defined BCCs mainly of the morpheic variety.

We manage benign lesions that GPs are unhappy to remove that they would have referred to secondary care and that are appropriate for the service.

All patients with suspected skin cancer and pre-malignant skin lesions are seen within two weeks and we operate on them within six weeks. Any benign lesion patients are seen within four weeks.

Success stories

So far we have picked up five malignant melanomas, two of which were incidental findings, as the patients were referred with BCCs in other anatomical areas.

Overall we have seen 176 patients, of whom 129 have been operated on in 133 procedures (some patients have more than one). Of the procedures, 30% were shown to be BCCs, and 12% were premalignant skin lesions. Our wound infection rate is 2.2%, compared with 5-10% in secondary care, and we have had no incomplete excisions or significant events. We referred eight (4.5%) patients on to secondary care.

Patient and GP benefits

We pride ourselves on offering a patient-focused service. Recurring themes from answers to a patient survey (drawn up by our patient representative) are satisfaction with access, quick turnaround, continuity of care and cleanliness of facilities.

To promote the service and provide a platform for GP education we have also set up a series of dermatology presentations to which a consultant is invited to give a talk, followed by Q&As and often a curry!

The future

Our future plans are to tout for more work from neighbouring clusters. We would also like to employ a nurse to do skin biopsies and assist in operations if the workload grows. Finally, we would be keen to get involved in the education and training of GP registrars and specialists who are new to dermatological surgery. We would also be keen for consultant dermatologists to come and do clinics alongside us.

Dr Neil Shroff is a GP in Keyworth, Nottingham, and a part-time dermatological surgeon at King's Mill Hospital in MansfieldDr Jim Hamilton is a GPSI in minor surgery

60 Second Summary 60 Second Summary

Initiative
The launch of a community dermatological surgical service on GP premises


Start-up costs
Minimal funds from PCTs to buy bipolar machine, operating table, surgical instruments, drapes, scrub suits, sutures, dressings, face masks and state-of-the-art dermoscopes


Staffing
Two GPs (one with a background in plastic and reconstructive surgery) take a day a week from their practice to run clinics and operate.

Results
• Majority of patients managed in primary care, 4.5% referred to secondary care
• Five malignant melanomas discovered (two incidentally)
• No incomplete excisions or significant events have occurred


Patient benefits
Easy to find location; free parking; shorter waits; continuity of care; avoidance of hospital-acquired infections

Savings
Current cost per case ‘substantially cheaper' than tariff costs for first appointment, follow-ups and operations


Contact
Dr Neil Shroff, neil.shroff@gp-c84048.nhs.uk

Patient and PCT feedback on the new service Patient and PCT feedback on the new service

Patient Jillian McLaren
‘I was extremely worried about having the surgery, but Dr Shroff was so gentle and extremely thorough. He told me exactly what was going to happen and put me totally at ease. I couldn't praise the service and staff enough, the staff were lovely, everywhere was spotless and I felt so relaxed after the surgery was carried out. I wouldn't have liked having to go to hospital for the surgery as it feels much more clinical and would have been quite daunting.'


Chris Kerrigan, director of commissioning and performance, Nottinghamshire County Teaching PCT
‘The dermatological surgery at Keyworth is an excellent example of one of the PCT's local and personalised services and will become an excellent example of practice-based commissioning and partnership working.'

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