Minor surgery under the new contract
Since 1990, simple monthly cryotherapy clinics and occasional steroid joint injections have resulted in maximum minor surgery payments. Beyond that, with no extra funding, GPs have either referred to the dermatologist or performed the surgery anyway, claiming back fees, sutures and anaesthesia, but generally ending up out of pocket. So how will things differ under the new contract?
At the lower end little will change, with cryotherapy, curettage and cautery continuing to be provided as an additional service. All GPs will be expected to provide these, unless they apply to opt out. Payments will be decided nationally, with no local negotiation possible.
At the higher level, practices deemed competent can provide a more advanced directed enhanced service, with procedures divided into:
· Injections (muscles, tendons and joints)
· Invasive procedures (incisions and excisions)
· Injections of varicose veins and piles.
Unlike additional services, payment for these procedures will be decided locally by agreement between the provider and the PCO. For the 2003/4 period a figure around £40 per injection and £80 per cutting surgery has been recommended with an upper limit for each practice, but this will vary betweens PCOs and practices depending on volume and complexity.
These fees are expected to increase by a further 3.225 per cent for 2004/5 and again in 2005/6.
The following will be required of practices wishing to provide directed enhanced services.
· An appropriate level of training in both minor surgery and resuscitation which will need to be updated, appraised and audited regularly. Providers will also need to show an ongoing level of activity.
· Appropriate facilities, including instruments and equipment for procedures undertaken, a suitable room with couch and lighting, a supply of sutures, blades and anaesthesia and facilities for storing these.
· Appropriately trained and competent nurses.
· Adequate sterilisation and infection control. Sterilisation either in-house (bench-top steriliser) or via packs from the local CSSD or disposable equipment, all which involve extra cost. All practices must have adhered to guidelines for handling of clinical waste, used instruments and so on.
· Written consent stored in lifelong records.
· Histology of all tissue advised (extra costs).
· Regular audit, such as outcomes, complication rates and percentage complete excisions for malignant tumours.
· Clear and accurate records.
Which procedures are cost-effective? The following should be within the range of most practices
Practical and cost-effective
Cryotherapy Quick and easy to do. Low equipment costs (remember liquid nitrogen). No histology and no nurse assistance needed, resulting in a highly cost-effective procedure.
Joint injections Some training required, but this is usually available via local rheumatologists, joint models or PGEA courses. Minimal equipment costs (all disposable). Nurse assistance not usually required.
Ingrowing toenails Easy to do, some nurse assistance required, but no histological costs and minimal equipment costs.
Tissue biopsies via punch Equipment can be all disposable (punch, syringe, blade), stitching not required (dressing only or steristrips). Nurse assistance useful but not essential. Histology essential.
Needs more training and equipment
Excision biopsies (non-malignant/diagnostic) Quite a high degree of equipment and skill needed (depending on location, for instance the face). Nurse assistance required, histology essential.
Sebaceous cysts and lipomas Knowledge of deeper structures and excision/suturing skills needed. Nurse assistance needed. Histology required. Fair bit of equipment needed.
Excision of malignant tumours High level of skill ideally. Histology essential. More equipment required. Nurse assistance.
Injection of veins and piles Special skills training, can be time-consuming. Nurse assistance essential. Special instruments not always required. No histology.
So is the new contract set to change the face of minor surgery in general practice? In some cases yes. But in many cases it will simply mean we are paid for what we have been doing for a long time. If you fall into the latter category you should contact your PCO and negotiating appropriate fees.