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Why it pays to fund extra GP training in minor surgery

PCTs or commissioning consortiums will be making a worthwhile investment if they fund local GPs to gain a diploma in minor surgery, writes Dr Jonathan Botting

PCTs or commissioning consortiums will be making a worthwhile investment if they fund local GPs to gain a diploma in minor surgery, writes Dr Jonathan Botting

One of the common features of many initiatives established under practice-based commissioning is the use of GPSIs to deliver secondary care activity in primary care. This development raises recurring questions:

• Is a GPSI a good thing? (It depends on your viewpoint.)

• Are they cost-effective? (It depends on your terms of reference.)

• Are they clinically effective? (Who knows?)

Most surveys of the use of GPSIs have concluded they are popular with patients. But the conclusion from NHS-funded studies is often that they are no cheaper than hospital services, they may not reduce hospital referrals and they may destabilise hospital departments.

Minor surgery, however, is different. As long as the referrals to a primary care-based service are the same as those referred to hospital, the primary care service will be cost-effective. It is a case of comparing like with like.

Much of the cost breakdown depends on how a procedure is classified by secondary care. In the early 1990s, a single excision of skin (procedure code S06) cost about £250 on average to a fundholding practice (according to figures from my own first-wave fundholding practice). It is unlikely this cost will have reduced after more than a decade, and day-case minor surgery now costs about £600.

Within departments of dermatology where minor surgical procedures take place outside of a day-case unit, the costs are much lower, at about £90, but this is an anomaly in pricing compared with the true cost of initial assessment, surgery attendance and follow-up. Much of this low-cost activity is for simple punch biopsy.

Pros and cons of various provider models

In primary care, a single surgical procedure is funded at about £80. At present there are three main models of providing a cutting service:

• A practice provides a service for its own patients, with suitable cases chosen by the practitioners themselves.

• A practice provides a service for their own and neighbouring practices through Choose and Book.

• A practitioner provides a sessional cutting service directly commissioned by the PCT or by a practice-based commissioning plan.

There are strengths and weaknesses for each method:

• The first relies on individual GPs in a practice to choose their own cases to fulfil their quota of procedures. There will be a natural tendency to choose the simple procedures and to refer anything more challenging to secondary care. There is no incentive to gate-keep demand – indeed, almost the opposite.

• The second only works if the practitioner has the skills to manage the variety of cases referred. The leap in skills required cannot be underestimated. The surgeon requires both diagnostic and surgical skills above those expected of a GP. With activity based on a cost-per-case basis there is the opportunity for a very lucrative service, possibly at the expense of their usual GP practice.

• The final model combines the diagnostic and surgical skills of the second model with the advantage of greater cost-effectiveness.

In a primary care service, each patient is usually allowed 20 to 30 minutes, meaning between six and nine patients can be seen and treated during a three-hour session. If eight patients are treated on each of 40 sessions over 12 months, at £80 per case, the sessional cost of £640 equates to £25,600 per annum. The equivalent hospital cost, based on £600 per case, is £192,000.

The differences are reduced if additional histopathology costs are factored in. If we add the cost of a histopathology report – say, £120 – to the minor surgery, this brings the total case to £200 per case, £1,600 per session or £64,000 per annum.

The total saving by basing such activity in primary care lies somewhere between £128,000 and £166,000, compared with traditional secondary care settings. And this is for one practitioner working one session a week.

Dramatic cost savings

The cost savings by a PCT or PBC group directly employing the practitioner are even more dramatic. A session may be costed at about £250 for three hours, and a nursing assistant at £45 for three hours. Allowing for disposable instruments, injectables and sutures (about £10 per case) brings the sessional cost to £375, or annually £15,000. Even allowing for cost-per-case pathology charges of £38,400, the yearly savings are more than £138,000.

The advantage of both the second and third model is that they enable the PCT (or the PBC group) to control what is and is not deemed suitable for a surgical procedure through selection criteria.

This is more easily policed when referrals are generated and sent to another practitioner. In this way the PCT avoids paying a practice for minor and potentially cosmetic procedures and then still paying for hospital-based activity.

So what are the set-up costs for the PCT or PBC group in commissioning such a service? If the practitioner is providing the service from their own practice there are no costs other than the training of the practitioner.

If they are commissioning sessions within a PCT-run facility the set-up costs are not great; they include lighting, electrical equipment, resuscitation equipment and administrative support.

Department of Health guidance published in May 2007 stresses three stages in commissioning GPSI services:

• accrediting the service to be provided

• accrediting the facilities needed to provide the service

• accrediting the individual who is going to deliver the service.

The first two are relatively simple as systems already exist to identify areas of priority and areas of exclusion, and also to assess facilities (through infection control and health and safety procedures).

Accreditation of the individual is much more difficult to quantify. FRCS training is unnecessary for most minor surgery; indeed it does not guarantee proficiency at skin surgery. Plastic surgery training to senior doctor level would be sufficient but there are few such surgeons within primary

care and, with the development of Modernising Medical Careers, this training is likely to be encountered less and less in primary care. This is where Middlesex University's Postgraduate Diploma of Minor Surgery, run by educational publisher Rila, can come in.

Assessing quality of service

There are many GPs who already provide a very high-quality and safe minor surgery service. But how can a PCT assess the level of training and the quality of the service? Audits provide some evidence but, as observed at the beginning of this article, it all depends upon your terms of reference.

A practitioner may have a zero-complication rate if they only remove small epidermoid cysts and seborrhoeic keratoses. A highly trained GPSI may be removing large skin tumours and undertaking plastic repairs with a small number of complications. So who is the ‘better' surgeon, and how do you assess them?

The diploma trains practitioners to identify and treat all common skin lesions and also to identify those lesions that should either not be removed or sent to secondary care. The course is spread over most of the academic year and as well as lectures and practical teaching it includes distance-based learning and mentoring. This last is the cornerstone of the diploma.

In essence the student needs to work under the direct supervision of a specialist, usually a hospital consultant. These sessions will normally be hospital based and allow the student to complete a workbook, write up a series of clinical cases and ensure they have experienced all the surgical procedures and diagnostic skills they will need for independent practice.

As well as the clinical cases being marked, students undertake an online assessment for each module completed. The final exam consists of a lesion identification and management session, a written MCQ-like paper and then an oral viva. Successful students are awarded a PG Dip MS.

Sponsored training

The diploma costs about £4,000 and is the only one of its kind in the country. There are other diplomas (such as the well-known one provided by Cardiff) combining dermatology with skin surgery, but the emphasis tends to be on dermatology.

GPs can sponsor the diploma course and negotiate with their mentor's trust for a paid, clinical assistant contract. Although these contracts are very poorly paid, the level of remuneration reflects their training and development role. Alternatively a PCT may decide to train a key GPSI win its area.

PCTs that sponsor a GP on this course should be entitled to expect that GP to contract with the PCT at a favourable rate – indeed it could be part of the PCT training agreement. PCTs can therefore expect the training to be cost-neutral and the subsequent cutting service to save them in excess of £100,000 a year per practitioner.

With accreditation of GPSI services and of enhanced services there is a demand for PCTs to ensure their doctors comply with NHS guidance. The PG Dip MS provides the necessary training to comply with NHS guidance on GPSI services.

If GPs self-fund they will be in a strong position to tender for PCT minor surgery services. If PCTs provide the funding for training they will be well placed to make considerable cost savings providing a service that is popular with patients and practices alike.

Dr Jonathan Botting is a GP trainer in Barnes, south-west London, and a dermatological surgeon for two hospital dermatology departments and his own PCT. He is also author, programme director and an examiner for the Postgraduate Diploma of Minor Surgery (run through Rila for Middlesex University.

It is simple to accredit the service and facilities, but much harder to accredit the practitioner It is simple to accredit the service and facilities, but much harder

It is simple to accredit the service and facilities, but much harder to accredit the practitioner

DOING THE MATHS DOING THE MATHS


Amount £ (per year)
Primary care service provided by GPSI with diplomA
in minor surgery
• Practitioner: £250 per three-hour session x 40 sessions 10,000
(eight patients a session, 320 cases a year)
• Nursing assistant: £45 per session x 40 sessions 1,800
• Disposable instruments, injectables and sutures @ £10 per case 3,200
• Histopathology report @ £120 per case 38,400
Total 53,400

Versus

Secondary care service
Equivalent workload of 320 cases a year @ £600 per case 192,000

TOTAL Saving 138,600

If the PCT or PBC group pays to put a GP through the £4,000 cost of the diploma,
they will still save more than £134,000 in the first year

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