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GP minor surgery procedures being ‘rationed’ by NHS managers



Exclusive GPs are being prevented from carrying out minor surgery procedures because local area teams across England are ‘rationing’ elements of the national enhanced service, Pulse can reveal.

Pulse has identified at least three areas where restrictions have been placed on the amount of activity GPs can undertake as part of the minor surgery DES, including preventing GPs from billing for multiple procedures carried out in a single consultation, and limiting activity to practices’ achievement in 2013/14.

Elsewhere, local area teams have imposed a minimum number of procedures for GPs to carry out to qualify for the DES, which local leaders have said has stopped practices from signing up.

GP leaders have said this practice is widespread and amounts to ‘simple rationing’, which is pushing more patients into secondary care leading to greater costs for taxpayers.

The DES, which was introduced in 1990, pays GPs around £45 per procedure for injections of joints and varicose veins, and around £85 for minor surgical procedures (incisions and excisions).

But there is evidence that local area teams are rolling back the amount of services offered by GPs.

In its 2014/15 minor surgery DES specification, Herefordshire, Worcestershire and Arden area team have told GPs that their activity for minor surgery will be limited to their achievement in the 2013/14 year.

The specification states: ‘At the point of sign up, the commissioner will agree with the contractor the basis on which the DES will be funded in light of the procedures to be carried out and the volume to be carried out, including setting an upper cap.’

‘The cap will be set at 2013/14 outturn unless otherwise agreed. Any activity over and above the agreed cap will be subject to prior approval by the area team.’

The local area team is also refusing to pay GPs for carrying out two treatments in the same consultation, even when it is in the best interests of the patient, and says that these measures are a result of the squeeze on NHS budgets.

However, Coventry LMC vice chairman Dr Grant Ingrams said the decision was ‘bizarre’ and that it would inflict pain on the local CCG who would have to budget for the increased referrals.

Dr Ingrams told Pulse: ‘This is the sort of bizarre decision you get when you split the CCG from the local area team,’

He added: ‘If the local area team says that’s your budget for the year, then what we’re going to have to do is refer to secondary care. That’s going to cost the CCG, but not the local area team.’

‘So you’re causing financial pain to the CCG, it’s going to cause disruption for the patient. It’s going to actually cost the whole health economy more, but it means the local area team have kept within their budget. So that’s alright then.’

In London, the LMC is also trying to renegotiate ‘unduly onerous’ requirements for minor surgery, which impose inappropriate infection control requirements and a rigid minimum number of procedures GPs are expected to carry out to remain accredited.

Dr Tony Grewal, medical secretary for Londonwide LMCs told Pulse: ‘[Due to that these requirements] ‘I’m aware of a number of practices that have been delivering under the DES, decided that they couldn’t or didn’t wish to comply with the requirements, and will be referring patients – who would normally have been treated under the DES – to secondary care, at about ten times the cost.’

In Merseyside, GP leaders have said that the local area team has excluded them from carrying out cryotherapy work under the DES even where they can provide state of the art facilities and had provided the service effectively in the past.

Merseyside GP and president of the National Association of Primary Care, Dr James Kingsland, told Pulse that the local area team’s decision meant that a lot of effective work being undertaken by primary care will be lost.

He said: ‘In my surgery the cryotherapy is done with state of the art equipment, and for specific conditions that would have otherwise required a referral for it: pre-malignant conditions that sort of thing.’

‘So it’s added value as opposed to “are you doing cryotherapy for viral warts on kids’ fingers”. But we can’t do it anymore.’

‘It is a rationing and financial decision, not a clinical care decision, which is sad when you think about what we’re trying to achieve in this new commissioning environment.’

GPC deputy chair Richard Vautrey told Pulse: ‘Many areas have placed restrictions on the number of minor surgery cases in their area. It is though simply rationing and commissioners should be open and honest with their local population about what they are doing and why they are doing it.’

‘It means some patients who happen to present at the wrong time of the year will either not be able to get their procedure done by a good local GP service or may be unnecessarily referred to a much more expensive hospital clinic, which is neither good for patients nor the taxpayer. ‘

Sue Price, Director of Commissioning for NHS England (Arden, Herefordshire and Worcestershire), told Pulse: ‘Demands on NHS budgets are high and we need to ensure we are commissioning services which are clinically appropriate for the NHS as a whole to provide.  We will work with CCG colleagues to ensure there is no transfer of a financial burden.’

Merseyside and London local area teams were unavailable for comment.

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