Tough new competencies recommended by the Department of Health are long overdue, says the RCGP’s Dr Soon Lim.
As GPs who have grown weary of the constant barrage of negative press from the media and our paymasters, we are quick to dismiss criticism of the profession as further GP bashing.
However, we are also fellow users of the NHS – and most of us have experience of sitting on the other side of the consultation. What proof of competence would you like to have from the GP excising a skin lesion from yourself, your father or your children?
I am not going to quote evidence. Lies, damned lies and statistics have led to the conclusions of published papers on the quality of minor surgery being favourable to whichever group the author belongs to. What I want to do is to take you to the place where you or your family becomes a patient.
Personally, I would like the GP to be accurate in diagnostic skills and case selection, able to discuss the range of treatments for any one problem and their respective risks and advantages and, lastly, to be a safe pair of hands surgically.
What’s good enough?
The GP has FRCS? Most surgeons have no dermatology experience and although they may be very good at hernia repairs, they might depend on the histology to make the diagnosis of a skin lesion rather than offer the least invasive procedure for the confidently diagnosed lesion.
The GP has been on a minor surgery course? Well, I have been on a Royal College of Surgeons course on hydrocoele surgery, but it does not mean that you can trust me to operate on one.
The GP has been doing it for years? Is length of service really a sufficient marker of quality?
If someone was going to operate on me or my children, I would want evidence of:
• basic training in diagnostics and surgical techniques
• a period of clinical mentorship under an experienced GP/secondary care surgeon with training and assessment in practice
• formal accreditation followed by a cycle of formal reaccreditation with ongoing clinical audit.
With primary care organisations reluctant to agree to a uniform process of accreditation and reaccreditation for GPs carrying out minor surgery, a Department of Health working party has formalised a set of accreditation criteria that demands diagnostic accuracy audits, patient satisfaction surveys and evidence of a sustained level of activity. The last requirement has been tempered with the alternative of a formal assessment of diagnostic and surgical skills.
It will drive minor surgery back into secondary care and the dermatologists and surgeons will have won, I hear you cry. But we must take ourselves out of the siege mentality that is the product of a decade or more of unfair criticism and put ourselves in the position of the people who matter – the patients. We need to screw our courage to the sticking place and not fail them, which is why a new curriculum for minor surgery is being written for the RCGP.
The new set of competencies recommended by the DH for the accreditation and reaccreditation of GPs carrying out any form of minor skin surgery is long overdue. Many GPs may feel this is a step too far and they may give up minor surgery altogether when the burdens of appraisal and revalidation become too much.
The question arises whether, as clinicians, we should go the extra mile to provide a service, or whether, as future commissioners of care, we should allow minor surgery to return to secondary care.
My opinion is that minor surgery reaches the parts that other areas of general practice do not reach – it allows GPs to exercise different skills and enhances the working week. It prevents burnout. Every GP should do it. Every GP should do it well.
Dr Soon Lim is director of minor surgery at the RCGP Bedfordshire and Hertfordshire Faculty, author of the RCGP Standards for Minor Surgery and a GP in Watford, Hertfordshire
Dr Soon Lim