Minor surgery - Specification for a directed enhanced service
April 2003 (revised February 2004)
Introduction
1. There is evidence from within the UK and abroad that minor surgical procedures carried out by general practitioners in general practice premises have high levels of patient satisfaction and are highly cost-effective. [see references 1, 2, 3] Since 1 April 1990 general practitioners on health authority minor surgery lists (and their equivalents) have been able to receive payment for undertaking a range [see reference 1] of minor surgery procedures on their patients.
2. There has been a huge variation in the range of procedures undertaken at practice level. Many practices have provided cryotherapy, curettage and cauterisation only whilst still referring other minor surgery into the secondary sector. This directed enhanced service scheme, which must be commissioned by every primary care organisation (PCO), seeks to ensure that there is the opportunity to provide the maximum range of minor surgery in the primary care sector.
Scope of service to be provided
3. Cryotherapy, curettage and cauterisation will continue to be provided by general practitioners as an additional service and practices wishing to opt out of providing these treatments will be obliged to apply to do so in the prescribed manner. Procedures in the categories below and other procedures, which the practice is deemed competent to carry out, will be covered by a directed enhanced service (DES). These procedures have been classified into the following three groupings for payment:
(i) injections (muscles, tendons and joints)
(ii) invasive procedures, including incisions and excisions
(iii) injections of varicose veins and piles.
Eligibility to provide the service
4. A practice may be accepted for the provision of this DES if it has a partner, employee or sub-contractor, who has the necessary skills and experience to carry out the contracted procedures in line with the principles of the generic GPs with special interests (GpwSI) guidance or the specific examples as they are developed. Clinicians taking part in minor surgery should be competent in resuscitation and, as for other areas of clinical practice, have a responsibility for ensuring that their skills are regularly updated. Doctors carrying out minor surgery should demonstrate a continuing sustained level of activity, conduct regular audits, be appraised on what they do and take part in necessary supportive educational activities.
5. Where a PCO believes a doctor carrying out minor surgery is not complying with the terms of the contract, it should invoke a remedial notice according to the procedure laid out in Regulation. There is considerable guidance available on techniques and facilities for conducting minor surgery in general practice. In assessing suitability for the provision of this DES, practices should pay particular attention to the following:
i) Satisfactory facilities. PCOs should be satisfied that practices carrying out minor surgery have such facilities as are necessary to enable them properly to provide minor surgery services. Adequate and appropriate equipment should be available for the doctor to undertake the procedures chosen, and should also include appropriate equipment for resuscitation. National guidance on premises standards has been issued. [see reference 4].
ii) Nursing support. Registered nurses can provide care and support to patients undergoing minor surgery. Nurses assisting in minor surgery procedures should be appropriately trained and competent, taking into consideration their professional accountability and the Nursing and Midwifery Council guidelines on the scope of professional practice.
iii) Sterilisation and infection control. Although general practitioner minor surgery has a low incidence of complications, it is important that practices providing minor surgery operate to the highest possible standards. Practices should take advantage of any of the following arrangements:
(a) sterile packs from the local CSSD
(b) disposable sterile instruments
(c) approved sterilisation procedures that comply with national guidelines.
General practitioners are responsible for the effective operation and maintenance of sterilising equipment in their practices. Practices must have infection control policies that are compliant with national guidelines including inter alia the handling of used instruments, excised specimens and the disposal of clinical waste.
iv) Consent. In each case the patient should be fully informed of the treatment options and the treatment proposed. The patient should give written consent for the procedure to be carried out and the completed NHS consent form should be filed in the patient’s lifelong medical record.
v) Pathology. All tissue removed by minor surgery should be sent routinely for histological examination unless there are exceptional or acceptable reasons for not doing so.
vi) Audit. Full records of all procedures should be maintained in such a way that aggregated data and details of individual patients are readily accessible. Practices should regularly audit and peer-review minor surgery work. Possible topics for audit include:
(a) clinical outcomes
(b) rates of infection
(c) unexpected or incomplete excision of basal cell tumours or pigmented lesions which following histological examination are found to be malignant.
(vii) Patient information. Practices must ensure that details of the patient's minor surgery procedure as part of the NES is included in his or her lifelong record. If the patient is not registered with the practice providing the NES, then the practice must send this information to the patient's registered practice for inclusion in the patient notes.
Pricing
6. Treatments under this directed enhanced service will be priced depending on complexity of procedure, involvement of other staff and use of specialised equipment.
7. In 2003/04 payment for an injection, for example joint injection, will be £40 and for cutting surgery the fee with be £80. The PCO will agree with the provider 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. These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
References
- Lowy A, Brazier J, Fall M, Thomas KJ, Williams BT. Quality of minor surgery by general practitioners in 1990 and 1991.British Journal of General Practice 1995: 44; 364-365
- Tarraga Lopez PJ, Marin Nieto E, Garcia Olmo D, Celada Rodriguez A, Solera Albero J. [Economic impact of the introduction of a minor surgery program in primary care]. [Spanish] Atencion Primaria 2001;27(5):335-8.
- Lopez Santiago A, Lara Penaranda R, de Miguel Gomez A, Perez Lopez P, Ribes Martinez E. [Minor surgery in primary care: consumer satisfaction]. [Spanish] Atencion Primaria 2000;26(2):91-5..
- Department of Health. Health building note 46: General medical practice premises. London: Department of Health.