GP Contract Enhanced Services

Ten tips on the minor surgery directed enhanced service

1. Minor surgery can be a good way of diversifying workload

Given the shortage of GPs and GP time, minor surgery might not seem as necessary as other primary care activities. However, it is appreciated by patients, is cost effective and gives good results. It is also a service that patients may otherwise struggle to access through the NHS. Minor surgery is also satisfying for the clinician – a potential advantage for recruitment and retention.

2. The procedures attract decent enhanced service funding 

Joint injections and incisions and excisions are funded under the scheme. Payments are the same nationally, at £43.54 per injection and £87.08 per excision or incision.

Benchmarking statistics from Lentells accountants show that, among practices signed up to the DES, average income from minor surgery was £1.48 per patient in 2017/18, and £2.70 for the best-performing practice. Variation will largely depend on availability of patients and how a practice promotes the service, but may also be influenced by any local cap – some CCGs limit the number of procedures funded, typically to nine cutting procedures and nine injections per 1,000-patient list size per year.

Most procedures bring the same profit margin, but ingrowing toenail surgery is less cost efficient than the others.

3. What lesions are covered

The range of lesions is narrow but includes epidermoid (sebaceous) cysts, lipomata, pyogenic granulomas and haemangiomas. Lesions must be significantly symptomatic or of diagnostic uncertainty and must need removal for clinical reasons, not solely cosmetic. Cryotherapy, curettage and cautery are not covered. Lesions where malignancy is suspected must be referred via cancer network services and are not included in the enhanced service. The specification is for minor surgery, not for anything involving grafts or flaps.

4. There are specifications for the room that you use for procedures

The room must be at least 16m2 with a sink that has elbow-operated taps. There should be a couch on which CPR can be carried out if necessary, with room to move around it. There should be an alarm call system and access to emergency equipment, but no extraneous equipment in the room.  Most modern consulting rooms will meet these requirements. Perhaps the most difficult, and potentially expensive, aspect is lighting. Most companies offer a ‘try before you buy’ scheme, but if they don’t, it is worth asking – it took us ages to find our perfect light. You’ll also need a suitably qualified assistant during procedures – usually a nurse or a healthcare assistant.

5. You’ll need specific kit

Most services use disposable instruments. There should be electrocautery or hyfrecation. A choice of dressings should be available, as well as local anaesthetic. If you don’t have scrubs, use disposable plastic aprons – especially for sebaceous cysts. A supply of histology pots is needed; you need to send everything you remove to histology (with the usual exception of toenails). This is a medicolegal recommendation and a requirement of the DES.

6. A dedicated service will save time

In my opinion, the best way to run a minor surgery service is to have a dedicated session at least once per month. One benefit of this is that you and your assistant can focus for an entire session. General practice is fiendishly busy, so it doesn’t make sense to prepare a room for just one or two cases. If a full session is not possible, you could do one or two cases at the end of a day or the start of a session, ensuring other work does not intrude. It is important you are not disturbed during minor surgery; a dedicated session makes this less likely.

7. Training and audit are essential

The surgeon can be a GP from the practice, or one employed or subcontracted from outside. An accredited minor surgery qualification is required, either from the RCGP or from another accredited provider such as FourteenFish. It is recommended that this be retaken every three years. The GP must be up to date with basic life support and preferably not squeamish about toenails – surprisingly common. They must be operating regularly, auditing surgical outcomes and complication rates, and must be appraised on their surgical role. You need to audit histology, complications and patient satisfaction. Develop an IT template to standardise notes for your procedures.

8. Get written consent

When it comes to consent, the term ‘minor’ surgery can be misleading for surgeons and patients alike. A complication such as a keloid scar can have major ramifications for patients, so consent should be verbal and written. Risks and benefits should be fully explained, with alternatives (including no treatment) explored.

9. Expect an initial outlay for equipment

There will be initial costs to be met for lighting and diathermy or hyfrecator equipment.

The standard costs to consider are:

• Kit – usually £7-£10 per procedure.

• Nursing time.

• The GP’s time.

• Admin time.

• Postage if you are writing to patients with appointments or results.

When you first start, most minor operations can be done in 30 minutes; with experience this can be reduced to 20-minute slots. Check your indemnity covers you for this work, in particular for toenails. Some indemnity providers have clauses that address these issues.

10. Minor surgery can open the door to other specialist services

Minor surgery can lead to further services, depending on local need, such as vasectomy, carpal tunnel, basal cell carcinoma and dermatology. These entail further training and a fair amount of paperwork to gain accreditation, governance and a contract of service – the Association of Surgeons in Primary Care can advise. If your practice doesn’t have enough of these patients, ask others in your area if they have the same issue. You could become a travelling surgeon.

Dr Jim Wood is a GP in Devon, a GPSI in basal cell carcinoma, carpal tunnel surgery and vasectomy and a dermatology surgeon at the Royal Devon and Exeter Hospital. Additional information provided by Andrew Spear, director of Lentells accountants.

Resources

Association of Surgeons in Primary Care. aspc-uk.net

Primary Care Dermatology Society. pcds.org.uk

RCGP. tinyurl.com/RCGP-minor-surgery

FourteenFish. fourteenfish.com/minorsurgery

Guide URL:
https://pulse-intelligence.co.uk/guide/minor-surgery-directed-enhanced-service/
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