Abstract
This article looks at how you, as a GP in training, might pursue an interest in minor surgery by looking at the changes not only in training and assessment but also in commissioning. From this background, we look at the knowledge and skills you need to achieve and the evidence you need to record.
The GP curriculum and minor surgery
Minor surgery exists in the GP
In addition to the requirement of the GP Curriculum, within the ePortfolio there are optional skill directly observed procedures (DOPs) for:
Curettage/shave excision
Cauterization
Incision and drainage of abscess
Excision of skin lesions
Suturing of skin wounds
As these are optional skills, there is no actual necessity to complete them in order to pass nMRCGP.
Having seen what the curriculum and nMRCGP specify, what are the existing minor surgery provisions within primary care? In order to answer that, we need to understand how this area of activity has developed:
Those who cannot remember the past are condemned to repeat it (George Santayana, 1863–1952)
In the past, GPs could apply to be on a local ‘minor surgery list’, often with rather arbitrary ground rules, and were permitted to undertake a certain number of procedures that were funded. Each procedure could be claimed and paid for especially if it was accompanied by a histology report. This led to the rare but regrettable practice of snipping off multiple skin tags from a patient, submitting each for separate histological analysis and claiming a separate minor surgery fee for each!
The last GP contract did away with this process and divided minor surgery into two categories, Additional Services and Enhanced Services. Additional Services included all the simpler activities such as:
curettage
electro-cautery
cryocautery
These were paid en-block irrespective of the number of procedures. Practices could opt to provide Additional Services as a contract right. Enhanced Services included all the more invasive procedures including:
incisions
excisions
joint injections
These contracts were Primary Care Trust (PCT) based and the practice had no right to the contract. The PCT could commission the service from the practice, from neighbouring practices or even from a private provider.
With PCTs in control, it was possible for them to limit activity both in number of procedures and in types of procedure. With mounting financial constraints, PCTs in some parts of the country elected not to commission any primary-care-based minor surgery, a move that led to disappointed doctors and frustrated patients.
Most PCTs that continued to commission minor surgery also decided to stop commissioning any basal cell carcinoma (BCC) surgical activity after the release of the National Institute for Health and Clinical Excellence (NICE) Improving Outcomes Guidance (2006) recommended that such treatment should be limited to GP with Specialist Interest (GPwSI)-trained doctors.
Knowledge and skills
So what do you really need to be able to complete, in terms of skin surgery, in order to qualify as a GP? Well, firstly the
As well as being a core curriculum requirement, this ability is stated within the definitive guidance for skin tumour care, guidance that is used to structure services across the National Health Service (NHS). Unfortunately, despite dermatological conditions accounting for up to 24% of all primary care consultations, the undergraduate training in dermatology in the UK has been sparse.
So even if a doctor possesses the skills to treat a skin lesion, do they possess the knowledge to diagnose it in the first place? Evidence from 2 week wait referrals for suspected skin cancers suggests that 88% of referrals turn out to be non-malignant so it would appear that as a profession we have not been doing very well with lesion recognition.
Are we doing any better with our surgical
The good news is that the number and range of training courses in minor surgery are increasing, enabling those with an interest to develop both the knowledge and the skills required. Although the framework is still developing, it is possible to progress from introductory courses, to intermediate courses (aimed at the Enhanced Services) and advanced diploma courses designed for GPs with Specialist Interests (GPwSIs). The Internet provides a wealth of teaching videos (Box 1).
Web-based training videos
Threats and opportunities
As the ex-surgically trained GPs and the generation of GPs practising under the ‘see one, do one, teach one’ method of training head towards retirement, who or what is going to replace them? Several models of community-based care are conceivable:
Surgical or dermatology-trained specialists with or without hospital contracts
Specialist nurses
Private companies employing suitably qualified staff (from the UK or abroad)
GPs
The first three are all potential threats to primary care minor surgery. It does not take a genius to realize that if care is being moved out of hospitals, there will be opportunities for hospital doctors to also move out to maintain their activity. It also follows that if nurses are cheaper to employ than doctors and can be trained to undertake the activity, then they may be the favoured operators.
To private companies, skin surgery can be a nice little earner. However, what none of these providers have is the continuity of care and completely integrated approach of primary-care-based minor surgery. This is our opportunity! So the demand for our skills should be there, how do we meet that demand?
Meeting the demand
As a GP, whether or not you wish to be able to provide a surgical service, you are expected to have the knowledge to know how to diagnose and manage skin lesions. We start to meet the demand by improving both our knowledge and our skills.
Many registrars attend a skin surgery training course that includes lesion recognition and management (deaneries should have a list of suitable courses; my own has been commissioned through the London Deanery for about 10 years) and ideally this should be followed up in your registrar year with attendance at your local dermatology/pigmented skin lesion clinic (if they will have you; so many doctors now want to gain this experience that clinics can become overrun with learners so use your own contacts and your trainer's contacts).
If in your third year of specialist training (ST3) you have a practice that performs minor surgery, you will also have the opportunity of undertaking observed procedures. After curettage and skin biopsy training, you will be able to undertake the surgical DOPs listed within the ePortfolio.
In this way, you will have evidenced your training. Keep your own log in addition to anything on the ePortfolio, both of what you have done and of the histological results.
The next steps
The next rung in minor surgery training could be attendance at one of the Royal College of General Practitioners (RCGP)-badged courses. These are run through local RCGP faculties and take place over 2 days. The courses provide all the latest evidence and guidance along with hands on surgical training, albeit on plastic skin. These courses are unable to provide observation of your real-life skills nor a thorough assessment of your knowledge of skin lesions. The Primary Care Dermatology Society also runs training and assessment workshops. As well as gaining knowledge about best evidence and surgical tips, these courses can provide an excellent way to network among like-minded GPs.
There are other courses that will provide advanced surgical skills training, in particular, the British Society for Dermatological Surgery training that is aimed primarily at dermatologists. However, this again specializes in the teaching of skills not in assessment.
Assessment
The reason that assessment keeps being mentioned is because of the increasingly evidence-based practice of medicine, within the NHS driven in particular by NICE. Within their latest review of BCC treatment (2010), there are numerous references to the demonstration of surgical competences.
While this guidance refers specifically to low-risk BCC surgery, it provides a framework for assessing and approving those GPs wishing to undertake skin surgery (and to be paid for it). While there is nothing stopping a trained GP from undertaking minor surgery procedures for benign lesions, they will only be paid for such activity if they are being contracted to provide such a service, and the commissioners of such activity are going to want evidence of training, not simply certificates of attendance. This evidence also becomes part of the accreditation process for the surgical service.
For those who are in training, DOPs and Applied Knowledge Tests (AKTs) are a way of life; for those who have been in practice for many years, they can represent very challenging (and to some insulting) assessments. Sadly, as mentioned earlier, the evidence available shows that surgical skills in primary care can be poor (hence the need to keep your own log of surgical activity, countersigned by your trainer). Already there are organizations prepared, at a price, to assess your ability to prepare for and undertake simple surgical closure under simulated conditions.
Photo: Julian Calder
The specialist generalist
Some GPs will wish to develop a much higher level of sub-specialization by becoming GPwSIs. In order to fulfil the training requirements for GPwSIs in dermatology and skin surgery, there is Department of Health (DoH) guidance that lays out not only the curriculum but also the practical training and assessment by some of the following methods:
Modified clinical examination (mini-CEX)
Case note review
360 degree appraisal
DOPs
Objective structured clinical examination (OSCE)
Reflective practice
AKTs
An alternative is the completion of a diploma in dermatology. This will include most elements of assessment listed above. Now that NICE have revised their guidance for the treatment of BCCs in the community, they have recognized the GP who has a specialist interest in skin lesion recognition and treatment but who may not wish to develop the full GPwSI interest in dermatology. This represents a newly acknowledged GP specialist (albeit one that has existed unofficially for a long time).
The DH is now preparing the specification for the training and assessment requirements for this new category of doctor that should mirror many of the GPwSI in dermatology and skin surgery processes, including a diploma level of training.
It is all well and good developing a specialist interest and training to the level of GPwSI but without a contract to provide a GPwSI service, there is little incentive, especially if undertaking an expensive and time-consuming diploma. So GPs undertaking this training should ensure:
It meets an identified personal development need (it should be part of your professional development plan)
You are prepared to fund your own training unless you have PCT funding
Your training opens up opportunities to develop your career
You understand how to prepare a business case to provide a service (through practice-based commissioning or similar processes).
Skin cancer surgery
Things have been a bit confusing lately regarding skin cancer surgery. The NICE Skin Cancer Improving Outcomes Guidance (2006) recommended limiting skin cancer work to specially trained GPs and then only to low-risk BCCs. The latest revision (NICE, 2010) has recommended that:
Low-risk BCCs below the neck can be treated by all minor-surgery-trained GPs
Low-risk BCCs above the neck can be treated by specialist trained GPs (GPwSIs)
GPs wishing to undertake low-risk BCC work below the neck will need to demonstrate:
Surgical skills with formal assessment of DOPs
Annual audits to your local multidisciplinary team (MDT) in addition to any quarterly returns to the commissioners (at present PCTs)
GPs wishing to train as a GPwSI and be able to treat all low-risk BCCs may well need to undertake a diploma level of training.
In addition, if you are able to forge a close relationship with your local MDT (ideally by working within one of their clinics, perhaps as a clinical assistant), then you may be able to achieve what the Improving Outcomes Guidance calls Model 2 working in the community. This means that you are working under Acute Trust governance, your patients are either discussed with or referred by a core member of the multidisciplinary team and you, as a Model 2 practitioner, are allowed to operate on a full range of skin cancers (you are in effect acting as a community extension of the Acute Trust). This level of service will require its own special contract.
Conclusion
Minor surgery in primary care can be challenging, the structure is complicated and it is changing. It is, however, a wonderfully rewarding service to provide patients and when done well and delivered safely, it is very popular, very economic to the NHS and yet also potentially financially rewarding to GPs and their practices. If you wish to pursue a career with this additional skill, I would recommend joining one or both of the relevant associations: the Association of Surgeons in Primary Care and the Primary Care Dermatology Society. These groups will enable you to network with like-minded GPs, to stay abreast of developments and to attend regular educational meetings. Finally, remember to keep your medical indemnity organization fully informed of the work that you undertake.
Key points
All GPs in training need to learn how to identify skin lesions
All GPs in training should learn how to undertake curettage, cautery and simple wound suturing
In order to show evidence of learning, you should consider ways of demonstrating both your knowledge and your skills
In order to show evidence of training, you should keep a surgical log and record: activity, complications, histological diagnosis as compared to your own clinical diagnosis, completeness of excision and complications