Minor surgery in primary care has reached a critical juncture. After years of GPs' duties being curtailed and funding withdrawn, this vital service is on its knees.
Some GP practices have stopped offering surgical services; others are reluctant to train, such is the dearth of opportunities when qualified.
But now there is hope that a new collaboration can revive this ailing service. Dr Jonathan Botting, RCGP minor surgery clinical champion, believes one key ingredient can help to rebuild what has been lost: evidence.
The profession needs proof that it can perform procedures in the community to the same standard as secondary care specialists, with equivalent outcomes.
To this end, the RCGP has teamed up with the NHS Information Centre to launch an ambitious three-year project to audit the performance of GPs practising minor surgery nationwide and report its findings in real time.
Dr Botting says: 'This system will be unlike any other. GPs will be able to upload minor surgery activity as it happens and then histological results as they come in. They can compare clinical and histological diagnosis.' Practices will compare their data with peers, and individuals will use the data for revalidation and appraisal.
It is an attempt to put minor surgery in general practice back on track after years of setbacks. Dr Botting says the decline started in 2006, with controversial guidance from NICE, Improving outcomes for people with skin tumours including melanoma.
LMCs complained this prevented GPs from treating basal cell carcinomas (BCCs) in primary care, forcing them to refer. Dermatology clinics were soon swamped. The only non-cancer work left was decommissioned by some PCTs looking to save costs, as a GP investigation uncovered (GP, 9 October 2011).
The debate rumbled on until April 2009, when NICE called a meeting of advisers and stakeholders, which forced a rewrite of the guidance in 2010.
Dr Botting believes GPs are still suffering from the fallout. 'That 2006 document really put a massive rift between primary and secondary care,' he says. 'It was a poorly organised piece of work that has had a significant impact on primary care activity.'
The 2010 rethink only partly resolved the problem. Since then, many GPs have stopped offering surgery because of the excessive rules and regulations surrounding BCCs, says Dr Botting. 'The whole thing has become such a pain.
'Those who want to enter the profession and provide services are put off and can't find training. It has disenfranchised primary care and the ability to learn through activity has been taken from us.'
A NICE spokeswoman said the 2010 update provided 'clarification' about the arrangements for GP minor skin surgery. This ensures 'the most appropriate healthcare professional treats each BCC, according to the level of risk and their specific skills and training', she said.
Stripping GPs of their minor surgery role has probably hit NHS finances too. For example, in dermatology minor surgery, secondary care costs are three to nine times higher than primary care for the same procedure.
The key question remains: are primary care outcomes as good as secondary care?
More data needed
Although the evidence is mixed, a significant development in GPs' favour came from a study by Aberdeen GP Dr Peter Murchie and colleagues published in the British Journal of General Practice in 2011. They found 'no evidence to support the belief that melanomas are more likely to be excised inadequately in primary care'.
The data came only from the Grampian region of Scotland. It may be that more extensive, national data are needed to provide more conclusive proof of GPs' abilities.
Even if the RCGP's audit can show that primary care activity is safe, effective and cost-effective, the decision will ultimately rest with commissioners. Their judgment will also determine whether more GPs are to be trained in minor surgery.
The RCGP's plan is a bold attempt to reverse the decline in primary care minor surgery and convince commissioners in the new-look NHS that primary care can deliver.