Amid the drive towards localism in healthcare in England, the fight to secure more training and funding for GP minor surgery in the community is now gathering pace.
South Yorkshire GP Mr Vijay Kumar, recently elected as the president of the Association of Surgeons in Primary Care (ASPC), has an ambitious target to focus commissioners' minds. He wants there to be one surgically trained GP in every local practice, nationwide, to improve the provision of community surgical care.
He believes this would benefit patients, doctors and commissioners alike, by reducing costs, easing pressure on hospitals, developing GP skills and training, and allowing practices to offer treatment in a more convenient setting for patients.
'We work on a very basic principle,' he says. 'Local services, local people, by local doctors, at the local centre.'
It is a big challenge, not least because minor surgery in primary care has taken a hammering. GP surgeons have been stung by criticism of the quality of practice-based procedures, arguments about which continue.
In addition, NICE withdrew its support for GPs to remove higher-risk basal cell carcinomas (BCCs) in its 2010 guidelines.
Now, in an attempt to prove GP surgeons have the skills to diagnose and treat dermatological conditions, including skin cancers, the RCGP has launched a nationwide assessment of all GP minor surgery.
The Community-Based Surgery Audit (CBSA) is an ambitious project organised in collaboration with the Health and Social Care Information Centre and led at the RCGP by Dr Jonathan Botting, RCGP clinical lead for minor surgery (see box). Above all, it aims to show the value of offering these procedures through GPs.
But improving the perception of GP minor surgery is only one challenge among many, according to Mr Kumar. He says commissioners have largely neglected GP minor surgery services since the NHS reforms took hold in England.
'With the change in the system, what's happened is, there's a lull. There's less recruitment with the loss of PCTs - NHS England hasn't recruited many GP surgeons.'
In addition, revalidation for GP surgeons has struggled in the changeover, he says, with some responsible officers unsure how to assess GPs who work as community surgeons. There is also a lack of 'clear-cut standards' for GPSIs, he adds, and variable provision of GP minor surgery services around the country.
The shortage of funding continues to be a stumbling block, with some practices running at a loss when trying to offer certain procedures.
Mr Kumar says it is 'wrong' that practices receive just £87 under the minor surgery DES for surgery including skin-flap removal, BCCs and even vasectomy. 'It's not possible to do that for that price, and I think NHS England needs to know that. Common sense has to prevail.'
His words echo previous calls for a more sophisticated payment system, which recognises that more complex procedures require greater resources, and that the current payment system makes some services 'unviable'.
Mr Kumar believes the UK needs to catch up with the leading nations on the local provision of surgical services.
He trained as a breast and colorectal surgeon and has spent 24 years in the NHS, along with spells in France and the US.
'I had an opportunity to look at how private healthcare provider Kaiser Permanente worked. A large amount of community surgical work was taking place in what you'd call office-based surgery. These were family practitioners: they had some training in surgery and continued to provide excellent care in the community.'
He admits big changes are needed if his vision of one surgically trained GP per practice is to become a reality. 'First, you've got to commission the service: if commissioning doesn't happen, you don't have a service and there is no impetus for somebody to do the procedures.
'NHS England should really consider the cost-benefit to see how much can happen in the community and what can be taken out of hospitals, so that the hospitals are under less strain to do things - they can do the complicated work.
'Second is the people we train. I'm one of the directors for community surgery for RCGP Yorkshire. We want more training to happen locally, to bring these young doctors in and for continuity. We have an advanced training stream so that people who are isolated and operating for a long time can know if they're doing the right thing or not.'
Third on his list is accreditation and Mr Kumar says the ASPC will work closely with the RCGP, NHS England, responsible officers and CCGs to ensure the quality of practising surgeons remains high. 'That's where Jonathan Botting comes in with his audit,' he says.
Mr Kumar says that in some areas of the country, secondary care doctors are coming into primary care to be trained by GPs and consultants who work there. He questions why GPs are not being trained instead.
Put simply, he argues, minor surgery 'hasn't been a priority in the past few years' and the loss of commissioning experience with the demise of PCTs means many CCGs are now unsure how to commission GPs to provide the services.
'ASPC has assisted three CCGs,' he says. 'They weren't sure how to commission the service.'
Mr Kumar (right) with colleagues at Mexborough Medical Practice
But he advises GPs looking to start or continue offering minor surgery services to make the case directly to commissioners. 'I think the best thing is to go to the head of procurement commissioning and go through the case with them.'
Essentially, he argues, it is about clearly presenting the costs and value of the service. 'We helped an organisation in the West Country which was almost doing it for charity. It was about to close the surgery and make some of the staff redundant. We assisted that organisation to talk to the commissioners and get back on track.'
He also advises making use of LMC resources to pursue the case. 'GPs pay for their LMC and I think they should get their money's worth,' he says. 'The LMC should work on it to show them this is what it costs.'
He adds that the ASPC 'is happy to help practices and GP surgeons who want help with that'.
Mr Kumar insists commissioners must sit up and engage with the skills that GPs can offer in this area, to protect the future of this essential community service.
As part of this, the RCGP audit will be vital to promote GPs' work. He says: 'It'll go a long way to prove we're doing a great job, making fantastic savings. We have excellent patient feedback and I think it's a win-win for all.'
|Making the case|
An upcoming RCGP audit of GP minor surgery is being billed as a chance to make the case for practice-based procedures, while providing much needed data on the provision of these services nationwide.
The RCGP says the CBSA will let GPs monitor and improve the quality of care they provide, including peer comparison. It will allow GPs to collect data to support reaccreditation, appraisal, revalidation and local contracting. Information will also be compiled into a national database for tracking UK-wide outcomes.
Announcing the launch of the audit last month, Dr Jonathan Botting, RCGP clinical lead for minor surgery, said: 'Our hope is that the CBSA will demonstrate GPs have the diagnostic and surgical skills to carry out such procedures, allowing us to take a more pivotal role in life-saving skin cancer treatments.'
The RCGP believes supporting suitably skilled GPs as part of an extended, community-based surgical network could contribute 'significant' cost savings by moving procedures out of hospitals.