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High standards are key to minor surgery in primary care

Charles Broomhead
MB ChB MRCGP DA DRCOG
GP and GP
Trainer
Sutton Coldfield

Honorary Clinical Lecturer
Birmingham Medical School

For any practice considering performing minor surgery there are multiple potential pitfalls. A proactive approach to risk management will ensure that the chance of harm befalling either patient or staff is minimised. Although by definition the procedures being performed will be of a less serious nature, there can be little excuse for standards that fall below those of secondary care.
As in so many areas, efficient nursing support is a key component of any good general practice-based surgery service. While only rarely performing the procedures themselves, nurses play a pivotal role in the overall management of the treatment room. They will ensure that the necessary instruments are sterilised and ready for use and that drugs and consumable items such as local anaesthetics, sutures and dressings are "in stock". They will usually prepare the patient, act as an assistant during the surgery, and be responsible for both dressing the wound and subsequently removing sutures.
Historically, many GPs performed minor operations both within their own surgeries and in cottage hospitals, often without specific remuneration. In 1990 a new contract was introduced that for the first time gave GPs the opportunity to earn a modest fee for carrying out a limited number of specified procedures (see Table 1) in patients who were on their practice list or that of their partners.(1) The criteria for inclusion on the "minor surgery list" were fairly flexible and were mainly based on a practitioner's declaration that they had the skill and adequate facilities to perform surgery within their practice. The number of procedures that could be claimed for was, and remains, restricted to five per month, meaning that when this maximum number was achieved no further payment would be made.(*)

*It should be noted that no fee is payable for any of these procedures performed by a nurse working on her own.

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The advent of "fundholding" and "total purchasing" in the 1990s resulted in a number of innovative ideas whereby special arrangements were made for some practitioners to perform surgical procedures on behalf of their colleagues. Brown and his associates demonstrated that this could be done in an efficient and cost-effective manner that was popular with both patients and doctors.(2) The creation of primary care trusts (PCTs) will undoubtedly widen the range of similar opportunities with the development and employment of so-called "GP specialists".
Many simple but necessary procedures are well within the capabilities of most GPs, all of whom have undergone at least some surgical training as part of their undergraduate and postgraduate careers. In spite of their theoretical competence, however, not all GPs will consider themselves to be proficient at performing minor surgery. Thompson et al found that many GPs perceived considerable gaps in their training and had a desire to improve their surgical skills.(3) This can be seen as an encouraging finding, illustrating the desire of doctors to provide the best care for their patients and a realistic assessment of their abilities. It does, however, highlight an area that demands attention during undergraduate and perhaps postgraduate training.

Record-keeping
Good record-keeping is considered a marker of good care. Studies, such as that undertaken by Somerset and Turton,(4) have linked poor record-keeping to a poor standard of general care. Written, informed patient consent to a surgical procedure and adequate record- keeping should be mandatory requirements and will aid in the defence of any doctor or nurse subsequently involved in litigation. Inadequate or missing records will result in enormous difficulty if a doctor or nurse is called to defend a charge of negligence.
There is a compelling argument that all excised specimens should be sent for histological examination no matter how obvious the diagnosis seems on clinical grounds. Sooner or later that apparently benign mole will prove to be malignant and that seemingly innocent lipoma will turn out to be a soft tissue sarcoma. It is important to remember that the initiator of the request for histology retains the legal and moral responsibility for ensuring that the report is received back from the laboratory, that the patient is informed of the result, and that any necessary further treatment or action is arranged. Systems need to be in place to ensure that this chain of events is robust with no opportunity for results to be lost.

Infection control
A major concern for everyone who performs any sort of surgery must be to ensure that their patients enjoy the best possible outcome, and infection control must figure prominently in this context. At present there appears to be no minimum accepted standards for this. Good practice would suggest that a separate operating room is desirable, that there is adequate protective clothing available, that facilities for handwashing and drying are appropriate, and that all instruments are either disposable or are correctly sterilised. While this may be ideal, it is unrealistic to expect a dedicated room to be ­provided in all practices. Consideration must be given to the type of procedure being performed: for example, different standards would be required of a practice that performs cryosurgery only on warts from that of a practice where more invasive procedures are undertaken.
There are wide variations in the standards of sterilisation. Gone are the days when it was deemed adequate to simply boil instruments in hot water. "Benchtop" autoclaves are now relatively inexpensive and are widely available. They must, however, be inspected and serviced regularly to ensure their safe and efficient performance. A record of each autoclave cycle should be kept in order to demonstrate, should it ever be required, the adequacy of the sterilisation procedures. An autoclave must also be operated correctly. For example, although it may appear desirable to store instruments in "sterile" autoclaved bags until they are required, many autoclaves will not adequately sterilise instruments that have been prepared and packed in this way.
An alternative may be for a practice to negotiate a contract with a nearby hospital clinical sterile services department for the regular provision of sterile equipment packs. Such an option is obviously not cheap, but if the costs of purchasing sterilising equipment, plus a service contract, the cleaning materials used, the time taken by nursing staff in washing and preparing ­instruments and record-keeping, are taken into consideration it may not prove to be significantly more expensive.
Wound infections will almost certainly affect a small number of patients undergoing any sort of surgery, but rigorous attention to sterile procedures will minimise these. The widespread prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals may actually mean that the patient is at less risk of significant wound infection following surgery in the community than if the same procedure is carried out in secondary care. Regular audit of outcomes and perhaps significant event audit when things don't go entirely to plan will provide the opportunity to identify and rectify problems, ensuring better outcomes for future patients. In an audit to assess the infection risks from minor surgical procedures undertaken in general practice, Finn and Crook concluded that there was little room for complacency.(5) They went on to illustrate a number of actions that their local health authority took in the light of their findings. These included:?the establishment and subsequent monitoring of minimum infection control standards as well as self-assessment of infection control and audit in those practices applying to provide minor surgery services.
 
Cost
The cost of minor surgery performed in primary care is something that must receive particular attention. Although it has been shown that it can be cost-effective,(6) careful control of materials and equipment used is essential. Submitting prescriptions and claiming on form 34D allows the recovery of the cost of local anaesthetics and sutures used. Care needs to be taken here, as not all suture material is reimbursable in this manner, and if the wrong materials are purchased there will be no way that a practice can recover the cost. Details of allowable items can be found in SFA (Statement of Fees and Allowances) 42.1-42.6. Similarly, the failure to complete an FP10 for the items used represents a direct loss to the partnership. Dressings represent a particular problem, as the cost of these cannot be recouped in the same way. The cost must either be borne by the practice or the patient themselves, possibly by issuing a ­prescription for the necessary items.

Summary
Minor surgery is well within the competency of most GPs. They provide a valuable service to their patients and at the same time reduce the workload of secondary care. At the same time, it can enhance the job satisfaction of both doctors and nurses involved. Careful planning will minimise the risks to all those involved and may generate a small profit for the practice. Failure to follow basic principles will increase the chance of harm to the patient and the risk of litigation and may result in a financial loss.

References

  1. Department of Health and the Welsh Office. General practice in the National Health Service. A new contract. London: HMSO; 1989.
  2. Brown JS, Smith RR, Cantor T, Chesover D, Yearsley R. General ­practitioners as providers of minor surgery - a success story? Br J Gen Pract 1997;47:205-10.
  3. Thompson AM, Park KGM, Kelly DR, Macnamara I, Munro A. Training for minor surgery in general practice: is it adequate? J R Coll Surg Edinb 1997;42:89-91.
  4. Somerset M, Turton AP. Impact of poor record keeping on leg ulcer care in general practice. Br J Nurs 1996;5:12:724-8.
  5. Finn L, Crook S. Minor surgery in general practice - setting the standards. J Public Health Med 1998;20:169-74.
  6. O'Cathain A, Brazier JE, Milner PC, Fall M. Cost effectiveness of minor surgery in general practice: a ­prospective comparison with hospital practice. Br J Gen Pract 1992;42:13-7.