Editor,
The NHS here faces challenging times with significant disinvestment over the next few years. The arrival of commissioning will provide an opportunity to continue to provide the best service we can within financial constraints. Now, more than ever, we need to be looking at who provides what service and where.
Minor surgery has always been provided in primary care. Changes in the GP contract in 1990 and 2004 have seen an increase and diversification of procedures. Everything from skin tag excision to hernia surgery is offered at primary care centres throughout the UK.
Evidence for the quality of minor surgery in primary care seems to be heavily influenced by who has undertaken the study. Two major recent studies reached opposite conclusions. Prof Primrose, a surgeon found outcomes to be better in hospital and Professor Murchie, a GP found better care in primary care. NICE revised its skin cancer guidelines in 2010 after its initial recommendations, written nearly entirely in secondary care, were rejected by GPs who had been effectively excising low risk BCCs and SCCs for years.
Community surgical services are delivered by a wide-ranging group of clinicians. Some are members or fellows of the royal college of surgeons and others have limited surgical experience. Indeed the RCGP does not include minor surgery as a core competency for GPs. This heterogeneity of providers has lead to some concern both within general practice and from our hospital surgical colleagues.
Some GPs are also working in inadequate facilities for the procedures they are providing. It is likely that the Care Quality Commision will curtail some practitioners when GP surgeries face licensing in the next few years.
We need to look again at community based surgical procedures and standardise facilities and training. The family planning model is one I feel we could borrow from. Family planning can be delivered from specially equipped centres staffed by clinicians with a special interest. It is based in primary care but works closely with both GPs and hospital consultants. A relationship builds up overtime with primary and secondary care. There is appropriate clinical governance so Consultants and GPs alike are confident in the service.
A similar care pathway could be developed for community surgery. Discussions need to be had between stakeholders as to what procedures could be offered and by what providers. In the Grampian region of Scotland they have appointed a community based Consultant Surgeon to oversee this process.
In Northern Ireland there are no competency criteria for GPs providing minor surgery and no requirement for audit of procedures that are done. There are no established training pathways for GPs to provide surgical services. There is also no regulation of premises from which the service is provided. There is little support from hospital colleagues for our minor surgery activity.
Now is the time to tackle the issue of primary care surgery in Northern Ireland. In Great Britian there are national audits on primary care vasectomy, carpel tunnel and other surgical procedures being collated. We need to become more pro-active and look at our own services or risk getting left behind with outdated, expensive and potentially dangerous care pathways.
The author has no conflict of interest.