DES - Minor Surgery

Contract Specification – DES: Minor Surgery (GG&C) 2015-16 v3

12/01/2015

DES - Minor Surgery 2015-16

Contract Mechanism and Specification

Introduction
1. There is evidence from within the UK and abroad that minor surgical procedures carried out by general practitioners in general practice premises have high levels of patient satisfaction and can be cost-effective. [1, 2, 3]Since 1 April 1990 general practitioners on Health Authority minor surgery lists (and their equivalents) have been able to receive payment for undertaking a range [1] of minor surgery procedures on their patients.

2. There has been a huge variation in the range of procedures undertaken at practice level. Many practices have provided cryotherapy, curettage and cauterisation only whilst still referring other minor surgery into the secondary sector. This Directed Enhanced Service scheme, which must be commissioned by every PCO, seeks to ensure that there is the opportunity to provide an appropriate range of minor surgery in the primary care sector.

Scope of service to be provided

3. Cryotherapy, curettage and cauterisation will continue to be provided by general practitioners as an additional service and practices wishing to opt out of providing these treatments will be obliged to apply to do so in the prescribed manner, resulting in a commensurate reduction in the Global Sum of 0.6%. Procedures in the categories below and other procedures, which the practice is deemed competent to carry out, will be covered by a Directed Enhanced Service (DES). These procedures have been classified into the following groupings for payment:

- injections* (muscles, tendons, joints, varicose veins and piles)

- invasive procedures, including incisions and excisions

* injections does not include ‘drainage’ of bursa/ganglia/hydroceles

CEL 30 (2009) dated 2nd July 2009 states that:

The Exceptional Aesthetic Referral Protocoldefines a list of cosmetic procedures, which, as they are not treating an underlying disease, are not routinely available on the NHS, and can only be provided on an exceptional basis where there is clear evidence of benefit to the patient.

NHS Boards should ensure that they pursue an engagement process with General Practitioners to share this approach.

Appendix 2 of CEL 30 provides a list of procedures not available on NHS for aesthetic reasons. This includes the excision of benign skin lesions.

This protocol states that the removal of benign skin lesions should not be performed except under these EXCEPTIONAL criteria:

• Diagnostic doubt – GPs should not remove but refer to dermatologists for an opinion on the need for removal (if required for diagnostic reasons removal will be performed by dermatologists, if not required for diagnostic purposes removal will not be performed by dermatologists)
• Significant (future) risk of neoplasia
• Lesions causing functional problems or significant disfigurement (for the former the functional problems should be as defined and excluded in Appendix 1 of the protocol; the latter will almost always require referral to secondary care due to size and / or position)
• Lesions prone to recurrent infection, (patient required to have had at least one previous infection

The protocol was updated by CEL 27 (2011) in November 2011 and this was circulated to Practices on the 30th November 2011. A copy (on pdf) of the updated protocol is embedded in this specification below:

Eligibility to provide the service

4. A practice may be accepted for the provision of this DES if it has a partner, employee or sub-contractor, who has the necessary skills and experience to carry out the contracted procedures in line with the principles of the generic GPwSI guidance or the specific examples as they are developed. Clinicians taking part in minor surgery should be competent in resuscitation and, as for other areas of clinical practice, have a responsibility for ensuring that their skills are regularly updated. Doctors carrying out minor surgery should demonstrate a continuing sustained level of activity, conduct regular audits and mayinclude this activity in their annual appraisal and take part in necessary supportive educational activities.

5. Where a PCO believes a doctor carrying out minor surgery is not complying with the terms of the contract it should invoke a remedial notice according to the procedure laid out in Regulation. There is considerable guidance [4] available on techniques and facilities for conducting minor surgery in general practice.

i) Satisfactory facilities PCOs should be satisfied that practices carrying out minor surgery have such facilities as are necessary to enable them properly to provide minor surgery services. Adequate and appropriate equipment should be available for the doctor to undertake theprocedures chosen, and should also include appropriate equipment for resuscitation. National guidance on premises standards has been issued. [4].

ii) Nursing support Registered nurses can provide care and support to patients undergoing minor surgery. Nurses assisting in minor surgery procedures should be appropriately trained and competent, taking into consideration their professional accountability and the Nursing & Midwifery Council (NMC) guidelines on the scope of professional practice.
iii) Sterilisation and infection control Although general practitioner minor surgery has a low incidence of complications, it is important that practices providing minor surgery operate to the highest possible standards. Practices should take advantage of any of the following arrangements:
1. sterile packs from the local CSSD

2. disposable sterile instruments

3. Approved sterilisation procedures that comply with national guidelines

General practitioners are responsible for the effective operation and maintenance of sterilising equipment in their practices. Practices must have infection control policies that are compliant with national guidelines including inter alia the handling of used instruments, excised specimens and the disposal of clinical waste.

iv) Consent In each case the patient should be fully informed of the treatment options and the treatment proposed. The patient should give written consent for the procedure to be carried out and the completed NHS consent form should be filed in the patient's lifelong medical record.

v) Pathology All tissue removed by minor surgery should be sent routinely for histological examination unless there are exceptional reasons for not doing so.

vi) Audit Full records of all procedures should be maintained in such a way that aggregated data and details of individual patients are readily accessible. Practices should regularly audit and peer-review minor surgery work. Possible topics for audit include: clinical outcomes, rates of infection and all unexpectedoutcomes, especially any incomplete excisions of basal cell tumours or pigmented lesions which following histological examination are found to be malignant.

Ineligible invasive procedures

6. In line with National Policy the removal of benign skin lesions will no longer be funded as part of this Directed Enhanced Service, except under the EXCEPTIONAL criterialisted in the relevant national guidance – any exception applying should be recorded in the patient file for payment verification purposes.

Benchmark pricing

7. Treatments under this DES will be priced depending on complexity of procedure, involvement of other staff and use of specialised equipment.

In 2015-16 payment for an injection will be£43.34 and for cutting surgery (incisions & excisions) the fee will be £86.69.

Claims for Payment
8. Claims for payment should be made using the electronic claim form for 2015-16 and these should be e-mailed to by the 5th of the month following the Quarter End. Claims made not using this form or not sent to the above e-mail address will not be paid.

References
1. Lowy A, Brazier J, Fall M, Thomas KJ, Williams BT. Quality of minor surgery by general practitioners in 1990 and 1991.British Journal of General Practice 1995: 44; 364-365

2. Tarraga Lopez PJ, Marin Nieto E, Garcia Olmo D, Celada Rodriguez A, Solera Albero J. [Economic impact of the introduction of a minor surgery program in primary care]. [Spanish] Atencion Primaria 2001;27(5):335-8.

3. Lopez Santiago A, Lara Penaranda R, de Miguel Gomez A, Perez Lopez P, Ribes Martinez E. [Minor surgery in primary care: consumer satisfaction]. [Spanish] Atencion Primaria 2000;26(2):91-5..
4. Department of Health. Health building note 46: General medical practice premises. London: Department of Health.

Department of Health. Building note 22: Accident and emergency departments. London: Department of Health.

NHS GG&C Service Mechanism

This DES is split into 2 sections, injections and incisions/excisions. Practices areable to opt in to one or both sections. Practices should note that cryotherapy, curettage and cauterisation are included within the Minor Surgery Additional Service component of the Global Sum and are thus not part of this Enhanced Service.

The payment system will be as follows:

For 2015-16 the total funding available for this DES will be distributed across participating Practices. The individual Practice funding cap is based on the Practices' historical funding, with an adjustment to take into account the reduction in activity due to the introduction of the aesthetics protocol.

This funding will be paid to Practices in 4 installments, following the quarterly claims. Each Practices activity will be looked at in the light of its financial cap. Full payment will be made up to the financial cap. For those Practices where activity is below the financial cap, the unspent funding will be set aside until Year End and utilized to fund any other Practice’s activity above their financial cap. This process has been in place for several years and has always resulted in practices with increased activity being fully reimbursed for that activity – even when it was above the financial cap.

Practices will be asked to complete a quarterly activity report/claim and forward this to the GMS Contract Team. The e-mail address is as follows: On receipt of the quarterly activity report/claim using this method, a payment will be made to the Practice, subject to the Practice’s financial cap.

Practice activity submissions will be considered as part of the Board’s post payment verification process.

Each practice is responsible for ensuring that the clinician carrying out minor surgery is carrying out enough procedures to maintain their expertise. Clinicians will only be able to carry out minor surgery under this DES if they were registered on the current minor surgery list, or in future (when the minor surgery list no longer exists) had demonstrated to GGNHSB that they had achieved the standard required currently to be registered on the list (GPwSI).

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