MINOR SURGERY IN PRIMARY CARE
Directed Enhanced Service (DES)
For the period 1st July 2010 – 31st March 2013
1. Minor Surgery
This Directed Enhanced Service (DES) is available to all practices in Great Yarmouth and Waveney and both GMS and PMS practices. The scope and level of activity for this specification is to help address wide variations in both types of procedures and levels of activity previously available to practices. Qualitative and quantitative data will be collected during the first year to evaluate the appropriateness of scope and level of service and inform what is required for subsequent years.
2. Introduction
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 are highly cost-effective. 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 of minor surgery procedures on their patients.
3. Aims
The aim of this DES is to provide a minor surgery service to:
· Ensure all procedures are clinically necessary and adhere to quality standards.
· Ensure equity of access to minor surgery services in general practice across NHS Great Yarmouth and Waveney (NHSGYW).
· Standardise the funding structure and provide continuity of service in general practice across NHSGYW.
· Support and encourage GPs to carry out appropriate minor surgery procedures in a primary care setting.
4. Scope of service to be provided
4.1 Minor Surgery procedures for cautery, cryotherapy and curettage, provided by primary care as an additional service detailed under GMS Regulation 16 Schedule 2 Section 8, are not included in this specification. Practices wishing to opt out of providing these treatments under an additional service will be obliged to apply to do so in the prescribed manner with the associated funding reduction.
4.2 Procedures available are split into two groups, which have been determined by the time taken to do the procedure and the clinical expertise and support to perform the procedure.
Group / DescriptionGroup A / injections (muscles, tendons, joints and haemorrhoids), invasive procedures including incisions and aspirations
Group B / excisions
4.3 Group B procedures covered by this DES can be carried out in the following instances:
· Diagnostic doubt - Practices will be expected to record all incidences of diagnostic doubt.
· Lesions which are a manifestation of an underlying syndrome;
· Recurrent trauma or significant pressure symptoms; e.g. large scalp sebaceous cyst;
· Recurrent infection;
· Risk or suspicion of pre-malignancy conditions such as solar keratosis and Bowen’s Disease only.
5. Exclusions
5.1 Cosmetic skin procedures will NOT be funded (including laser treatment) by NHSGYW.
5.2 The following Benign skin lesions are excluded from this DES EXCEPT where
4.3 applies:
· Lipomata
· Sebaceous cysts
· Skin tags including anal tags
· milia
· seborrhoeic keratoses
· warts of hands and feet (except if interfering with mobility and employability or if immunosuppressed)
· asymptomatic benign melanocytic naevi (pigmented moles)
· corns/callous
· physiological androgenetic alopecia (male pattern baldness)
· physiological idiopathic hirsutes with a normal menstrual cycle
· dermatofibromata
· fungal infections of toe nails
· telangiectasiae and spider naevi (except if occurring on the face of a child who is being teased or bullied)
· comedones
· tattoo removal
· molluscum contagiosum
· mild or moderate non scarring acne vulgaris which has not been treated with 6 months of systemic therapy
· xanthelasma
· any other minor skin lesions
5.5 Low risk basal cell carcinoma should be referred to only those clinicians recognised and approved by NHSGYW who are providing a specialist service.
5.6 Procedures suitable for referral to a GP who has been commissioned to provide Enhanced Minor Surgery, who has been recognised and approved by NHSGYW, are those of a more complex nature which are outside the competence and skills of the referring GP, but do not fall into the guidance for referral to secondary care. Referrals to this service must include clear clinical indications for the necessity for Minor Surgery. Full details of the specialist service are available on request from the NHSGYW.
5.7 Patients with suspected malignant melanoma, squamous cell carcinoma, high risk basal cell carcinoma or where the diagnosis of malignancy is suspected but of uncertain aetiology should be referred to secondary care via the urgent 2 week wait referral system.
5.8 Removal of lesions for other clinical indications will require prior approval for funding on an individual basis. Clinicians may refer to the NHSGYW Individual Funding Request Process (IFR) for a decision. Practices are required to submit, in writing, a detailed description of the case, which should include the reason and justification for referring the case for consideration by the panel.
6. Eligibility to provide the service
6.1 The practice must identify a GP Clinical Lead within the practice who will have overall responsibility for the service.
6.2 Each clinician providing minor surgery under this enhanced service must be able to provide evidence that they have undertaken appropriate accredited training and have up to date skills and experience to carry out the contracted procedures. In addition, they will be required to provide evidence of a continuing sustained level of activity and regular clinical audits, take part in necessary supportive educational activities and be appraised on what they do.
6.3 The Practice must ensure that 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.
6.4 Appropriately trained nurses and healthcare assistants can provide care and support to patients undergoing minor surgery.
6.5 Where NHSGYW can provide evidence that a clinician carrying out minor surgery is not complying with the terms of the contract it will invoke a remedial notice according to the procedure laid out in Regulation. There is considerable guidance available on techniques and facilities for conducting minor surgery in general practice.
6.6 The Practice must ensure that all staff undertaking any procedures under this specification have full indemnity and liability cover; where a sub-contractor is employed by the practice to provide this service; the practice retains liability for all actions and will indemnify NHSGYW against any future claims where the sub-contractor does not comply with current standards.
7. Infection Prevention and Control
7.1 Patients undergoing invasive procedures such as minor surgery will have an increased risk of infection. It is essential therefore that appropriate infection control procedures. NHSGYW will need to be assured that practices comply with the following Infection Control Core Standards as discussed with the Director of Public Health:
7.1.1 The environment must comply with the relevant Health Technical memorandum’s (HTM’s). Details are specified in Appendix C (to be inserted).
7.1.2 Decontamination of reusable medical devices must take place in a fully compliant accredited Sterile Services Department (SSD) or be single use.
7.1.3 All medical devices must be fully traceable through the full cycle of use and processing with records also traceable to all patient records.
7.1.4 Standard Precautions must be adhered to at all times (see Appendix C)
7.1.5 If a ventilated operating area is required please refer to ‘Infection Control Standard for a Theatre Complex’.
7.1.6 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.
7.1.7 Practices must undertake annual infection prevention and control training accredited by NHSGYW.
8. Equipment and Consumables
The practice is responsible for the cost of providing all the equipment necessary to provide the service. The cost of drugs and dressings for these procedures is covered under the practice prescribing budget and they are obtainable by writing a prescription.
9. Consent
In each case the patient should be fully informed of the treatment options and the treatment proposed. Consent will be recorded in the patient’s lifelong record, and where appropriate written consent will also be documented.
10. Pathology
All tissue removed by minor surgery should be sent routinely for histological examination unless there are exceptional or acceptable reasons for not doing so.
11. Audit:
Full records of all procedures must be maintained in such a way that aggregated data and details of individual patients are readily accessible. Practices should annually audit and peer-review minor surgery work. Full details of audits and peer-review must be made available to NHSGYW at annual review or on request. Information collected should include:
· Number and type of procedure
· The operator (who performed them)
· Clinical diagnosis
· Tissue diagnosis (adequate removal, for example clearance in excisions)
· Clinical outcomes
· Complications and Rates of Infection
· Unexpected or incomplete excision of basal cell tumours or pigmented lesions which following histological examination are found to be malignant.
· Untoward Incidents
· Patient Complaints
12. Patient information
The practice will produce a patient information leaflet containing full details of scope and provision of service.
13. Record Keeping
The practice must ensure full details relating to the patient’s minor surgery procedure provided under this service are included in his or her lifelong record. If the patient is not registered with the practice providing the service, then the practice must send this information to the patient's registered practice for inclusion in the patient notes.
Practices must maintain adequate records of the performance of the service provided, incorporating any other appropriate information into the computer record, as deemed necessary or required by the practice guidelines, all using agreed Read codes. This information should be made available to the NHSGYW upon request, e.g. the annual review meeting.
14. Pricing and Monitoring
14.1 Treatments under this DES are priced depending on complexity of procedure, involvement of other staff and use of specialised equipment. The level of Practice budget will be determined on an average practice list size basis (Average Practice List = 5891).
In 2010/2011, payments made will be made quarterly in arrears:
Group A : The cost of an injection, incision and aspiration will be £42.01 + annual recommended uplift.
Group B: The cost for an excision will be £84.02 + annual recommended uplift.
Subsequent annual inflationary payment increases will be in line with the DDRB recommendations.
14.2 For the purpose of budgetary control, a budget will be set at practice level at the start of each year. There will be no defined ratio for injections and cutting procedures within that agreed budget, but all procedures must be fully documented. Levels of activity and budgets attributed to this Directed Enhanced Service will be reviewed on an annual basis.
Payments over and above the level of agreed budget will not be paid to practices where they exceed their agreed value without written confirmation from NHSGYW.
14.3 Following receipt of data for Quarter 2, NHSGYW will review activity levels, so that requests for additional activity can be considered. Any increase in activity will be at the discretion of NHSGYW based upon financial constraints and demand. Practices will be required to provide supporting information and evidence of procedures completed in year to support any request for additional activity. NHSGYW will confirm any additional activity in writing.
14.4 Practices will be asked to provide the information on the NHSGYW Enhanced Services Reporting website.
14.5 Suggested READ codes for services provided under this DES
Description of Procedure covered under this DES / EMIS / IPS Vision / SystemOneInjections for Haemorrhoids
Injection of sclerosing substance into haemorrhoid
Phenol injection of haemorrhoid / 77352
-- / 77352
-- / --
XaBAi
Injections for muscles (intramuscular ),
tendons (tendon injection)
and joints (injection into joint NEC) / 7L18.
85B3.
7K6Z3 / 7L18.
85B3.
7K6Z3 / Xa3wj
X6013
X00OE
Minor Surgery done (Injections) / 9877. / 9877. / XE2K8
Minor Surgery done (Incisions) / 9879. / 9879. / 9879.
Minor Surgery done (Aspirations) / 9878. / 9878. / 9878.
Minor Surgery done (Excisions) / 987A. / 987A. / 987A.
Exceptions to exclusion list (not suitable for minor surgery in primary care setting?) / 9kC0. / 9kC0. / XaPBW
Suggested READ codes for reporting purposes only for those services provided under GMS/PMS Additional Services
Procedures provided under additional services not covered by this Directed Enhanced Service / EMIS / IPS Vision / SystemOneMinor Surgery done Cautery / 9876. / 9876. / 9876.
Minor Surgery done Cryotherapy / 987D. / 987D. / XaJJw
Minor Surgery done (Other) Curettage / 987B. / 987B. / 987B.
15. Notice Period
There is a six months exit notice period on both sides with regard to provision of this enhanced service.
16. Quality Standards and Outcomes
All practices participating in this DES will be expected to ensure compliance to the appropriate quality standards for the service and the eligibility criteria as stated in this document.
Quality Standards and Policies are as follows
16.1 The practice aspires that the clinical environment conforms to NHSGYW Treatment Room Standards determined through the Treatment room standard audit tool.
Practices who are not yet compliant will carry out a risk self-assessment. Where there are not adequate controls in place to mitigate against the risk, the practice will contact the Infection Prevention and Control Specialist to agree appropriate action.
A copy of the risk assessment is to be retained by the practice and provided to NHSGYW if requested.
16.2 Compliance to NHSGYW Policy on sharps disposal.
16.3 Compliance to NHSGYW Standard precautions.
16.4. Compliance with relevant NICE guidance.
16.5 The practice complies with current infection control standards, including staff training. This will be reviewed by the NHSGYW as part of their infection control visits.
16.6 All staff involved in the delivery of this service have current immunisation against Hepatitis B.
16.7 The provider will follow the current Occupational Health Guidance for the management of needle stick/sharp injuries. Each needle stick/sharps injury should be reported to NHSGYW.
16.8 All staff involved in the delivery of this service will have the appropriate training and/or relevant experience.
16.9 Patients and or carers receive relevant information in a format which is appropriate for the patient’s individual needs.
16.10 Processes to ensure all results are received back to the practice and patients are informed of their results within an acceptable time frame.