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DES - Minor Surgery - DOC - DOC by linzhengnd


									             Contract Specification – DES: Minor Surgery (GG&C) 2011-12 v4

DES - Minor Surgery         2011-12

Contract Mechanism and Specification

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. 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

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

- invasive procedures, including incisions and excisions
CEL 30 (2009) dated 2 July 2009 states that:
The Exceptional Aesthetic Referral Protocol contains a series 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 fro diagnostic purposes removal will not be performed by
     Significant risk of neoplasia

             Contract Specification – DES: Minor Surgery (GG&C) 2011-12 v4

       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

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, be appraised on what they do 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 the
procedures 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 United Kingdom
Central Council (UKCC)           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
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

             Contract Specification – DES: Minor Surgery (GG&C) 2011-12 v4

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 unexpected or incomplete excision 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 criteria listed 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 2011-12 payment for an injection will be £43.34 and for cutting surgery (incisions & excisions)
the fee will be £86.69.

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
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 are able to opt in to
one or both sections. Practices should note that cryotherapy, curettage and cauterisation are
included withing the Minor Surgery Additional Service component of the Global Sum and are thus
not part of this Enhanced Service.

In previous years the total budget available for this DES was allocated across the Practices,
based on their historical activity and monthly payments made in year. This year, with only those
invasive procedures applicable under the NHSGG&C aesthetics protocol being eligible for
payment, the number of eligible procedures is likely to decrease and the overall budget has been
reduced accordingly. Consequently each Practice’s financial cap will be reduced by an
appropriate amount.

Practices will be asked to complete a quarterly activity report and forward this to Irene Maclean of
the GMS Contract Team. Irene’s e-mail address is as follows:
and her telephone number is 0141-211-0357. On receipt of the quarterly activity report, a
payment will be made to the Practice, subject to the Practice’s financial cap.

            Contract Specification – DES: Minor Surgery (GG&C) 2011-12 v4

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

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).

Decontamination of Reusable Devices

Practices wishing to provide this DES should note the current guidance concerning the
decontamination of reusable devices and must comply with this. GGNHSB is aware of two
companies which can supply single instruments: B. Braun Medical Ltd    TEL (0114) 225 9000
                                               Robinson Care Ltd       TEL 01909 735000
Practices may wish to contact these companies and evaluate their products for suitability.


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