ࡱ> orjklmn ^bjbj hh$U+& & i:,$PC O6S({nnnXZZZZZZZnL"nnnZo6&6&6&nX6&nX6&6&u}I4txHD0x83V3}3}Dnn6&nnnnnZZ#(nnnnnnn3nnnnnnnnn& /:  PRIMARY CARE DEVELOPMENT 4.1.4 ENHANCED SERVICE SPECIFICATION FOR MINOR SURGERY 1 INTRODUCTION 1. 1 There is evidence from within the UK and abroad that minor surgical procedures carried out by General Practitioners (GPs) in general provider premises have high levels of patient satisfaction and are highly cost effective  . Since 1 April 1990, GPs 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. 1.2 There has been a huge variation in the range of procedures undertaken at provider level. Many providers have provided cryotherapy, curettage and cauterisation only whilst still referring other minor surgery into the secondary sector. This Directed Enhanced Service (DES), which must be commissioned by every Primary Care Trust, seeks to ensure that there is the opportunity to provide the maximum range of minor surgery in the primary care sector. 2 SERVICE OUTLINE 2.1 Cryotherapy, curettage and cauterisation will continue to be provided by GPs as an additional service and providers 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 provider is deemed competent to carry out, will be covered by a DES. These procedures have been classified into the following three groupings for payment: injections (muscles, tendons and joints) including Zoladex invasive procedures, including incisions, excisions, resection of toenails and aspirations Triptorelin 3 TRAINING/ACCREDITATION 3.1 A provider 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 General Practitioners with Specialist Interests (GPwSI) guidance or the specific examples as they are developed. This includes being competent in resuscitation and having annual updates. Each doctor carrying out minor surgery should demonstrate a continuing sustained level of activity (minimum of 20 procedures per annum for the provision of joint injections and/or cutting procedures), conduct regular audits, and provide evidence regarding educational activities to enable the appraisal process. All clinicians should have read the clinical guidelines attached at Appendix 1, practices should complete Appendix 2 and return this to the Primary Care Trust. 3.2 Where the Primary Care Trust believes a doctor carrying out minor surgery is not complying with the terms of the contract it may invoke a remedial notice according to the procedure laid out in General Medical Services (GMS) and Personal Medical Services (PMS) Regulations. There is considerable guidance available on techniques and facilities for conducting minor surgery in general practice. In assessing suitability for the provision of this DES, providers should pay particular attention to the following: Satisfactory facilities Primary Care Trusts should be satisfied that providers carrying out minor surgery have such facilities as are necessary to enable them to provide minor surgery services properly this includes good lighting, ventilation, appropriate hand washing facilities and suitable flooring and storage 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 the Provider should self-assess their compliance using Appendix 3, providers should not use this as the sole evidence of compliance with national standards and may use another tool to provide evidence. The Primary Care Trust will carry out a further assessment 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 and Midwifery Council guidelines on the scope of professional practice Sterilisation and infection control although GP minor surgery has a low incidence of complications, it is important that providers providing minor surgery operate to the highest possible standards GPs are responsible for compliance with decontamination regulations, as a result of the new regulations providers are expected to use single use instrumentation providers must also have infection control policies that are compliant with national guidelines including inter alia the handling of used instruments, excised specimens, the disposal of clinical waste, needle stick incidents, environmental cleanliness and standard precautions including handwashing 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, an example of this is for pilar/sebaceous cysts. The reason should be documented in the clinical record. Clinical Audit Full records of all procedures should be maintained in such a way that aggregated data and details of individual patients are readily accessible. Providers should regularly audit and peer review minor surgery work. Possible topics for audit include: clinical outcomes rates of infection unexpected or incomplete excision of basal cell tumours or pigmented lesions which following histological examination are found to be malignant waiting times for treatment for enhanced service procedures Somerset Primary Care Trust requires one audit per annum to be shared with Primary Care Trust a month prior to the annual contract review. Patient Monitoring Providers must ensure that details of the patients monitoring as part of the DES is included in his or her lifelong record. If the patient is not registered with the provider providing the DES, then the provider must send this information to the patients registered provider for inclusion in the patient notes. Suggested Read Codes 9877 Injection 9879 Incisions 9878 Aspirations 987A Excisions 7G03C Excision (face/head/neck) 7G2A3 Zoladex 7G320 Toenail resection 8920 Consent for operation given 8921 Consent for operation refused 72126 Meibomian cyst removal CONSENT In each case the patient should be fully informed of the treatment options, risks and the treatment proposed. 4.2 National guidelines suggest that written consent should be obtained from patients. The Primary Care Trust wishes the providers to note that their interpretation of written consent in this context is the recording of consent by Read Code. Where the provider Read Codes consent given, the Primary Care Trust will take this to mean that the patient has been fully informed of the treatment options and risks, has been offered written information and has given consent. 4.3 The Primary Care Trust would expect that there would be exceptions to this interpretation in certain circumstances (for example if a patient was not competent or appeared uncertain) and or for certain procedures, where actual written consent would be required. It would be for the individual clinician to make the judgement as to what should be deemed necessary. Due consideration should be given to obtaining written consent where risks of dissatisfaction are higher, for where visible scarring is likely. Please refer to the Somerset Primary Care Trust Consent Policy for further guidance/consent forms if needed. 4.4 The indication for surgery should be recorded, alongside advice given with regard to possible adverse outcomes, this may obviate the need to provide written information mentioned in Section 4.2. However as noted in Section 4.3, where risk of dissatisfaction is higher clinicians should consider this carefully. 4.5 Providers will need to maintain waiting times for enhanced service procedures at less than two weeks. Where this is likely to be exceeded the Senior Primary Care Commissioning Manager for the locality should be informed. SIGNIFICANT/ADVERSE EVENTS 5.1 The Department of Health emphasizes the importance of collected incidents nationally to ensure that lessons are learned across the NHS. A proactive approach to the prevention of recurrence is fundamental to making improvements in patient safety. 5.2 The Provider should be aware of the various reporting systems such as: the National Patient Safety Agency National Reporting and Learning System the Medicines and Healthcare products Regulatory Agency reporting systems for adverse reactions to medication (yellow card system), and accidents involving medical devices the legal obligation to report certain incidents to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 5.3 In addition to any regulatory requirements the Primary Care Trust wishes the Provider to use a Significant Event Audit system (agreed with the Primary Care Trust) to facilitate the dissemination of learning, minimising risk and improving patient care and safety. 5.4 In addition to their statutory obligations, the Provider will give notification, within 72 hours of the information becoming known to him/her, of all emergency admissions or deaths of any patient treated by the Provider under this enhanced service, where such admission or death is or may be due to the Providers treatment of the relevant underlying medical condition covered by this specification. Notifications are to be sent to the Director of Nursing and Patient Safety with a copy to the Senior Primary Care Commissioning Manager for the specific locality. 5.5 Incidence of post operative MRSA and/or Clostridium difficile infection should be regarded as an adverse incident and as such be reported to the Primary Care Trust Infection Control Team and the individual clinician with peri-operative responsibility. 6 PRICING 6.1 In 2008/09 payment for an injection, for example a joint injection, will be 43.82, for Triptorelin injections a fee of 7.73 will be payable. For patients prescribed and administered Zoladex historically (as requested by secondary care) this will continue to be paid at 43.92, however providers should consider whether the patient could be transferred onto Triptorelin. For cutting surgery the fee will be 89.13. Providers using Sterile Services from an acute or Foundation trust are no longer eligible to receive payment under this enhanced service. 6.2 Multiple skin tag removal within the same appointment will count as one procedure. 6.3 The Primary Care Trust will agree with the provider the basis on which the DES will be funded in light of the procedures to be carried out and the volume to be carried out, including setting an agreed activity level, based on historical data. 6.4 The activity level agreed up to 10% above or below require any further negotiation, however where providers are approaching their activity level earlier than anticipated it is expected that the providers will approach the Primary Care Trust to discuss activity levels to date and agree a way forward. 7 PAYMENT 7.1 Payments will be made on a monthly basis via the Exeter system using a budget based on the specified levels of activity. 7.2 Reconciliations will be completed after the end of the financial year by the Primary Care Trust. 8 PATIENT AND PUBLIC INVOLVEMENT 8.1 The service will conform to professional and legal requirements especially clinical guidelines and standards of good practice issued by the National Institute for Clinical Excellence (NICE) and professional regulatory bodies, and legislation prohibiting discrimination. It is anticipated that for the majority of enhanced services translated information will be available via the Department of Health. If a patient wishes to communicate via a language that is not covered via these leaflets please let the Primary Care Trust Equality and Diversity Lead know and use the commissioned interpretation and translation service (Applied Language Solutions) to facilitate the consultation and provision of information to the patient. Use of the interpretation/translation service should be recorded in the patients lifelong medical record including confirmation of the first language of the patient. 8.2 Practices should encourage, consider and report any patient feedback (positive and negative) on the service that they provide and use it to improve the care provided to patients, particularly if there are plans to alter the way a service is delivered or accessed. 9 REFERENCES 9.1 LOWY, A. BRAZIER, J. FALL, M. THOMAS, K. J. and WILLIAMS, B.T. 1995. Quality of minor surgery by general practitioners in 1990 and 1991. British Journal of General Practice, 44, pp.364-365. 9.2 TARRAGA LOPEZ, PJ. MARIN NIETO, E. GARCIA OLMO, D. CELADA RODRIGUEX, A. and SOLERA ALBERO, J. 2001. Economic impact of the introduction of a minor surgery program in primary care (Spanish) Atencion Primaria, 27, pp.335-8. 9.3 LOPEX SANTIAGO, A. LARA PENARANDA, R. DE MIQUAL GOMEX, A. PEREZ LOPEX, P. and RIBES MARTINEX, E. 2000. Minor surgery in primary care: consumer satisfaction ( Spanish). Atencion Primaria. 26. pp.91-5. 9.4 GREAT BRITAIN. Home Office, Department of Health. (Undated). Health building note 46: General medical practice premises. Home Office: London. 9.5 Need more info: Standards. The Code: Standards of conduct, performance and ethics for nurses and midwives (2008) 9.6 The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections, The Stationary Office, updated 2008. 9.7 SOMERSET PRIMARY CARE TRUST (Unpublished, 2007). Policy for consent to examination or treatment. Report dated 13 November 2007. 9.8 NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE). (2006) Cancer Service Guideline: Improving Outcomes for People with Skin Tumours including Melanoma. Report published February 2006. Available at  HYPERLINK "http://www.nice.org.uk/Guidance/CSGSTIM/Guidance/pdf/English" http://www.nice.org.uk/Guidance/CSGSTIM/Guidance/pdf/English 9.9 NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE). (2005) Clinical Guideline 27: Referral for suspected cancer. Report published June 2005. Available at  HYPERLINK "http://www.nice.org.uk/CG027" http://www.nice.org.uk/CG027 APPENDIX 1 CLINICAL GUIDELINES FOR MINOR SURGERY 1 INTRODUCTION 1.1 Through the minor surgery DES the Primary Care Trust aims to commission provision of appropriate minor surgery in primary care. Each provider will be commissioned to provide appropriate levels of minor surgery activity for their provider population, according to the level of competency in the provider. Historically the arrangements for minor surgery in general practice have been confusing, and it is intended that there will now be greater clarity as to which procedures should be undertaken in specific service settings, as follows: - Minor Surgery Additional Service (global sum) Minor Surgery Directed Enhanced Service Primary Care Trust dermatology interface service secondary care 1.2 It is recognised that not all providers are able to undertake the same range of procedures, and the service will therefore be commissioned flexibly to take account of this. By agreement specific providers will be commissioned to undertake the more complex procedures and providers not commissioned to provide these services will be advised to refer to a named provider for these procedures. It is then the responsibility of the providers concerned to agree arrangements for sharing of information, record keeping etc, and ensure the specification requirements are met. 2 PROCEDURE CATEGORISATION The procedures are grouped in the following categories of service: 2.1.1 Minor surgery additional service (global sum) curettage, cryotherapy and cauterisation: skin tags seborrhoeic warts viral warts benign naevi spider naevi nasal cautery papilloma with base <3-4mm 2.1.2 Providers providing this service should not refer patients requiring any of these services on to another provider unless there is a clinical reason. 2.1.3 These procedures should not be claimed for under the DES. Minor surgery directed enhanced service injections and invasive procedures, all providers: joint injections injections of Zoladex for patients who have previously to this financial year been prescribed it, transfer onto Triptorelin should be considered where appropriate injections of Triptorelin excision biopsy of skin lesions (excluding head and neck) incision: abscess cyst excision: sebaceous cyst dermatofibroma small lipomata aspirations hormonal implants Some providers will also provide: excision biopsy of skin lesions face, head and neck; wedge resection of toenails; removal of toenails and phenolisation of nail bed; removal of meibomian cysts. 2.4 In order to provide the procedures listed above in Section 2.3, practitioners will have either: obtained an additional qualification in the relevant area/had specific training in the relevant specialty area maintained a sustained level of activity (minimum of 6 per procedures per annum per practitioner) 3 Inclusion criteria for benign skin lesion removal 3.1 The Primary Care Trust only supports the removal of seborrhoeic keratoses and sebaceous cysts if any of the following criteria is met: skin lesions are causing symptoms, such as itching, irritation or bleeding the lesion has evidence of inflammation the lesion is strikingly disfiguring and the consultant / GPwSI agrees that it should be treated by the NHS 3.2 In the absence of any of the indications below, removal of these skin lesions is considered cosmetic and therefore not funded. 3.3 Removal of lesions for cosmetic reasons has the potential to cause frequent patient dissatisfaction due to their perception of the outcome. 4 INADVERTANT REMOVAL OF MALIGNANT LESIONS 4.1 A record of any removal of malignant lesions should be kept and provided as part of the annual audit, this information should be recorded by individual clinician. 4.2 The NICE clinical guideline on skin tumours (including melanoma), states that the rate of skin tumours biopsied in primary care should be reducing. Estimated rates in 2006 were as follows: between 1.4% and 13% of malignant melanoma are biopsied in primary care;` between 0.7% and 10% of squamous cell carcinomas are biopsied in primary care; between 1.3% and 8.8% of basal cell carcinomas are biopsied in primary care. 4.3 Recommendations for additional training or CPD regarding identification of malignant lesions may be made as part of the annual review. APPENDIX 2 LIST OF NAMED PRACTITIONERS Provider Name: The below named General Practitioners will be providing the Minor Surgery Directed Enhanced Service for patients registered with this provider. General PractitionerSignatureDate             The above signed General Practitioners declare that they have read and understood the Somerset Primary Care Trust clinical guidelines associated with this specification. APPENDIX 3 FACILITIES AND EQUIPMENT SELF ASSESSMENT Practice Name: Items to checkDo you have sole use of the room? Is the room fit for Minor Surgery use i.e. dedicated space / access around operating table?Yes / No / Not applicable Do you have sole use of the patient waiting area?Yes / No / Not applicableDo you have recovery facilities? (number of spaces)Yes / No / Not applicableDo you have:Dand washing facilities?Yes / No / Not applicableLiquid Soap? Yes / No / Not applicableAlcohol hand gel? Yes / No / Not applicablePaper Towels? Yes / No / Not applicableGloves sterile?Yes / No / Not applicableGloves non-sterile?Yes / No / Not applicableAprons?Yes / No / Not applicableMasks?Yes / No / Not applicableEye protection?Yes / No / Not applicableLatex free products?Yes / No / Not applicableUse of single use items where appropriateYes / No / Not applicableAre trolleys/work surfaces appropriate for their use?Yes / No / Not applicableAmple, safe storage facilities?Yes / No / Not applicableFoot operated bins?Yes / No / Not applicableRegular Waste Collection?Yes / No / Not applicableSharps Containers labelled and signed?Yes / No / Not applicableLinen Disposal?Yes / No / Not applicableWashable working surfaces?Yes / No / Not applicableResuscitation equipment, Oxygen/Defibrillator/ Emergency Drugs/Ambi-bag or venti mask?Yes / No / Not applicableFloor & Wall Coverings are washable, durable, clean?Yes / No / Not applicableCleanable lighting (if manually operated)?Yes / No / Not applicableIs there a suction machine/suction tube available?Yes / No / Not applicableWhere appropriate privacy screens/curtains in place?Yes / No / Not applicableCleaning schedule for clinical areas?Yes / No / Not applicableCOSHH reports for all hazardous substances?Yes / No / Not applicableSpecimen storage (fridge) not stored with other products?Yes / No / Not applicableStaff vaccinations?Yes / No / Not applicableEquipment maintenance contract?Yes / No / Not applicable This list is not intended to be the sole requirements for facilities, please refer to Section 3.2.1 of the specification. If any questions are answered negatively the Primary Care Trust may wish to discuss any necessary changes to facilitate the continued commissioning of this service.  See reference 9.1.  See reference 9.2.  See reference 9.3.  See reference 9.4.  See reference 9.5.  See reference 9.6.  See reference 9.7.  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2004-10-26T09:51:13Z com.apple.print.ticket.stateFlag 1 com.apple.print.ticket.APIVersion 00.20 com.apple.print.ticket.privateLock com.apple.print.ticket.type com.apple.print.PaperInfoTicket com.apple.print.ticket.APIVersion 00.20 com.apple.print.ticket.privateLock com.apple.print.ticket.type com.apple.print.PageFormatTicket 8BIMxHH8AAKg{HH(dh 8BIMXX8BIM&?8BIM 8BIM8BIM 8BIM 8BIM' 8BIMH/fflff/ff2Z5-8BIMp8BIM@@8BIM8BIMWdSomerset PCT ColAdnullboundsObjcRct1Top longLeftlongBtomlongdRghtlongslicesVlLsObjcslicesliceIDlonggroupIDlongoriginenum ESliceOrigin autoGeneratedTypeenum ESliceTypeImg boundsObjcRct1Top longLeftlongBtomlongdRghtlongurlTEXTnullTEXTMsgeTEXTaltTagTEXTcellTextIsHTMLboolcellTextTEXT horzAlignenumESliceHorzAligndefault vertAlignenumESliceVertAligndefault bgColorTypeenumESliceBGColorTypeNone topOutsetlong leftOutsetlong bottomOutsetlong rightOutsetlong8BIM( ?8BIM8BIM (K JFIFHH Adobe_CMAdobed            (" ?   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