Minor Surgery? Major Implications!
Dr Jonathan Botting
RCGP Clinical Lead for Minor Surgery, 2012-2015
RCGP Clinical Champion for Minor Surgery, 2009-2012
Once in a while a development comes along to address one issue and it turns out to do something else rather well (Minoxidil originally developed for Hypertension, but rather more successful as a hair growth stimulant comes to mind), and so it is with the CBSA - the Community-Based Surgery Audit. This was developed by the Clinical Innovation & Research Centre (CIRC) at RCGP in partnership with the Health and Social Care Information Centre (HSCIC) to enable GPs to record their surgical activity and also to compare their results to their peers. But it has turned out to be capable of something else altogether.
GPs across the country who undertook surgery in the community (commonly referred to as minor surgery) were invited to sign up to use the CBSA via the use of a web-based system hosted by the HSCIC. By the end of the pilot phase (from 2013 to March 2015) it had over 150 users and over 6000 surgical procedures recorded.
From this pilot phase the data from all the users was presented as a poster at the 2014 RCGP Annual Conference, and was highly commended in the ‘Audit’ category – the most popular category with over 100 poster submissions.
The data was then analysed with the help of the academic department of General Practice at Surrey University. The idea was to produce a report for the College about the development of the audit, feedback from users and future plans. However the data outcomes were so conclusive and the implications so important to the NHS that we (CIRC) drew up plans for a peer reviewed publication. A paper has been accepted and is waiting to be published.
To the individual surgeon the CBSA tool has allowed them to compare their own surgical activity, diagnostic accuracy, surgical competence and complication rates with their peers (be they GPs working under the governance of Directly or Locally Enhanced Services, GPs with a specialist interest or GPs working under acute trust governance). Comparisons can be made with GPs working under the same governance arrangements or with all other GPs. As data entry was standardised all aspects of surgical care could be compared (including waiting times for surgery, types of surgical procedure, even to the provision or not of post-operative advice sheets).
Much of the existing evidence that has been used to develop skin cancer guidance shows GPs to be poor at skin lesion diagnosis, to provide inferior surgical skills to hospital colleagues with greater incomplete excision rates, to send inadequate numbers of samples for histological analysis and to have higher rates of surgical complications. Much of this evidence has come from studies undertaken by secondary care colleagues.
The reason the CBSA data has turned out to be so much more than expected is because of the quality of diagnostic accuracy, surgical skills and low complication rates it has demonstrated. This is combined with the speed of access to surgery for patients (which has been reported in previous studies) and for the first time a statistical difference in quality between GPs with specialist training and those without. The latter will help to counter some previous adverse reporting about the cost of GPwSIs compared to secondary care.
How does all of this fit in with what we already know? The incidence of all common skin cancers is increasing dramatically, in particular melanoma in the elderly. The conversion rates for two-week wait referrals made by GPs for query skin cancer varies across the country from less than 5% to 13%: nationally it stands at 8%. In other words: 92 out of 100 two-week referrals for skin cancer turn out to be benign (National Cancer Intelligence Network data). The cost to the NHS in terms of wasted time and resources is considerable.
Interestingly the accuracy of cancer diagnosis amongst the CBSA users over the pilot period was much, much better than the figures from the NCIN. The conversion rate varied from 69% to 93%, in other words: seven out of ten increasing to nine out of ten of all lesions operated on as cancerous turned out to be cancers. Whilst not directly comparable to the referral for opinion of the 2-week wait cases, it does still indicate a high level of diagnostic accuracy
The data also shows that the GPs with specialist training have impressive surgical skills as well as very good clinical diagnostic skills. Their completeness of excision rate approached 100%. It was statistically better than that for GPs without specialist training who still managed complete excision rates for skin cancers far better than historically quoted from previous studies. The GPs with specialist training have demonstrated diagnostic and surgical skills to match hospital specialists. Of the 6019 lesions treated surgically, nine out of ten were sent for histological diagnosis, this figure is very much higher than the low rates of histological analysis of specimens sent by GPs noted in past studies.
Finally, the CBSA has recorded complication rates post surgery. The system generates a report showing when 2 months have elapsed since surgery to ensure any reported complications are entered. The overall complication rate for the 6138 procedures (including nail surgery) was 2% and the majority of these were minor (redness, minor pain etc).
In conclusion, the CBSA - an on-line data collection system designed to help GPs record their surgical activity - has provided something much more useful. At last we have large number data to show that amongst our group of volunteer GPs, community-based surgery is both safe and effective.
Time perhaps to look again at some of the curbs on our service provisions?
To find out more about the audit and the tool and how you can be a part of it please visit our webpage.