There is no new money coming into primary care so it makes sense to ensure that practices are checking they are adequately rewarded for all their current work.
Minor surgery is a case in point. There are several ways in which generating income from a practice minor surgery service can easily be missed.
Primary care organisations (PCOs) and, in England, clinical commissioning groups (CCGs) are sensitive about restricting services but are under pressure to reduce costs. When the current bill from secondary care is studied, reallocating money from funding these procedures in hospitals to general practice is often an easy step with reductions in costs.
Some PCOs that previously underfunded or capped spending on enhanced services for minor surgery have relaxed their previous decisions, realising they have inadvertently increased overall costs. GPs are contractually obliged to refer patients if there is a clinical need, so patients requesting treatment may have ended up having these procedures undertaken in the more expensive option of secondary care.
Contract to do more
It is worth investigating with your PCO (or CCG) if there is scope for contracting to provide minor surgery procedures. Each PCO will have a degree of difference in how it implements rules for a minor surgery enhanced service. The first job is to study these rules and to look at any caps and exclusions.
Where a large number of patients are having procedures undertaken in secondary care, collecting data can show the extra costs this is generating to the local NHS. This can be difficult because it is important to ensure all the potential departments are monitored, including dermatology, plastic surgery, ENT, general surgery, orthopaedics and maxillofacial surgery, but will help you to make a persuasive bid.
Transferring care here is one of the relatively simple 'low-hanging fruit' areas for CCGs to target. Large savings from the secondary care budget can be made with direct transfer to a more convenient location for patients in primary care.
As well as generating income by doing more minor surgery, it is worth reviewing if the practice is claiming all it is entitled to.
Patients booked into dedicated slots for minor operations are usually claimed for, but others may be missed. This is especially true for minor procedures that are undertaken without delay because there is an acute problem. Such cases particularly include the incision of abscesses, since these are normally undertaken urgently and include lancing in addition to fuller incisions.
Joint injections and aspirations of bursae are again often undertaken during a normal appointment because it is more convenient for the patient to be treated immediately rather than being obliged to return for a future minor operations session.
It is important for staff to remember to claim for these procedures and the use of computer templates facilitates this. GPs should not feel reticent or embarrassed to claim for these procedures because they are providing a rapid, local service for patients and commissioners will be glad of the saving from these operations being completed in a primary care setting.
If these small abscesses are sent to hospital care, the cost to the NHS is far higher, as many will be considered to be acute cases costing several hundreds of pounds more than any fee paid for primary care treatment.
Aspirating bursae is often undertaken during normal appointments (Photograph: SPL)
Claim back costs
Beyond the income generally derived for each procedure, there is also reimbursement generated through remembering to claim for the items used and not losing out through slack protocols.
Performing minor surgery incurs costs for the practice.
Although the highest of these is in medical and nursing time, there is also the cost of the items used, much of which can be claimed back though generating a prescription.
Whenever a GP or a practice nurse injects or applies an item to a patient it is worth considering whether a prescription can be written. With minor surgery in particular, there is often scope for issuing a prescription.
The local anaesthetic injection and any suture material used are personally administered (PA) items. This means a prescription can be generated and submitted for payment with no charge to the patient.
Dispensing and non-dispensing doctors may submit a prescription for these items and be reimbursed the cost of the items minus any clawback plus a dispensing fee - this is around £2 an item. This might not sound much but it can add up for a minor surgical list.
It is possible for all GPs to claim for other items too, including ones that are not PA items.
Many dressings, antiseptics and even dressing packs can be prescribed and consequently a prescription generated, leading to increased fees for the practice.
The problem is that these are not PA items and if the patient pays prescription charges, they should pay a fee for each item and the practice would have this fee deducted from any reimbursement if they failed to collect it. This is harsh for the patient because most of these items cost less than £1.
At my practice we only generate and submit a prescription if the patient is exempt from prescription charges. This will not make us rich but often means another three prescription fees for each patient.
With a devolved NHS there are variations as to who is exempt from prescription charges. There are also variations in what can be prescribed and reimbursed; for example, a 100ml ethyl chloride spray used for incising a paronychia can be prescribed and claimed in Scotland, but not England.
While some practices offer a private minor surgery service, this should be looked at cautiously. No charges can be made to any patient registered with the practice and defence organisations may raise GPs' subscriptions if what you do is a form of cosmetic surgery. In short, GPs should avoid private minor surgery.
- Dr Phipps is a GP in Lincolnshire