The carpal tunnel decompression service at my practice, Churchfield Medical Centre in Chingford, Essex was set up under practice-based commissioning. It receives high patient satisfaction scores and also saves a great deal of money compared to performing this operation in a hospital setting.
In 2006/7, the amount saved was over £93,000 for 216 procedures and we anticipate saving at least that amount in 2007/8.
It all started in September 2004, when I received a telephone call from Waltham Forest PCT asking me if I would be interested in doing carpal tunnel decompression in primary care for patients in its area.
I was already accepting GP-to-GP referrals for normal primary care minor surgery (moles, lipomas, cysts and so on) and I was also offering a local anaesthetic vasectomy service. As I had not undergone any orthopaedic surgical training - and could not even recall seeing an orthopaedic operation as a medical student - my initial response was to say that I was uncertain but interested in finding out more.
The background to the request was that, like so many PCTs around the country, Waltham Forest was looking into ways in which it could save money while increasing primary care services.
The national orthopaedic team (part of the NHS Modernisation Agency) had assessed the orthopaedic department at the local acute trust. It identified a range of activities to reduce the demand for hospital care and hence waiting times. The carpal tunnel service, for which the waiting time from referral to treatment was 18 months, was one such activity.
I met the trust's orthopaedic lead to discuss this further and then observed him performing carpal tunnel decompression operations.
From watching him, I felt that this was a procedure that could readily be done in primary care, with appropriate training and the correct team.
To provide this service in primary care, I felt that the standard of patient care needed to be at least equal to the acute trust's service, but with a shorter waiting time, at lower cost and financially worthwhile for my practice.
The PCT held discussions with the acute trust and the two extended scope practitioners working within the service about them continuing their work, but within a GP setting.
Both were more than happy to try this. I then undertook training at the trust and attended the regular Monday morning carpal tunnel decompression operation list for about three months. During this time a consultant supervised me until we felt I was competent to perform the operation unsupervised.
Forming a team
I then needed a theatre team. Fortunately one of our practice nurses was a former scrub nurse and assisted me with our minor surgery. She agreed to assist me with the carpal tunnel operations.
Also, one of our healthcare assistants who occasionally assisted with operations including vasectomies, agreed to help with the decompressions, primarily doing pre/post-operative observations and managing the tourniquet machine.
We started operating on patients in September 2005. The patients have the same journey as if they were referred to secondary care. GPs within Waltham Forest are aware of the service and most refer directly to us.
Any patients who are referred to the acute trust are redirected to our service.
In 2005/6 we performed 150 operations; in 2006/7, 216 operations and this year's target is also for 216 decompressions.
Compared to the £929 cost per procedure incurred in secondary care, each decompression performed costs on average £480.
As well as a positive patient satisfaction survey, we have received a number of complimentary comments about the service verbally and in writing. The PCT has also had positive feedback from patients.
In summary, carpal tunnel decompression is a procedure that with appropriate training and the appropriate team can readily be undertaken in primary care.
Advantages include reduced waiting times and lower demand on secondary care.
It is economically beneficial to commissioning groups and PCTs, preferred by most patients as they do not have to attend the hospital.
Lastly, it is a professionally satisfying procedure for a GPSI to perform.
Carpal tunnel surgery in secondary care
- Seen by extended scope practitioner (ESP).
- Sent for electromyogram (EMG).
- Seen by ESP and referred for operation where appropriate.
- Carpal tunnel decompression operation (18 months after referral).
- Seen by ESP a fortnight later. Either discharged or given anotherfollow-up appointment with seen ESP.
Criteria for primary care services
- Bring service into primary care.
- Standard of patient care needed to be at least equal to hospital'sservice.
- Reduce waiting time for patients.
- Cut the cost to the PCT.
- Must be financially viable to practice and GPSI.
Benefits of practice-based scheme
More convenient for patients.
- Reduced waiting time (at the time of writing); new patient appointment within three and a half weeks; EMG in three to four weeks; and operation at six and a half weeks.
Lower cost to PCT
- Secondary care cost, £929 per case; primary care cost, £480 per case giving a saving of £449 per case.
Standard of service
- Infection rates approximately 2 per cent.
- 2006/7 patient satisfaction survey results survey (51 patients; excellent, 73 per cent; good, 21 per cent; no comment, 6 per cent).