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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Surgeons who are also GPs
- Dr Andrew N. Crowther (6 January 2007)
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GPs, operations and the community - a risk too far
- Peter J. Holt (6 January 2007)
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Give me 5 years of hard work, then you can cut me.
- Hamed N Khan (10 January 2007)
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Surgeons available for general practice
- Nikolaos Papadakos (10 January 2007)
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UK has much to learn from Developing Countries on this
- Tarry Asoka (14 January 2007)
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GP surgeons : are we putting patients at risk?
- Sujatha Tadiparthi (16 January 2007)
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Dr Andrew N. Crowther, Retired GP. President Community Hospitals Assoc. GL20 6HY
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Current crises in the NHS and in manpower planning as outlined by Roger Kneebone do have a solution that is available to the NHS right away. In England and Wales there are over 400 Community Hospitals, although many are currently under threat of closure because PCTs have to find savings. Many of these hospitals have operating theatres or MIUs suitable for carrying out minor surgery. At these hospitals GPs have carried out simple minor surgery safely for years. Where such facilities exist, there is no lack of applicants for GP vacancies. There are also examples of Community Hospitals where regular surgical lists have been carried out by GPs (eg Brecon and Wimborne). These GPs have had surgical training, and have been supported by their surgical colleagues in the DGHs (District General Hospitals). They have been able to keep the waiting lists for so called 'minor' operations moving, and have made a valuable contribution to the NHS. In The Times of January 4th (No 68900), a front page article announced 'Operations cancelled as NHS runs out of money'. More alarmingly it reported that some PCTs (Primary Care Trusts) are now considering refusal to pay for some 'minor' procedures such as varicose veins, carpal tunnel syndrome, or arthroscopy of the knee. These operations may be classed as minor by the PCT executives, but can solve a real problem for the patient. Other articles have appeared in the press recently pointing out that junior grades of surgical trainees will soon not be able to find consultant posts, while there will be over 1000 GP vacancies that cannot be filled. General Practice is still an interesting branch in which to practice medicine. If a doctor with surgical training were to re-train as a GP and find a practice that has attachment to a community hospital, they would be able to practice surgery on a wide range of 'minor' ailments, would bring lasting relief to the patients and their eternal gratitude, and practice family medicine. This is not as far fetched as it might seem, and underlines the real value of Community Hospitals in this country. Now that Practice Based Commissioning is coming on stream, money from General Practice can be spent in their local community hospital, and the PCTs will not have the expense of paying the acute sector. If more work of this nature could be guided to Community Hospitals, everyone would benefit. The surgeons could practice what they have been trained to do, the PCTs can keep expenses 'in house', and the patient can have their problem sorted out closer to home. Even disillusioned surgeons might find real satisfaction in their work. Competing interests: None declared |
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Peter J. Holt, Vascular Research Fellow St George's Vascular Institute
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BMJ Reply: Roger Kneebone Article BMJ 2007;334:5-6 Mr Kneebone’s editorial “GPs, operations, and the community (1)” was interesting, informative and largely balanced, although the author writes from a background highly supportive of expanding the roles of healthcare providers (both professional and non-professional). My concern, which I hold in common with many of my colleagues, is that a healthcare system targeting the local access of care for patients, emphasised in Our Health, Our Care, Our Say (2), may well be to the detriment of patient outcomes. A key passage in the editorial stated: “Any procedure should be necessary, appropriate, performed by a suitably trained clinician and carried out in facilities of a required standard. Effective training and maintenance of skills and practice within an established professional group are essential and must ensure risk assessment, patient selection, recognition of personal limitations, and the provision of suitable backup in case of complications.” This passage, which is written in a supportive light, actually highlights many of the criticisms and limitations of local care. This benefits of local care were further stressed by the statement: “moving care closer to the patient…offers obvious advantages to patients,” which only holds true if the procedure is appropriate, with correct patient selection, performed competently, and no complications arise. My real concern is supported by the plethora of evidence that for complex procedures high-volume specialist surgeons working in high-volume units with appropriate specialist support produce the best results and lowest complication rates (3-5). The principals underlying these volume-outcome relationships are applicable not only to complex procedures, but even for “simple” procedures such as inguinal hernia repair, or varicose vein treatment, that can be performed under local anaesthetic in a day case format. For example, the rates of recurrence are reduced for varicose veins when provided by experienced surgeons (6). Furthermore, any surgeon who has performed the above procedures knows that complications can occur intra- operatively that require experience and an adequate setting to manage – a torn femoral vein, or opening of a hollow viscus in a sliding hernia being cases in point. These complications are relatively simple to manage in the appropriate setting, but perhaps not in a GP surgery with poor lighting, inadequate IV access, and a limited range of instruments, and technical skills. In some cases, overnight observation may be required, a service not offered by GPs, and therefore the local A&E and surgeons will be burdened with managing the complications of other physicians. Ultimately, we may be judged on the outcome of our interventions. There is no other adequate benchmark for medical professionals, despite the popularity of patient satisfaction and quality of life surveys. Patients will be the first to criticise their care when there are complications, and they are put at the inconvenience of an emergency admission to hospital via A&E. It may be easier for patients to walk down to their local GP for their hernia repair, I worry that for the sake of a journey to hospital patients may be put at unnecessary risk. References 1. Kneebone R. GPs, operations, and the community. Bmj 2007;334(7583): 5-6. 2. Health Do. Our Health, Our Care, Our Say. In: Health Do, editor, 2006. 3. Holt PJE, Poloniecki JD, Loftus IM, Gerrard D, Thompson MM. Meta- analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. In Press: Br J Surg 2007. 4. McCabe JE, Jibawi A, Javle P. Defining the minimum hospital case- load to achieve optimum outcomes in radical cystectomy. BJU Int 2005;96(6):806-10. 5. Urbach DR, Baxter NN. Does it matter what a hospital is "high volume" for? Specificity of hospital volume-outcome associations for surgical procedures: analysis of administrative data. Qual Saf Health Care 2004;13(5):379-83. 6. De Maeseneer MG, Van Schil PE, Philippe MM, Vanmaele RG, Eyskens EJ. Is recurrence of varicose veins after surgery unavoidable? Acta Chir Belg 1995;95(1):21-6. Competing interests: None declared |
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Hamed N Khan, SpR Surgery North Trent
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I read the article and was unable to decipher what the bottom line was, except that trained personnel should operate. I am unsure of others but if I had to have either my inguinal hernia or varicose veins operated on then I would want my `surgeon` to have done atleast 5 or more years of expert training. All surgical trainees can tell each other of horror stories during these two `minor` operations where lives would have been lost if not for an expert trainer athand or the right instruments. For Gods sake lets not kill anyone in the community for political reasons. I can assure you those with money will go private to ensure a surgeon whereas those without will take the chance of either a nurse or GP. Competing interests: None declared |
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Nikolaos Papadakos, Senior House Officer, Neurosugery King's College Hospital London, SE5 9RS
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The editorial by Kneebone (1) raises many questions. One of the principle issues is that of training existing general practitioners to perform surgery. The editorial fails to mention the large group of already surgically trained junior doctors who are (and will be) unable to enter higher surgical training. A recently published survey (2) by the Postgraduate Medical Education and Training Board (PMETB), reports that 16.4% of the Senior House Officers questioned wish to pursue a career in surgery. The Modernising Medical Careers (MMC) website also recently published the figures of all training posts available from August 2007 (3). Of the 5241 posts available at the entry level for specialist training (ST 1), only 378 (7.2%) are surgical posts. Therefore many of the trainees will not be successful in entering the ST system and will opt to take Fixed Term Specialty Training Appointments (FTSTA) in surgery. 453 FTSTAs are proposed at the equivalent ST 1 level 3. Only a few of these posts will eventually lead to re-entry to the ST system and many unsuccessful candidates may opt for a career in general practice. Rather than retraining existing general practitioners, this group of doctors would be ideal candidates to continue using their surgical experience in the primary care setting. If implemented, this will provide reassurance to patients that they are being treated by a doctor with previous surgical training. It will also allow these doctors to pursue a career which still contains elements of their original career aspirations. References: 1. Kneebone R. GPs, operations, and the community. Bmj 2007;334(7583): 5-6. 2. Survey findings to help trainee doctors in planning applications to MMC run though training. Postgraduate Medical Education and Training, December 2006. http://www.pmetb.org.uk/fileadmin/user/Press_releases/PMETB_Specialty_choice_press_release_181206.pdf 3. Modernising Medical Careers. MMC transitional spreadsheet, December 2006. http://www.mmc.nhs.uk/download_files/MMC%20SHO%20Transition%20Figs.xls Competing interests: None declared |
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Tarry Asoka, Health Management Consultant/Family Practitioner Care Net Nigeria, TMC Estate, Abuloma, Port Harcourt 500001, Rivers State, Nigeria.
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Equiping doctors to provide a wide range of service at the interphase between primary and secondary care has been the strategy for providing medical care in the developing countries. With the progress made in the academic discipline of General Practice/Family Medicine in the past two decades this strategy has become more relevant in the face of acute shortage of doctors in these countries. No country is immune to the crises in human resources for health irrespective of the stage of development. Despite advances in technology, healthcare is demanded and provided locally. This also means as near as possible to the people - in the community - where they live, work or recreate. It is only common sense that doctors who practice on the frontline are equiped adequately to deal with the range of problems that would be presented to them including surgical treatment, emergency obstetric care and other mediccal emergencies. It is not all about cost but meeting the desire of patients who want to be treated as people with friends and family being part of the therapeutic community. For the UK to achieve this, the NHS has to review the sort of training being provided to 'frontline doctors' in places such as Nigeria, Ghana, Zambia and other developing countries that have adopted this model. These doctors are actaully called 'very GPs' due to their vast skills and competence in areas such as surgery, Obstetrics, clinical medicine and Management of healthcare small business. Competing interests: None declared |
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Sujatha Tadiparthi, SHO plastic surgery University Hospital North Durham
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I read with great concern the editorial by Mr Kneebone. Although these new plans may improve patients’ access to treatment, reduce waiting lists and save money, I feel they may put patients at greater risk. Procedures such as carpal tunnel have many potential complications and are only ‘simple’ when performed routinely by an experienced surgeon. When there is move for an increasing subspecialisation in secondary care, I wonder how more surgical procedures can be encouraged in primary care. It is the patients who ultimately suffer and it is hospital doctors who have to deal with the consequences of complications of these ‘simple’ procedures. We recent performed an analysis of malignant melanoma referrals to our unit. Even though NICE guidelines state that biopsies of malignant skin lesions should not be performed by primary care doctors, a significant proportion of patients had inappropriate biopsies performed (punch, shave and cauterisation). This was mainly secondary to poor clinical diagnosis and lack of knowledge of the current melanoma guidelines. When diagnosis and management of such ‘simple’ skin malignancies is poor, I wonder how more complex procedures can be performed in the community? Furthermore, there are implications on training, as surgical trainees will have less exposure to such procedures. I agree with Mr Papadakos that if major surgery is to be performed in the community, we should utilise the skills of doctors who have previously undergone surgical training and have more experience with such procedures. Ultimately, patients should have a choice as to who does their operation. Competing interests: None declared |
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