GPs, operations, and the communityBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39049.376829.43 (Published 04 January 2007) Cite this as: BMJ 2007;334:5
- Roger Kneebone, senior lecturer in surgical education firstname.lastname@example.org
Recent dramatic headlines have claimed that general practitioners will be encouraged to carry out operations such as hernia repairs, carpal tunnel decompression, and varicose vein removal.1 2 The implication is that general practitioners with little surgical experience will suddenly be picking up a scalpel to carry out operations they are not trained to do. Not surprisingly such a prospect has generated much controversy.
The headlines have been prompted by the government's white paper on community services in the English NHS, Our Health, Our Care, Our Say, which proposes a shift in the locus of healthcare.3 The chapter on “Care closer to home” sets out various alternatives to current practice, arguing that patterns of care should adapt to a changing healthcare environment and to the wishes of patients. This means shifting the emphasis towards local services wherever possible. Are the white paper's proposals really as radical as they have been portrayed in the press (and by some surgeons)? And what are the advantages and disadvantages of changing the balance between primary and secondary care?
In many ways the changes proposed in the white paper are not that radical but build on innovative approaches which have been taking place for years. To anyone practising from the early 1990s onwards, the arguments will have a familiar ring. Many general practitioners carry out minor operations already. And, of course, the debate is not just about general practitioners. The establishment of nurse practitioners and the widening of roles for other healthcare professionals have consistently generated controversy. My experience is that despite initial opposition, such new roles can offer great benefits, provided their development takes place within a clear framework of training, governance, and audit.4 5 So the question is whether the proposed changes will allow such frameworks to be established and maintained?
Moving care closer to the patient and exploring alternatives to current patterns of practice6 offers obvious advantages to patients, including convenience and support from family and community networks. Although sometimes framed around the primary-secondary care divide, the central issue is really about ensuring standards of care, regardless of where and by whom such care is carried out. 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. These requirements should be no different in the community from anywhere else.
Outside a secondary care environment and without its inbuilt checks and balances, the burden for ensuring these standards must rest with the commissioners of care. The commissioners must therefore have effective mechanisms for ensuring standards of governance and for auditing outcomes. But there are worrying indications that this may not always be the case, especially with the treatment of malignant skin lesions.7
Cost is clearly another important issue, but it is not easy to establish the true cost of community based treatment. General practitioners with special interests offer high quality care but the service they provide can be more expensive than the equivalent specialist service offered in hospitals.8 9 And there is a danger that offering community based operations will simply increase demand by meeting previously unmet need yet fail to relieve the pressure on secondary care.
So what evidence is there, or will there be, that more specialist services can be safely moved into the community? In the white paper 30 demonstration sites (drawn from dermatology, urology, gynaecology, ear nose and throat surgery, general surgery, and orthopaedics) have been selected for independent evaluation by the National Primary Care Research and Development Centre at Manchester University.10 Each provides an established example of innovative practice, often challenging boundaries between primary and secondary care and between traditional disciplines. It remains to be seen whether the evaluation will be sufficiently resourced and sustained to provide the necessary level of evidence.
In the end, this is not so much a debate about general practitioners wielding scalpels as about who can best deliver a patient-centred service tailored to individual needs. Patients stand to gain from high quality care offered locally, provided this is delivered within a rigorous framework and effectively monitored by those who commission it. Whether such care is delivered by general practitioners, hospital specialists, nurses, or other practitioners is much less important than the underlying principles of quality and safety. A framework for effective training is crucial, and engagement with royal colleges and specialty associations is key to ensuring quality and safety, especially for the small number of instances where practitioners offer more complex procedures.
Provided the changes are carefully evaluated and the outcomes weighed up before taking action, the white paper's developments have a lot to offer. But history shows the dangers of premature change based on inadequate evidence and driven by political expediency. Avoiding these dangers will be crucial if innovation is to flourish without compromising patient care.
Competing interests: None declared.
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