Rationing in the NHS: audit of outcome and acceptance of restriction criteria for minor operations
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7310.428 (Published 25 August 2001) Cite this as: BMJ 2001;323:428All rapid responses
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Competing interests: No competing interests
Editor--
Skin lesions which need minor surgical management for diagnostic or
cosmetic reasons are a common problem in general practice. The amount of
minor surgery resoursed in our practice under the GMS contract was
approximatly one third of patient needs. When we moved to a PMS contract
we tried to negotiate as a "plus " element to cover these needs, we were
able to perform these proceedures closer to the patient without waiting
and at a cheaper price ( one third of the cost quoted by the local acute
trust).
The Health Authority were unable to agree to this for various reasons. We
now therefore refer these patients to Plastic Surgery or Dermatology
outpatients where they are seen after a long wait and put on another
waitng list for the minor proceedure to be performed. This inconviences
the patient and extends waiting lists so those patients who actually need
a specialist opinion wait longer. This seems to fly in the face of common
sense but as I tell my patients common sense is a rare comodity in the NHS
and is hence rationed.
Dr Keith Wells
Marple Cottage Surgery,
50 Church Street,
Marple,
Stockport SK6 6BW
keith.wells@gp-p88006.nwest.nhs.uk
Ref- O'Boyle and Cole. Rationing in the NHS:audit of outcome and
acceptance of restriction criteria for minor operations
BMJ 2001;323:428-9
Competing interests: No competing interests
The study highlights the vital snag in attempts to ration the
healthcare system although the duration of the study as well as the number
of patients were limited.
Of the referrals rejected, the authors state that many of the
referral letters were not specific but did not suggest malignancy. There
is a significant subjective bias in such cases with regards to malignancy
as a simple lack of specific description from a busy physician office can
lead to the failure of treatment of potential malignancy. As only 19% of
the patients who were rejected for referrals had excision of the skin
lesions with pathology, the study does not account for the rest of the
patients. Therefore the number of patients having malignancy with rejected
referral letters may actually be higher in case all lesions could be
evaluated pathologically.
Seema Kureel, MD
Alabama, USA
Competing interests: No competing interests
Cash is the answer
I carry out skin surgery both as a GP and as a clinical assistant in
dermatology, and it is perfectly clear to me seeing the problem from both
sides that many if not most skin lesions referred to hospital could
perfectly well be treated in primary care. Logically, this ought to reduce
hospital waiting times and be better for patients, provided that at least
one GP per practice has the right level of skills.
The main barrier to this happening is the illogical way that GPs are
paid as independent contractors in the NHS. A "minor op" fee of about £25
is paid for a limited number of defined procedures, this fee must pay for
GP and nurse time, purchase and depreciation of autoclaves and other
equipment, premises, etc.A GP is entitled to claim for a maximum of 60
procedures per annum. The same derisory fee is paid for all procedures. To
illustrate this, one week this summer in my surgery I removed a splinter
from a boy's finger (it came out very easily) and also excised a basal
cell carcinoma from a man's chest. I will (quarterly, in arrears) be paid
the same fee for each procedure. What kind of incentive is that?
An adequate scale of remuneration for surgical procedures, with
appropriate training and audit, would motivate GPs to treat these lesions
in primary care, aquiring the skills where neccessary. All it takes is
money.
Competing interests: No competing interests