Where Next?

1. Where Next? Dr Jonathan Botting RCGP Clinical Champion for Minor Surgery Author PG Diploma in Minor Surgery

2. Aims • Clinical Champion Role • Audit for all • Training standards • Revalidation • Skin Cancer work

3. Clinical Champion Role

4. Clinical Champion Role • 14 Clinical Champions, across 12 domains. 3 yearly posts • Managed through CIRC Not paid • Aims ? • Improve education & training • Agree core curriculum for CPD training in MS • Develop CPD training courses • Work with other medical royal colleges • Evidence based review of minor surgery in primary care • Accreditation of competencies • Disseminate best practice inc guidelines and standards • Quality Practice Award inc audit and research. • Work with RCGP Patient Partnership Group

5. Audit for all • MiSTIC Study • 313 procedures, 30% missing histology, • 16 malignancies 56% incomplete • National Skin cancer audit • Jonathan@Botting.net • RCGP audit tool • On line • Various specialties • Allow comparisons

6. Audit criteria. Example: • All malignant lesions excised should be completely excised • All BCCs reports should state the type of BCC • All histology reports should state the excision margins • All patients with MM, SCC & KA should be offered referral to the MDT • BCC excision margins should meet current guidelines

7. Results 51 lesions 100% Complete

8. Joint Workings • RCS • Standards of training and assessment • BAD • Feel threatened, approach via PCDS • NPSA • Surgical safety check lists • AfPP • Standards for minor surgery • NICE • GDG for BCC work • HQIP • Audit

9. RCGP Minor Surgery working group Looking at course delivery Introductory DES standards GPwSI standards Accreditation Looking at assessment DOPs AKT Training standards

10. Revalidation • Area 6 • Learning credits • Areas 7 & 8 • Feedback from colleagues • Feedback from patients • Area 10 • S.E.A • Area 11 • Clinical Audit

11. Revalidation • Area 13 • Outside GP training & MRCGP, • GP needs further training • Contract or setting outside standard GP • Eg GPwSI • Fee outside of care to the practice population • teaching, training, • research, occupational medicals, medico-legal reports, • cosmetic procedures, etc.

12. Undergraduate teaching – Statement from university Vocational training – Deanery statement inc date & outcome last trainer approval visit Research– Statement from recognised research institution(s) & Research Governance Team in the local PCO Appraisers – Statement from employing PCO Out-of-hours work – Statement from OOH provider GPwSIs with PCO contract – Statement of accreditation from PCO Other non-clinical activities - Statement from a responsible organisation will suffice. Clinical activities, including GPwSIs not in contract with a PCO: Describe in detail the role Qualification for role? prior experience, education and qualifications. Keeping up to date in role? Reference to all education & refreshment undertaken in revalidation period, inc learning credits Demonstrate fit to practise in this role? Include appropriate audits Revalidation Supporting Info:

13. Revalidation Supporting Info: • GPwSIs with PCO contract – • Statement of accreditation from PCO • Clinical activities, including GPwSIs not in contract with a PCO: • Describe the role in detail • Qualification for role? • prior experience, education and qualifications. • Keeping up to date in role? • Reference to all education & refreshment undertaken in revalidation period, inc learning credits • Demonstrate fit to practise in this role? • Include appropriate audits

14. Skin cancer workNICE Guidance on Cancer Services Update • Management of low risk BCCs in the community • Low risk definition depends upon who you are

15. DES & LES criteria • Annual audit • clinical vs histological accuracy • Annual educational update to include: • Audit results • CPD session • No minimum activity • No MDT attendance Any GP who can show: • Surgical competency • DOPs & revalidation • All specimens to histology • Site and provisional diagnosis on histo form • Fail-safe log • Quarterly PCT/LHB feedback

16. DES & LES Low risk BCC? No GP meets LES/DES? Refer to LSMDT Yes Refer to LSMDT No GP confident diagnosis=low risk Yes • Patient with BCC is not: • Aged 24 or younger • Immuno-suppressed or Gorlins The lesion is: • Located below clavicle • Less than 1cm diameter (clear margins) • Not recurrence following incomplete exc’ • Not high risk type • Not located over high risk area • If SBCC offer full range of medical treatments No Refer to LSMDT Yes Manage low risk BCC appropriately

17. LES or GPwSI Model 2 Practitioners: • Acute Trust Governance • skin surgery competency • (SS1 & SS2) • Named MDT • Surgery on • pre-diagnosed skin cancers, • Core MDT member refers • Same annual audit/CPD Model 1 GPwSI: • Group 3 • Dermatology & Skin Surgery • Group 3a • Skin Lesions & Skin Surgery • Linked to MDT • 4 meetings a year • Annual audit • clinical vs histo ∆ • Educational meeting • 1/yr same as LES/DES

18. Model 1 GP Model 2 Practitioner Low risk BCC? Pt referred to accredited GP: Model 1, Group 3 or 3a • Low risk excludes • Patients who are: • Aged 24 or younger • Immuno-suppressed or Gorlins Or lesions that are: • On nose & lips (inc naso-labial folds around eyes or on ears • Greater than 2cm diameter below clavicle • Greater than 1cm diameter above clavicle Unless SBCC treated medically • Morphoeic, infiltrative or basosquamous • Poorly defined edges • located over high risk area • If SBCC offer full range of medical treatments • If incomplete excised BCC discuss with LSMDT Unable to confirm low risk BCC Refer to LSMDT No Is the Group 3 GPwSI also a Model 2 Practitioner Yes Discuss pt Rx & care with core member MDT. Agree management plan Yes Manage appropriately Low risk BCC? Manage low risk BCC appropriately

19. Network Configuration • PCTs agree network configuration with: • the NSSG and • cancer lead clinicians. • PCTs can choose ≥ 1 of the 3 models • Can choose not to commission a community skin cancer service • Can choose to commission from the independent sector. • BUT: • Where does this leave patient choice?!

20. Any Questions?  Jonathan@Botting.net