Do we really have to crowd our hospitals with patients who have ingrown toe nails? Why not encourage GPs to take care of minor surgery? Laura Slattery reports
A swollen, tender toe can be easy to ignore - at first. But as the redness deepens, a yellow blister takes up residency and it feels like the nail is clawing into your flesh, it will soon be all too clear that this is an ingrown toenail that could require surgical intervention.
But fear of both the surgery itself and the accompanying hoop-jumping through the Irish healthcare system can put people off seeking treatment for minor - ie disfiguring but probably non-life threatening - ailments such as ingrown toenails, skin lesions, moles and lipomas.
"An ingrown toenail could easily be removed by a GP," says Dr Tony O'Sullivan, who is one of two GPs running a Dublin clinic, the Baggot Street Community Hospital, which specialises in minor surgery.
"GP-based surgery is convenient, because people can go to a local setting and be treated by their own GP. It is also low cost, because GP services are cheaper than consultants' services," says Dr O'Sullivan.
And not only is it low cost, it is comparatively quick.
"What happens is that people are referred to a public hospital, where they could be waiting for up to six months for treatment, and that's after waiting one or two months to see the consultant. At our clinic we see and treat the person within four weeks," says Dr O'Sullivan.
In countries such as Australia and the US, it is common for general practitioners to run clinics that are fully equipped for minor surgery, where patients can walk (or hobble if they have ingrown toenails) into the clinic and get the treatment they need, fuss-free.
While there are a handful of similar GP-led clinics here, the Irish College of General Practitioners (ICGP) believes GPs are being discouraged from offering minor surgery services because the level of payments from the General Medical Services (GMS) Payments Board does not cover the cost of treating medical card holders.
The ICGP has been offering training courses in minor surgery for GPs for the past decade.
"There is keen interest out there," says Dr Niall O'Cleirigh, chairman of the ICGP's communications committee.
"The one factor that mitigates against GPs doing minor surgery is cost. On a GMS patient, the payment is derisory. On a toenail removal, the payment from VHI is about four times the GMS payment. On any procedure involving local anaesthesia or suturing, the GMS payment wouldn't cover the costs."
If more GPs were encouraged to perform minor surgery, it would take pressure off hospital waiting lists, the ICGP says.
"Especially for our country colleagues, it makes sense for them to be able to offer this to patients instead of having to send them 40 or 50 miles to the nearest hospital," Dr O'Cleirigh adds.
Greater availability of minor surgery at GP level certainly fits in nicely with the Government's proposed expansion of primary care services at a time when hospitals seem permanently overburdened.
Admitting people to hospital is more than just inconvenient. The non-urgency of the cases means minor surgery patients are often fobbed off into corners. One specialist told The Irish Times, some cases too small to be seen by anyone but the most junior doctors when they can find a free half hour.
The problem with all this waiting is that some minor health problems can turn out to be not so minor after all: skin lesions can be a sign of skin cancer, moles might not be benign.
Special clinics for minor surgery are a halfway house between GPs offering those services in their own practices and entering the public hospital roundabout.
The Baggot Street Community Hospital clinic at which Dr O'Sullivan performs minor surgery was set up three years ago by the former Eastern Health Board, now the Health Service Executive (HSE) Eastern Region, which pays the two GPs a stipend for their services. All GPs in the area can then refer their patients to the clinic.
When the clinic first opened it ran once a fortnight and had 20 GPs referring patients to it. But a three-month waiting list quickly built up, according to Dr O'Sullivan, and the clinic is now open one afternoon a week.
"But clinics run by GPs with a special interest in minor surgery are just one way of doing it," he says. "Most GPs have some surgical skills. They have all had hospital training and around two-thirds have done further training."
Some GPs are deterred from offering minor surgery because of the set-up costs.
"They have to invest in the additional training and then they must have a sterilised surgery and proper surgical equipment in place."
The GMS payments for medical card patients then present an ongoing problem.
"A realistic economic fee for a toenail procedure is €200 and for a removal of a cyst, it would be about €160 to €180. The GMS pays €22," says Dr O'Sullivan. "A single suture can cost €25, so if you're getting paid €22 by the GMS for a half-hour procedure, then there's no incentive."
The HSE has agreed to conduct a review of the GMS contract with the Irish Medical Organisation and a HSE spokeswoman said this review would start in the immediate future.
Under the current GMS contract, fees are payable for a range of 18 special services, including excisions and suturing.
Last year, GPs provided more than 530,000 special services and received fees from the GMS Payments Board (also known as the HSE Shared Services Primary Care Reimbursement Service) totalling €16.1 million. However, the special services category also includes fees for non-surgical services such as vaccinations and family planning. Most GPs who do offer minor surgery do it for the custom of their privately insured patients, according to Dr O'Sullivan.
And consumers with private medical insurance (PMI) like VHI or Bupa who need or want minor surgery will save money if they are able to locate a GP service.
"If you go to a hospital you will pay a consultation fee and perhaps a post-op consultancy fee that won't be recoverable through PMI. You could be paying €450 in consultants' fees," says Dr O'Sullivan. In a GP surgery or clinic, the consultancy fee will be €40 to €50.
The procedure itself is usually covered in both settings. But there are some discrepancies. For example, if a GP removes a skin lesion that turns out to be malignant, he or she is covered, but if it turns out to be benign, he or she is not. Only a consultant will be paid for both.
Nevertheless, the savings available in most instances and the speed of treatment should make the idea of GP minor surgery services attractive - to consumers and health strategists alike.