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Financial implications and adherence to 2 week wait referral times from minor surgical lists in primary care with regards to malignant skin lesions

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Financial implications and adherence to 2 week wait referral times from minor surgical lists in primary care with regards to malignant skin lesions


Aims & Objectives


Minor operative lists in general practice shoulder a significant proportion of dermatological diagnostics work from secondary care, saving the NHS money. Majority of skin incision biopsies from primary care are benign however suspicious lesions require efficient referral under 2 week wait (2WW). In this regard it reduces the burden of minor surgery cases on secondary services. We set out to:

•assess the number of cancerous and non-cancerous skin lesions noted in a general practice list
•assess if concerning lesions meeting the two-week wait (2WW) criteria were correctly referred and seen in clinic within 2 weeks
•assess the financial implications of this community service vs secondary care

 Tanworth-in-Arden represents an affluent Caucasian community with a stable patient base with significant number spending many months a year abroad in temperate climates. We retrospectively analysed the data of 317 patients in the area that attended a minor operative list for excision of a skin lesion and had a biopsy between 2014 and 2016. Cases were analysed for formal histological biopsy diagnosis as well as GP impression of lesions were noted for low risk lesions from the notes.

Malignant or suspicious lesions meeting 2WW criteria were assessed for timing: from diagnosis to referral and referral to outpatient appointment. We also made an assessment on the financial saving of these patients being managed in primary care vs. secondary care.



•271 / 317 cases involving excision of a skin lesion were sent for a biopsy of one or more lesions for formal histology = 85.4%. 346 lesions were excised including 37 basal cell carcinomas (BCC), 7 squamous cell carcinomas (SCC), 3 melanomas and 1 lymphoma (Fig. 1).
•23 BCCs were referred routinely with median clinic appointment time of 56 days (SD 8.84).
•15 patients met 2WW referral criteria with median time from diagnosis to referral of 5.6 days (SD 2.51) and from referral to outpatient appointment of 10.3 days (SD 3.27).
•Primary services are cheaper than the same service in secondary care. NHS / CCGs reimburse GPs £75 for excisions vs. the local Heart of England Foundation Trust that was reimbursed £140 for excisions and often not excised at the first appointment. Furthermore, cases are often are referred via an initial primary care appointment causing more expense and taking longer.
•Based on cost of services for the benign lesions in this study: primary care costed £23,700 vs £44,200 had secondary care managed these cases.


Primary care is invaluable for minor operative diagnostics work for benign conditions. It has the potential to deliver a high standard of care for concerning pathology. As treatment in secondary care requires a GP appointment first anyway, excision in primary care is overall more cost-effective whilst saving time. In this regard we should explore and remain open to strategies of safely mobilising further surgical work to primary care in future.





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