1. Primary care surgery: reaching our potential Tony O’Sullivan GP, Irishtown, Dublin

2. We are all surgeons aren’t we? MB, ChB, BAO ICGP skills courses since 1992 Cryotherapy for warts Growing elderly pop Hospital waiting times Hospitals withdrawing skin surgery services VHI Swiftcare offering surgical services

3. LEO

4. Surgery in general practice Cryotherapy Family planning procedures Incision/drainage abscesses Joint injections, ganglion Ingrown toenails Cysts, lipomas Shave excision/cautery Ellipse excisions Suspect lesions (BCC, SCC, melanoma) PCSA survey 2013, 100 members, 71% response 89% full PHI providers 10% op on private only, 0% GMS only <60% do most procedures, yet only 14% refer to other GP > 80% have training in A&E, SHO or higher

5. Barriers to surgery in GP 57% concerns about litigation 58% lack of training or skills 68% costs of equipment and instruments 86.8% say financially unrewarding

6. Sustainability - Costs Ellipse excision – Facility, staff – Instruments – Sterilisation – Sterile gloves – Scalpel – Subcut suture (Vicryl) – Skin suture (Nylon) – Handling sample – Records, results Manage costs – Clinical assistant – Disposables – Shop around – Monocryl suture – Stock order form

8. Sustainability - fees GMS PHI Neither Both HSE funding Inter-referral, STCs add up Facility charges Co-payments Cross-subsidisation – Cryo and skin tags – Toenail / ellipse – PHI v GMS?

9. Irishtown Primary Care Centre 1.5 days per week Referrals from 130 GPs See and treat same day Some HSE funding 690 procedures 2013 – Toenail, cyst, other – 8% LARC – 17 malignancies

11. Primary Care Surgical Association www.pcsa.ie For all interested docs Education, basic training Mentoring after training Standards eg sterilisation Accreditation in relation to cancer work & high volumes Annual Conference (Dublin Autumn 2015) Audit tool Advocacy – HSE – SDU – National surgical programme – PHIs – Irish Cancer Society – NCCP – ICGP

12. A word about dermoscopy Now a fundamental diagnostic tool Naevus vs Seb keratosis BCC vs Intradermal naevus or dermatofibroma Benign or not Buy it, use it PCDSI (5-7 Mar 2015, Galway) PCSA (Autumn 2015, Dublin) Books

13. A vision of the future Transfer of much surgical work to primary care Much greater inter- referral in primary care Surgical facilities in most primary care centres HSE € per case supports for care of public patients PHI facility fee in GP Advanced training and skills recognised Strong collegiate network

14. Ready to get involved? Look at quantity of surgical work in your practice Join PCSA Upskill, get some mentoring Equip sensibly Inform colleagues Work out sustainable business model Get started!