Skin cancer excision performance in Scottish primary and secondary care

I agree with the authors view that a secondary care specialist, supported by a multidisciplinary team within the hospital, will excise skin cancers with a greater degree of skill than the average GP.¹ This seems obvious. What is much less clear, however, is whether this incremental technical quality, achieved at considerable cost, is truly clinically meaningful. This is the key issue to be addressed if the debate reinvigorated by this article is ever to move forward.

The authors raise several valid methodological issues with our own previously published and related work. They are right to do so. Our work is flawed and provides no definitive answers. Unfortunately, however, they have not themselves improved on our approach and their results offer no new insights. Particularly, it appears that pathology reports were audited without blinding as to the source (primary or secondary care). This compounds the flaw of nearly all earlier work except our own ‘anomalous’ results. The potential for partial auditors to favour their own in this type of analysis is too important a source of bias to ignore. Additionally, the decision to compare 1 month of secondary care data with a year of primary care data is not properly justified and seems idiosyncratic. The shorter period of observation for secondary care in the study may further bias the results in favour of secondary care operators. Furthermore, they have made no allowance for different levels of experience among GP excisers.

These data are unconvincing and I do not believe they take us any further forward. As we have repeatedly stated, a prospective randomised trial is needed. Only then will we have the high quality evidence on which to base future guidelines and the best models of care for patients.

• © British Journal of General Practice 2014