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Independents' Day

GPs required to take pictures of lesions before skin cancer referrals

Exclusive GPs will be required to submit photographs with any referrals for skin cancer, which will determine whether the patient is seen by specialists, under plans from CCGs in the North East of England.

Under the new system, GPs will have to take three photographs using their mobile phones and a dermatoscope and submit those with the referral. A consultant will then review these and offer either an urgent or routine appointment, or an alternative treatment plan

The CCGs leading the project - NHS North Durham CCG; NHS Durham Dales, NHS Easington and Sedgefield CCG; and Darlington NHS Foundation Trust - said the move is a response to receiving about 150 referrals for urgent dermatology outpatient appointments every week, most of whom do not have cancer.

Pulse understands that NHS South Tyneside CCG is also considering implementing the scheme.

The plans, the CCGs said, will help determine how quickly patients need to be seen and enable other patients to get earlier appointments if they need to see a consultant quickly. They will also fund the dermatoscope and training for the GPs.

Although the plans are intended to remove unnecessary appointments, GPs can request appointments for their patients even if a consultant initially thinks it is not necessary.

Pulse understands that several South Tyneside GPs have expressed concerns to them that the new scheme, intended to save OPD appointments and potentially money for the CCG, will lengthen GP appointments and expose GPs to risk if and when dermatology decline to see these patients. They add that no funding has been offered to compensate for the likely increase in workload, and that the issue has been raised with the LMC.

Another GP told Pulse: ‘I find it hugely disappointing that at a time when it is widely recognised that primary care is under unprecedented levels of pressure, our CCG has decided to further increase our workload with this additional step before an urgent skin cancer referral can be made. We have an excellent local teledermatology service to assess less suspicious skin lesions so I’m struggling to see why this new step is required.

’As well as adding to the workload of already overstretched GPs, I have concerns that it may potentially delay skin cancer diagnoses by making the referral process unnecessarily bureaucratic. For instance, we have been told that if a photo is not uploaded within 24 hours of a referral having been made then it may well be rejected.’

However, Dr George Rae, chief executive of Newcastle and North Tyneside LMC, said he was broadly supportive of these plans - as long as they are implemented correctly: “There might be technical problems with it. Having said that, if the technology is right, if the photograph is absolutely succinct and able to see definitively what the actual lesion is, this is not at all a bad idea.

’It will expedite things. It will make it such that patients will get quicker reassurance of the way forward.”

He said that in his personal experience, he has found that mobile phone images have not been clear enough for definite conclusions, but that the addition of the dermatoscope could be beneficial. He was also optimistic that, with training, the plans should not have an “inordinate” impact on GPs’ workload.

A spokesperson for the CCGs said: ’Digital technology is used increasingly across the NHS and evidence indicates it improves patient experience. This particular technology is already being used successfully in other trusts.

’We have training and other support in place to help with the initial implementation and will be monitoring the programme. Our priority is to ensure patients receive the care they need in the most appropriate place and as soon as possible.’


Readers' comments (26)

  • National Hopeless Service

    Remind me where in GMC regulations it states you have to do any of this? You can refer on the back of an envelope if you wish and they have to accept it.
    Admittedly as a Dermatology GPwSi I have been appalled by some GPs lack of dermatological knowledge for even simple benign lesions.

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  • Dear All,
    On the funding issue, the money they save in OPD referrals could move to the GPs to train and equip them to do this work.
    Paul C

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  • And who is paying for the dermatoscope?

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  • Apologies, and to Dr Cundy - the CCGs will be funding the dematoscope and training for the GPs. This was not left out of the story intentionally, but we have included a line now.

  • It won't be every GP who gets trained to use a dermatoscope. So that's an appt to see me, me to refer to my partner with the training, who's on holiday for a fortnight...
    We have an obligation to refer ALL suspected cancers within 24 hours.This is dangerous.
    PS the only thing more appalling than my knowledge of dermatology are my photography skills. Our local consultant has asked we do NOT send her photos!

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  • Good idea, provided it is properly resourced, funded and training is given. But who does the work for the GPs while this is being put in place and when it is in use?

    Is there a word we could invent to describe 'GP mission creep', I wonder?

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  • BMA negostiated contract is always extra underfunded mission creep for GPs.The last time it wasnt was in 2004.Lets call it GPCrap.

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  • Cobblers

    This is a clear money saving exercise leaving GPs with the legal liability. Unacceptable.

    How many of us have sat through dermatology lectures with slides, aka photographs, of lesions which defy analysis, let alone the diagnosis given to them by the expert?

    How many of us have tried using phones, cameras, whatever, to photograph a skin? Very difficult to get the focus (even if auto) distance, contrast, positioning, shadowing, lighting right in order to do justice to the lesion.

    Even then the suspicions of a Mark 1 eyeball 'hands on' view may be inadequately expressed.

    Mistakes will be made and I hope those refusing the referral will be made to take the responsibility. It will concenrate their minds.

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  • No new work , without new money!!!

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  • David Banner

    So a fuzzy photo of a melanoma is incorrectly dismissed as a seb. keratosis. Who gets sued? The photographer for not having a better camera? Or secondary care for not seeing the patient?
    What if the 2WWait is breached because the photo would not upload? (It happens. A lot.)
    What if the photo accidentally ends up in cyberspace on Facebook accounts?
    What if the patient refuses a photo?
    Why can’t the patient be given access by secondary care to upload their own photos?
    The mind boggles.......

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  • Dear All,
    Perhaps i was being too subtle. This is a cr*p idea. We all know dermatology referrals vary massively. I've had a patient who is a GP insist on my reviewing a "definite malignant melanoma" on his wife's back which i was able to cure instantly when i removed the keratin plug. The sort of GP who will be bothered to take a quality photo is unlikely to be the sort that is clogging their OPD with seborrheic warts.
    Paul C

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  • From experience, some melanomas and tumours look normal until histology says otherwise. Experienced doctors knows this. Sack the pathologists if the photos are that good and accurate.

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  • Just a gentle reminder if you are worried and do not refer, not only is it immoral and against the GMC rules but Gross Negligence Manslaughter Charges for the one that stops the referral.

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  • Cobblers

    "the move is a response to receiving about 150 referrals for urgent dermatology outpatient appointments every week, most of whom do not have cancer".

    Oddly that applies to all 2WW referrals. So that excuse is out the window then.

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  • Obvious question here - who gets sued when the cancer is missed? The GP for 'not taking a good enough photo' or the hospital for not seeing the patient? Should we not trial this system first? Is there a good evidence base a dermatologist can screen using photos?

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  • So , Leeds CCG , been doing this for about 1 yr now . CCG provide the dermatoscope , and ipod , the training is c 10mins long
    Its really easy to do. Clinical responsibility lies with the consultant - if they feel they can be sure its benign , then they inform the patient directly and the 30% of 2WW referrals in Leeds that were for Seb k's don't even need an appointment
    And yes , to those who might refuse , if I send it in "on the back of an envelope they will triage the patient to face to face within 2 weeks

    Really sorry , but I just don't see what is not to like. Not everything new in GP is rubbish , sometimes they are improvments

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  • For ONCE, what a wonderful and clear picture: 2 eyes, nose, mouth, even a forelock!
    My lesion photos never look so clear and friendly.
    Its a pity it also cleary shows malignant features, or I would have been inclined to keep it until it grew a bit bigger!
    Well done that photographer!

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  • I'm curious about the Information Governance about this. Are they asking GP's to use their personal mobile phones to take clinical photos and then ?email them to the hospital.

    There are a number of software options available that can make this better but the article doesn't say what's being used.

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  • Send all Rashes and skin lesions that you see in clinic to dermatologist even when diagnosis is obvious. That should clog up system and they will say “ no more pictures please”

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  • I am a GPwSpI working for WKD (West Kent Dermatology), which is part of Sussex Community Dermatology just starting the 3rd year. We are given excellent training in skin tumour diagnosis & as a specialist I wouldn't be without my dermatoscope. (cost about £700). I am in my mid 60s and went part time 8-9 years ago and now concentrate on skin lesions. The best thing is that there is a beginning, a middle & an end to all I do. I am very well supported by WKD. I am one of several senior GPs, who do the same. It is very satisfying work & I would not still be in general practice if I did not do this.

    Several points:

    A consent form is needed for photographing patients even if it is an isolated skin tumour. (takes about 2-4 minutes)

    It takes several years to become good at using a dermatoscope. Training courses are £100 and one is not enough.

    Pattern recognition of skin tumours is down to seeing many of them & correlating the final histology results.

    Referral letters vary enormously. Even from experienced quality GPs I am frequently only told only where the lesion is, but no measured sizes, no description, no attempt at a diagnosis (How does one learn if no attempt?)

    The bottom line here is that it is better to train up local interested GPs as a cost effective exercise to make better diagnoses. In my letters I always give the site, a good description of the tumour, the measured size & my diagnosis. Some of this is beginning to rub off now in that some of the GPs have greatly improved their referral letters & diagnosis. A dermatoscope or the training is not really necessary, but a lighted magnifying glass (cheap) is incredibly useful. One can easily see the stuck on and waxy appearance + the pseudocysts so typical of a seborrhoeic keratosis or the ulcer crater & arborised blood vessels of a nodular BCC.

    WKD has worked really well in West Kent & patients are seen really quickly(1-4 weeks). It is win, win, win as the patients are readily seen (fears often allayed), my practice is paid, I do satisfying work.

    If anyone has a better suggestion, I would be surprised. TB

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  • We have this requirement already in my CCG; dermatoscopes have been provided for us. I can't say it has caused many problems to my knowledge.

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  • NICE guidance is that we should aim for 3% Positive Predictive Value for cancer referrals. So you’ll have to forgive me if 97% of my referrals turn out not to have cancer.

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  • All these patients are going to need to be seen so it will mean GPs doing more work, with no reduction in the work of the specialists. Obviously all BCC's need to be seen and assessed as 2WW as some of them are SCCs.
    Waiting lists do not reduce work - they increase it ! as this stupidity demonstrates.

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  • Such a shame GP have to refer and not deal with these lesions as GPs do in Australia where I have worked. There was a study eons ago from Liverpool that suggested GPs were better at it anyway (better margins). But it is the description and history that counts. If photo needed use dermascope, if you have that kit might as well do all in house.

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  • GPs are capable of doing these procedures, but not quite so easy on the face without extra training. It is important not to damage nerves & to leave good acceptable scars. There is not enough training set up for this in most of the country. There is also politics. Many dermatologists & plastic surgeons would be resistant to GPs doing this kind of surgery.

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  • Dear Colleague,

    I think this lesion could be sinister according to years of training, experience and gut feeling.

    Kind Regards

    Dr No Time To Waste on BS

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  • Paul C exactly,
    I do Derm 2 days a week and see lots of 2ww referrals. I know the GP's who have already given me the correct diagnosis in the referral before I even look and those I wouldn't trust not to end up setting fire to themselves with the dermatoscope

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