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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)

  • 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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