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GPs buried under trusts' workload dump

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.
    Regards
    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.
    Regards
    Paul C

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