Advice and guidance (A&G) should be the main referral pathway for access to dermatology services, NHS England has suggested.
In a document setting out the principles for ‘referral optimisation’ for people with skin conditions, the use of ‘pre-referral specialist advice’, such as A&G, followed by specialist triage is advocated as the main referral pathway with the exception of suspected skin cancer.
This will improve working between primary, intermediate and secondary care, the document states, and will ‘facilitate a clinical dialogue’ before a referral is considered.
With dermatology departments prioritising the two-week skin cancer pathway, this has an ‘inevitable impact’ on access for people with inflammatory skin conditions, such as eczema, psoriasis and acne and A&G could help mitigate the long waits they face, NHS England said.
It is estimated that a third of face-to-face hospital outpatient attendances could be saved by 2023/24.
In February, the Government set out its long-awaited elective recovery plan that stressed that GPs’ role in tackling the NHS hospital backlog will focus on the use of A&G to try to avoid ‘unnecessary’ referrals to secondary care.
Professor Martin Marshall, chair of the Royal College of GPs said they had been clear that this approach must be optional, not mandated, for GPs and their teams.
‘Whilst the aim of reducing referrals is commendable, GPs will only refer to secondary care once they have reached the end of the clinical pathway they are confident with.
‘Having the option of asking for advice when unsure of the next step in the treatment pathway is very useful, and GPs and their teams must be allowed to refer those directly to secondary care who need onward management.
‘If every referral ends in an electronic conversation between primary and secondary care, this will only add to the workload pressures in general practice and across the NHS.’
It was important to prevent patients being caught between primary and secondary care, he added.
Dr Selvaseelan Selvarajah, a GP in East London, said he would be very worried about this proposal, which does transfer extra work to GPs and should be fully resourced.
‘A&G should be renamed Advice or Referral in the first place. GPs are expert generalists who train for years so are aware of what they need to do for a patient.
‘GPs refer for three main reasons. Diagnostic uncertainty. Know the diagnosis but further investigations and/or treatment are only available in secondary care. Or the patient would like a second opinion.
‘Advice should rightly be obtained for patients when there is diagnostic uncertainty but there should be a referral option for the latter two reasons. So, overall, whilst advice or referral is a great concept and has many benefits for the clinicians, patients and the NHS, we shouldn’t have a blanket policy of all referrals must be A&G only.’
Dr Hussain Gandhi, a GP in Nottingham, where there have been concerns over the introduction of A&G for neurology, said dermatology was an area where such an approach could work better but systems had to be developed in collaboration with GPs.
‘There are patients where it can be useful but for some patients it can delay their care and it is important to recognise it takes away patient choice.’
In 2019, a number of CCGs in the North East of England decided to require GPs take three photographs using their mobile phones and a dermatoscope and submit those with any referral for skin cancer.
In related news, NHS England has told GPs that patients with ‘a FIT of fHb <10μg Hb/g, a normal full blood count and no ongoing clinical concerns’ should not be referred on a lower GI urgent cancer pathway but should be ‘managed in primary care or referred on an alternative pathway’.