This Dermatology Blog will keep track of all the activity undertaken by the Dermatology Specialty Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wishes to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
Guest blog by John McFadden, GP and Managing Partner Inverness Primary Care LLP
Inverness Primary Care LLP is a GP federation consisting of the 12 general practices in Inverness. We have a contract with NHS Highland to provide more dermatology within practices in order to reduce the number of referrals to dermatology and the number of skin lesion excisions performed in hospital below an agreed number. The LLP works collaboratively with another 25 practices in NHS Highland to provide this service covering a population of approximately 123,000 patients.
To help achieve our objectives, initially we triaged referrals and ran a small community clinic at which an Associate Specialist in Dermatology both saw patients and educated GPs. However as practices took on more dermatology we were able to stop this.
The way we achieved the required outcomes was;
1. To report to practices the referral rates so they could see if they needed to change, by how much and how other practices were performing.
2. We performed an analysis of referrals to dermatology which led to education focussed on the dermatological conditions which we though could be treated within general practice.
3. We encouraged practices to scrutinise their referrals before they are made and to develop within practices individual GPs who have an interest in dermatology to act as a resource for their colleagues.
This project meets the first key principle of the Scottish Access Collaborative in that patients now have to travel less. The other five principles are not really relevant to this project as it reduces referrals before use has to be made of the other five principles.
Sharp eyes will see initially we made a greater reduction in referrals than the 30% we were required to achieve. This is because we had designed a system that we thought could reduce referrals ultimately by somewhere between 50-60% but the funding was not available for this degree of reduction. Secondly, some of you will have noticed that we are unfortunately now breaching our referral target. We think this is because interest in the project waned partly because of other pressures on General Practice and partly because of difficulty engaging with NHS Highland management. With a new Dermatology Service Manager in Highland, ongoing Consultant support for the projects and efforts by the LLP the project is being reinvigorated and as you’ll see referral rates are falling again.
The follwoing images are also available as PDFs in the dermatology document repository
National Dermatology Improvement Nurse
Guest Blog by Dianne Ross for Scottish Access Collaborative
The posts of National Dermatology Improvement Nurse are both for a fixed term of three years. One is hosted in NHS Greater Glasgow and Clyde and the other in NHS Tayside but both have responsibility for developing services across both Scotland and the CAWT regions of Ireland.
The Modern Outpatient Programme is designed to support the delivery of high-quality, effective, and sustainable dermatology services across Scotland ensuring care is delivered in as responsive and person-centred a manner as possible, and, critically, as close to home as possible
A revamp of the way dermatology care is delivered is imperative if increasing demand on services and patient expectation is to be met. One way of doing so would be the advancement of the role of the nurse in line with current health policy. There are over 300 nurses employed to provide dermatology services in secondary care across Scotland. This development of nursing roles will require assurances that nurses are competent and capable of carrying out such a role and that they are sustainable for the future.
The Scottish Government Modern Outpatient programme and CAWT (Cooperation and Working Together) which is based in Northern Ireland and bordering counties in Republic of Ireland have similar priorities for dermatology services and have united in the goal of developing a standardised national training programme for dermatology nurses, primarily in secondary care.
Currently dermatology nurse education is organised locally, study days are limited and academic education does not go beyond degree level. A programme of education on four levels is proposed. The first level would be mandatory for Health Care Support Workers, and the second would be mandatory for all trained nurses. The third level would be optional for those nurses wishing to progress to specialist nurse roles and the fourth for those in advanced roles. This education would include a mix of e-learning, competency based, study days, virtual education sessions, speciality specific courses and academic education.
Over the first year in post the nurses have carried out a scoping exercise involving every health board in Scotland. This has allowed them to map the existing service provision and identify current training opportunities, specialist academic courses and local internal training programmes. This scoping work has helped to identify current education resources, future service developments, gaps in current training provision, future training need and barriers and facilitators to education.
In January 2019, the Digital Health and Care Institute (DHI) began work with the NHS Scotland Dermatology Specialty on improving pathways for patients and staff. Under the umbrella project The Scottish Access Collaborative, the specialty group and the DHI team will work together to unpick current dermatology services and make recommendations for service innovations based on the findings and insights gathered over the coming months.
The aim of the Scottish Access Collaborative is to sustainably improve waiting times for patients waiting for non-emergency procedures. The program is guided by its six founding principles which foreground patient experience, clinical benefit, and transparent services. The six principles can be seen here.
The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. It is part funded by Scottish Government. DHI support innovation between academia, the public and third sectors and businesses in the area of health and care.
The DHI was commissioned by Scottish Government to design workshops for the Scottish Access Collaborative clinical specialty-led programme. These workshops involve a range of clinical staff from primary and secondary care, health managers, patients and third sector organizations undertaking a cycle of design-led workshops.
In this first workshop, the aim was to map out the common symptoms and conditions dermatology deal with currently as part of their non-acute out-patient service, and prioritize what issues the group want to focus on in the next two workshops.
To begin with the conversation centered on the general state of dermatology services. There are currently long waiting times across all health boards due to overall under-capacity of the service to meet current demand. There was discussion around the impact of staffing shortages in some areas and the impact on capacity resulting from this. Long waiting times impact GPs as some patients return for multiple appointments while they are waiting to be seen in secondary. There is variation in waiting times between boards yet the reasons are not well understood and there is an opportunity to fully explore this.
The group recognised that dermatological complaints are a significant part of the primary care workload and that the majority of patients are managed in primary care. Concern was raised that any loss of GP capability and capacity can and will have a major impact on secondary care referrals/demand with a resultant impact on dermatology waiting times. Diverting some roles from GPs to other professionals may be the impact of the new GP contract; the increasing role of ANPs was raised as one area with an adverse impact on dermatology demand. One area for further exploration would be enhanced training for ANPs to mitigate the effect of capability and capacity loss.
Although there was a recent update of referral guidance formulated by both primary and secondary care, it is not being universally adopted with some areas using local guidance. It was also suggested that visibility and accessibility of these guidelines were limiting use. There is a lack of sharing of best IT practice across boards.
Vetting of referrals in secondary care should be a crucial part of dermatology work, there are examples of this being done well across Scotland but it varies. It requires investment of clinical time but it can give you ‘big wins’ in terms of getting patients the correct care quickly. One major issue is the varied IT systems in place across the boards.
Common Symptoms: Why focus in this?
Through a discussion around common symptoms and opportunities for improvements, the group focused in on a number of areas for focus for the next two workshops. To help prioritize the aims for the next two workshops, it was useful to reflect on each common symptom and ask ‘why’ this would be a good area to focus on.
- Skin lesions (pigmented and non-pigmented): this is a significantly large volume of referrals into dermatology. Pigmented lesions cover brown marks that patients and GPs worry might be cancer. There are several potential diagnoses and the majority of pigmented lesions referred are benign, but cause a high level of anxiety for patients. There are some simple educational things that could be done for GPs to increase accuracy of referral which will significantly help with triage. To date, education has focussed on recognizing skin cancer rather than recognizing benign legions and it was suggested that focusing on malignant lesions may not be the best way of managing demand. A change in demographic (older population) is leading to an increase in lesion referrals. There is geographical variation in referrals, i.e. some boards use photos, some do not, some referrals come from AHPs rather than GPs, but ANPs do not have the right training to make a diagnosis and so they tend to refer more (risk management). Enhancing capability for minor surgery in primary care was suggested as a way of reducing referrals to dermatology appointments. However, current guidelines state potential melanoma skin cancers should be managed in dermatology. Building capacity to do this in primary care is also expensive and needs to comply with strict standards which can be a barrier to services. There are established referral guidelines for GPs but they are not universally applied and many GPs do not know they exist. There is an opportunity to invest in high quality information resources, especially for patients to help support self-help.
- Rash: inflammatory skin diseases are a large percentage of dermatology work the other large part being lesions. It can be a resource intensive chronic condition. Triage of patients relies on the GPs description and consultants decide level of urgency based on this resulting in variation of referrals. As with lesions, who and how referrals for skin disease are done varies nationally, some ANPs can some can’t, some are done then vetted by a GP some are not vetted by a GP. GPs deal with a lot of skin conditions in primary care, any decrease in their capacity will have a significant impact on secondary care referrals
- Leg ulcers: this is a fairly common symptom for dermatology and an increase in ageing population and lifestyle conditions like obesity will only drive the number of cases up. Traditionally, most leg ulcers had been seen in primary care but currently the capacity, in terms of resource and infrastructure, is not there. There is regional variation in terms of the approach to dealing with this symptom. It is a labour-intensive investigation and management process. There is some crossover with dermatology and an opportunity to look at this symptom in the context of the two services. Inpatients who develop leg ulcers are sent to dermatology for treatment (compression bandaging), treating these patients takes away capacity from outpatients. For some this is a sizable volume of work and resource. Secondary services have developed ‘organically’ based on special interests in specific clinics. When departments change, i.e. staff change, the service design cannot deal with the demand. GP practice has an increased responsibility for chronic care management for conditions like diabetes, so the management of leg ulcers is less of a priority. Socio-economic factors are impacting on the amount of leg ulcers with knock on effect on primary and secondary care.
- Monitoring of systemic medications: while not a symptom, the monitoring of drug treatments is an area for focus for dermatology. There is currently huge variation in how this is managed, many patients are monitored in secondary care. For stable patients, monitoring does not necessarily require a secondary care consultant led clinic. However, a point of discussion was the clinical responsibility for results and ease of primary/secondary care communication. Getting agreement and acceptance on protocols is an issue. Improving the pathway for monitoring with a focus on community capacity can reduce the number of miles’ patients must travel for follow ups, and free up capacity in secondary care.
- Acne: most patients with acne need to start treatment from the moment they visit the GP. However, not all explore the available options before attending secondary care. The provision of isotretinoin for acne (a retinoid medication which is teratogenic and requires monitoring during the treatment course) is another significant part of the secondary care workload. Discussion explored the possibility of other protocols for monitoring involving primary care. There is an opportunity to develop alternative ways of dealing with acne that require fewer visits to secondary care
The next steps for dermatology will be to dig deeper into the issues and opportunities for the identified prioritised areas and highlight any recommendations for service improvements in line with the Access Collaborative principles. This will take place over two further design workshops facilitated by the DHI team. While the Access Collaborative aims to develop new ways of working for NHS services, there is also recognition that there are national work programs already underway as well as existing innovations in individual boards and hospitals. Over the coming months the DHI team will also work with the dermatology group to promote relevant national initiatives and share examples of best practice through this blog.
If you would like to know more about this work or would like to attend the next workshops, please contact the DHI project team via email at firstname.lastname@example.org
Guest blog by Dr. Rita Rigg, General Practitioner
The estimated prevalence of leg ulcers in the population is 0.1 to 0.3% in UK with a risk of developing a leg ulcer in ones lifetime estimated to be 1%.
60-80 % of leg ulcers have a venous component. Venous leg ulcers are the most severe manifestation of venous disease caused by venous hypertension. Mixed arterial - venous causes affect up to 26% of patients. 9% occur in cases of rheumatoid arthritis. 5% have diabetes.
The cost of treating an ulcer is over £1600 / year. The total annual cost in Lothian for dressings is £3.72 million (ISD).
The mainstay of treatment is compression bandaging where ABPI is more than 0.6.
Management advised is to offer early referral to vascular specialists for ulcers that have not healed within two weeks of treatment or that recur. (ÉVRA trial Semin vascular surg 2015:28:54-60)
Duplex USS can confirm diagnosis.
Early endovenous ablation of superficial venous reflux promotes healing of venous leg ulcers. Surgery can be performed for arterial revascularisation as indicated.
Best medical therapy for arterial cause should be given. Refer early to vascular surgeons. If not either venous or arterial cause found refer dermatology (optimal skin care, patch testing, malignancy), plastic surgery (grafting), rheumatologist (Vasculitis), diabetologist (association), haematogist (anaemia, polycythemia)
Amongst the risk factors are high BMI and sedentary lifestyle. Providing dietary and phsyiotherapy services in the community will reduce risk factors.
Service requirements to provide optimum, cost-effective, evidence based timely care:-
- Facilities and resources to provide timely vascular specialist investigation and intervention
- Resources in primary care to provide weight management programmes and physiotherapy services
In February 2019, the Scottish Access Collaborative Dermatology specialty reconvened for their second design led workshop. The ultimate aim of the collaborative is to collectively enhance clinical pathways for staff and patients so patients who need primary and secondary care are identified, diagnosed, and treated appropriately and efficiently. This will involve mapping current service designs, identifying current issues, responding with ideas for new innovations, and also identifying and replicating best practice where possible. In the first Dermatology workshop, some common symptoms were proposed and some common issues identified resulting in a number of specific symptom profiles. This second workshop reviewed the proposed symptoms, enhancing the existing symptom profiles by adding more issues, developing some focussed challenges in the form of ‘how might we’ statements, and proposing some initial ideas for improvements. The reason for developing how might we statements is to combine and prioritise some of the main issues for Dermatology into individual manageable tasks that form the basis of new ideas and innovations that the group will propose and detail in the next phase.
What follows are short summaries of the enhanced key symptom profiles for Dermatology as well as a summary of a general discussion, the how might we statements that developed as part of the group discussion and some initial ideas of how to improve current services.
Symptom 1: Rash
Huge range of possible diagnosis with some diagnostic uncertainty. There is some variability in practice when referred. The range of expertise with rash in primary care varies. There can be periods of waiting where there is no contact with the patient.
Issues: The issues around rash can occur in primary care, for example knowing when to refer a patient. In secondary care, there are a shortage of consultants. Issues can arise following referrals, for example during waiting times between primary and secondary care. Throughout the pathway there is a patient expectation quite often his is to do with the language used, for example a ‘referral’ raises the expectation for some that they will be seeing a specialist.
Flagged issues include an inconsistency of referrals leading to varying severity of condition being referred. The difficulty in triage if no photo is included or the description is poor. It was identified that some patients could have had treatment in primary care. During waiting times a patient can become anxious, rashes can improve or worsen with no advice or contact during this time.
For who: This is an issue for GPs, patients, nurses, administrative staff, medical team, managers. There is an issue for technology specialists looking at referral systems fit for purpose. For primary care, if treatment pathways need developed then time and resources will be required.
How might we…:
- Make referral guidelines support which is available to GPs
- Support the diagnosis and treatment of psoriasis eczema, lesions, and acne in primary care?
- Decide on the balance between what is done in primary care and secondary care?
- Manage patient expectations?
- Find and communicate another term for triage and vetting that is about finding the best pathway?
- Get a fuller history with the referral?
Ideas: For the how might we….get a fuller history with the referral?
On referral, potentially via a phone call on triage / pre-assessment, collect information on patient history, medication past and present, surgical history, condition specific information and compliance with medication.
The patient can collate information. The GP can provide as clear referral information as possible, a fuller history with photos. ANPs could, have the ability to phone / contact patient to get more information.
Impact: The impact of this change could be time saved in consultation, improves the quality of consultation, improves the pathway for patients, and reduce the number of consultations. This benefits consultants and patients. The effect would be a reduction in waiting times and the number of patients in secondary care receiving treatment they could have received in primary care.
Rather than triage of referrals would be re-assessment would be a more efficient streaming pathway.
An ‘ask for a specialist opinion’ option instead of the usual triage / vetting.
Symptom 2: venous ulcers
Summary: There can be a delay in diagnosis of ulcers. Inappropriate treatments can be administered for too long. There is perhaps a lack of early assessment by the appropriately trained staff.
Issues: There is a direct cost implication with treating leg ulcers that exacerbates over time if the condition is not dealt with. There are currently not enough staff who are appropriately trained in dealing with this symptom. More could be done in terms of prevention. Ulcers can be linked to public health issues like smoking and public health messaging around the link between smoking and this condition could be improved. Dealing with ulcers effectively can be effective in reducing morbidity, helping patients return to work earlier, and improving quality of life.
For who: The issues impact mainly on patients in terms of their discomfort, the impact on their general health and the time it takes to treat the ulcer. For secondary care, more time would be freed up if better care could be delivered earlier. For GPs, there would also be a saving in their time if ulcers were treated earlier.
How might we…:
- Prevent more leg ulcers?
- Improve early diagnosis and treatment of ulcers?
- Improve public health messaging about ulcers?
- Improve uptake of education to nurses to recognise and assess ulcers?
Ideas: For the how might we…improve early diagnosis and treatment of leg ulcers?
A community service with secondary support, potentially a leg ulcer liaison nurse. The community service would provide early assessment, treatment, and monitor patients for an initial 12-week period. If there were no sign of improvement after the initial period, then the community team could refer non-healing ulcers. There is a question as to whether the referral would be to dermatology or a vascular referral, both specialities deal with ulcers.
The challenges to this idea would the time for training, the investment costs for equipment for example the purchase of Dopplers, and the impact of other community based activity.
Impact: The impact of such a change could be fewer venous leg ulcers with a reduction in costs. An improvement in job satisfaction in ulcer care nurses. Improved outcomes for patients, fewer dermatology referrals and in patient stays.
Symptom 3: lesions & changing moles
Summary: There is a difficulty in diagnosing. The GP training currently is poor and there is a difficulty getting GPs to access it. There are long waiting times in some areas and there is variation in access GPs with a special interest. Some clinicians are using photo triage, but this can be time consuming for GPs. There is a lack of good patient information Minor surgery is very expensive to set up and maintain.
Issues: The current situation leads to unnecessary referrals. Many lesions can be managed in primary care but are not. There is a lack of good quality technology options for sending pictures and a lack of minor surgery facilities in the community. Few GPs are trained in dermatology and patients are poorly informed.
For who: The issues mainly affect patients, consultants and nurses.
How might we:
- Give better patient information?
- Improve access to minor surgery in the community?
- Improve local access to dermatology specialist advice for patients to reduce travel for patients?
- Enhance better trust and working relationships between primary and secondary care across all boards?
- Improve GP access to training?
- Improve diagnostic accuracy / appropriate referrals from primary?
- Improve technology in primary care?
- Improve support for GPs with special interest?
Ideas: For how might we…improve GP training / support GPs with special interest.
Special interest clinics perhaps within clusters, with more training of GPs with special interests. Enhancing / more minor surgery in the community. Special interest clinics can upskill a primary workforce and take on a transfer of resources into primary from secondary care.
Impact: This new idea would potentially increase patient satisfaction while reducing the cost to secondary care. There will in this scenario be an increase in workload for GPs and additional minor surgery nurse support required. The change should reduce referral rates from primary to secondary and see an increase in patient satisfaction.
Barriers: Funding will be key for training in terms of time away from practice, also costs for equipment. There would be a cost to GPs along with the additional time and workload. Secondary care would also lose some of its funding. Not a barrier as such, but the scope for technology disruption in dermatology referral practice could affect the need for / content of GP training.
Taster weeks for GPs
The next step in a third workshop will be to return to the how might we statements, develop more detailed ideas to address the challenges, and develop some associated action plans. All the agreed actions will be documented as recommendation in the Dermatology report to be published via this site.
The Scottish Government, Scottish Enterprise and NHS Scotland are running a Small Business Research Initiative (SBRI) competition designed to identify innovative new ways to improve dermatology services.
The competition is divided into two phases. In phase one, which lasted six months, five companies developed proof of concept ideas. At the end of this, two companies were selected for phase two, which will last for 18 month. During phase two, the companies will develop and demonstrate their prototypes in a variety of health boards in Scotland.
The context for this competition is: how can we best optimize the use of a consultant’s clinical time? How can we support consultants to ensure they see the patients they need to see, when they need to see them? How can we ensure that they can treat as many patients as possible?
In response, one company looked at the upstream solution working with GPs to restrict the number of referrals. The other company looked at the downstream solution looking at how a consultant can use asynchronous virtual consultations to make best use of the consultant’s time.
The phase 2 companies are Storm ID and GP Commissioning Solutions (GPC).
Storm is developing an asynchronous virtual clinic model that allows patients to log into a website and upload photos and answer questionnaires that can be then reviewed by the consultant. This includes the ability to request more information from the patient. The consultant can then decide on the appropriate outcome, in much the same way as a traditional appointment.
GPC are developing a set of software applications that uses machine learning to help GPs to carry out more accurate diagnosis and treatment of skin conditions, assisted differential diagnosis and context sensitive education materials. They are also developing a patient planner application to assist patients with reminders, help and advice and adherence to their treatment plan. This will include integration with Amazon’s “Alexa”.
The links below are to a recent Health and Social Care Innovation Network meeting where both companies presented their work to date. Please see “HSCN19 - Murrayfield - 230119 – Dermatology” for links to the slides and the video of the presentation.
In March 2019, the Scottish Access Collaborative Dermatology specialty met for their third and final design led workshop facilitated by the Digital Health and Care Institute. The aim of the Collaborative is to collectively enhance clinical pathways for staff and patients so patients who need primary and secondary care are identified, diagnosed, and treated appropriately and efficiently. For Dermatology, this involved mapping current service designs, identifying current issues, responding with ideas for new innovations, and also identifying and replicating best practice where possible. In the previous two Dermatology workshops, some common symptoms were proposed and some common issues identified, resulting in a number of specific symptom profiles and challenges for current service designs. Small working groups re-framed these current challenges as a series of ‘how might we’ statements, that positively re-states an issue as an opportunity for change. In the previous workshop the group tackled some of these challenges, developing some ideas for innovation and action plans for the next steps. In this third workshop, small working groups revisited the remaining ‘how might we’ statements, selecting the most salient and developing some more ideas and action plans.
What follows are short summaries of the ‘how might we’ statements that the Dermatology group prioritised in the workshop and the group responses to the challenges.
Ideas and Actions
- Community Surgery Network
How might we:…improve access to community surgery when appropriate? …link into a seamless primary and secondary care diagnostic and skin cancer system? …reduce unnecessary surgery?
Introducing community surgeons who might be nurses, GPs, GPSIs, podiatrists and would perform skin surgery, vasectomies, nail surgery, and cryotherapy. Using existing / planned community hubs to create a managed national clinical network with national standards. Encouraging interface funding between primary and secondary care. Integrating diagnosis, digital imaging and Dermatology input from start of patient journey.
If implemented, this change could reduce the surgery and pathology burden on secondary care; improve access to diagnostic tools; improve staff experience of community surgeons; improve the ability to train and attract new staff; reduce costs, waiting times, and variability of outcomes.
The first steps in making these changes would be to establish a Scottish Government community surgical network development group, and to include multiple stakeholders such as GPs, patients, Dermatologists, Healthboards, pathology, secondary care surgery, nurses, admin, design, skin cancer representatives. This idea could build on good models across Scotland, on the developing AI expertise which lends itself to this model, and on existing properties, skills, and infrastructure. Challenges might be around implementing digital diagnosis, keeping up with a rapidly changing field, funding, communication and IT systems, potential lack of controls and oversight leading to problems, and the cost of a good quality managed network with national standards.
- Dermoscopy within GP clusters or on personal phones
How might we:…embed technology in primary care enabling access to Dermoscopy which would allow phototriage
Offering patients an NHS app with clear guidance and a camera add-on to take and send high quality photos from their phones. And/or allowing patients to self-refer to a GP cluster offering consultations and Dermoscopy. At these clusters, staff (not necessarily healthcare professionals) can be trained to take macroscopic and dermoscopic images, for interpretation by primary or secondary healthcare professionals with appropriate training. This would enable photo triage, definitive diagnosis, as well as open up opportunities to build a database for a learning AI system to support diagnosis and triage in future.
This could mean that patients can access the service they need quicker and closer to home, patients can be reassured quicker, and there might be less inappropriate appointments within secondary care. However, there is a risk of deskilling GPs.
The first step would be to allocate time to this idea and ensure long-term commitment. Next, there is the need to consider and build an app, as well as to clarify and resolve privacy issues. This would involve getting patient consent and raising awareness among staff. For clusters, the idea might involve high equipment cost. There also needs to be a consolidated and joined-up database for training.
- Dermatology training aspiration
How might we:…improve GP access to training – especially for those who do not have special interest already?
Introducing and encouraging training targeted at gaining core skills and an overview of common conditions within Dermatology. It would also include skills in Dermatology history taking and examination, in order to describe conditions better and recognise red flags. This training would start at undergraduate level, but also be available to GPs, registrars, and within post-qualification training.
This could lead to a better patient experience with more immediate, appropriate, and effective care. It might also result in an increased number of accurate diagnosis and treatment, a reduced rate of inappropriate referrals, and an improvement in confidence and satisfaction for GPs and ANPs who could then manage common conditions effectively. It would allow easy access to knowledge and skills updates for all staff. However, it might mean increased cost for primary care, and an increase in the rate of referrals to secondary care overall.
Involve medical schools and universities as well as Healthboards to establish links and implement standardised mandatory training. There is a need to invest in protected clinical time, to engage stakeholders, and to build a career-long training programme starting at undergraduate level for medicine and nursing. There are challenges around motivation, time, funding, and recognition that this is valuable. However, there are existing assets which could support this idea such as enthusiasm, IT resources, rooms and other infrastructure, and experienced clinical teams.
- Drug monitoring protocols
How might we:…establish shared care protocols for drug monitoring between primary and secondary care, including remuneration or transfer of resources?
Ensuring community treatment and care centre funding is given to each health service care provider. Reviewing protocols in place in Tayside where this has been resolved.
GPs getting paid for additional workload, patients receiving monitoring near home, and intermediate funding being available to support local enhanced service.
It is unclear how widespread this issue is, and there is a need to clarify this before taking further action.
The next steps for the SAC Dermatology work will be for the DHI design team to collate the recommendations from across the three design workshops into a final Dermatology report that will be presented to the SAC board later in the year. Prior to it being taken to the board participants from the three workshops will have the chance to review the draft report before a final version is agreed. Once agreed, the final report will be published through the Turas website.
Dr Freida Shaffrali, Consultant Dermatologist/Clinical Lead
Dr Rory Mackenzie, (MK) Chief of Medical Services
Teledermatology as an element of telemedicine and e-health was first described over two decades ago. Teledermatology usage has steadily increased in the UK, from around 17% in 2006 to 48% in 2016. Opposition to utilising teledermatology for lesions has dropped from 31% in 2011 to 6% in 2016.1 Despite its prevalence for over a decade, rejection of referrals has not been widely adopted as a means of demand control.
The British Association of Dermatologists (BAD) 2013 guidelines on Teledermatology state that “Referral of patients with benign skin lesions for face-to-face consultations is often unnecessary. The referring clinician may be confident that a lesion is benign but may be uncertain of the clinical diagnosis. In such a situation, a specialist diagnosis can provide reassurance for both patient and referring clinician and also an important educational element for the referring clinician”.2
Different models of teledermatology have evolved in Scotland, with usage currently limited to four health boards: Tayside, Highlands, Forth Valley and Lanarkshire. In Tayside, General practitioners (GPs) are encouraged to attach clinical images to referrals to aid triage, whilst in Highlands real time as well as store-and-forward teledermatology is practised. In Forth Valley, patients attend community settings for photography which is then used to direct patients either to specific therapy, surgery or clinic, or alternatively patients are reassured without subsequent clinic appointments if photographs and dermoscopy reflect benign lesions.
In Lanarkshire, teledermatology was set up in 2005 as a pilot under the auspices of the Centre for Change and Innovation. Over the last 14 years, the department has used teledermatology and teledermoscopy for phototriage of skin cancer. GPs refer patients to Dermatology along with a telephone referral to Medical Illustration where high quality clinical and dermoscopy images are taken. Patients can attend any of the three acute hospital sites closest to them for photographs within 48 hours of referral. Referrals are vetted and phototriage allows prioritisation of patients to either an urgent suspicion of cancer clinic in 2 weeks, urgent clinic in 4-6 weeks, or a routine clinic in up to 12 weeks. Utilising phototriage, the need for large ‘screening’ clinics is circumvented, allowing better use of medical staff and outpatient clinic space, and allowing appropriate use of one-stop surgical capacity. It also frees up skin tracker time, as non-melanoma referrals do not need to be tracked, while GPs receive a downgrade letter to notify that the patient’s image has been viewed and the risk of melanoma was low. Feedback obtained from patients regarding the additional visit for photography is that they find it reassuring that a Dermatologist is looking at their lesion at the time of referral.
Uptake of teledermatology in Lanarkshire has gradually increased over the years. Recent graphs demonstrate a significant increase from 2013 to 2014, which may be partly attributable to the method of coding the source of referrals (Graph 1).
Graph 1: Number of referrals per annum from Primary Care directly to Medical Illustration via the skin cancer phototriage pathway (2013 -2018)
The use of teledermatology has remained largely unchanged in Lanarkshire up until 2017 when the Department piloted a ‘proof of concept’ e-clinic for managing classic seborrhoeic warts. Previous audit in 2016 showed that seborrhoeic warts accounted for up to 9% of all referrals. Patients with classic seborrhoeic warts were identified at phototriage, and medical staff confidence in the e-clinic diagnosis was classified as either 100% or 95%. All patients (n=90) in the pilot were seen in a face-to-face standard clinic. Concordance between e-clinic versus standard clinic diagnosis was 92%. Of the patients with an alternative diagnosis at clinic, none were malignant.
To obtain feedback on the proposed model, patients attending a routine clinic where they had waited up to 12 weeks to be seen were surveyed to ask if they would have been reassured by a letter with a diagnosis, rather than needing to attend a clinic, with 90% showing support for this model. A recent pilot study in London of 100 patients showed that a similar system allowed the clinicians to confidently phototriage with a reported concordance for teledermatology and face-to-face clinic assessment of 50%.3 Image IT trial with 200 patients showed 87.7% concordance between clinical and teledermoscopy, and of 12.3% lesions with disparate diagnoses, only one malignant lesion was missed.4
Table 1: Pros and cons of an e-clinic using teledermatology
Reduced waiting times for patients
Provides feedback only on lesion that is imaged
Avoidance of unnecessary hospital attendance
Potential to miss other incidental malignant lesions
Reliant on history provided by Primary care
Early reassurance for patients
Inability to palpate the lesion
Educational resource for GPs due to rapid feedback following referral
Depends on high quality images
Efficient use of scarce resources
More time consuming for clinician compared with non-phototriage vetting
With increasing consultant vacancies throughout the United Kingdom, new ways of working are required. Lanarkshire has adapted its well established service to provide patients with an improved pathway, resulting in either shorter waiting times or removing the need to attend clinic completely.
New developments include:
- e-clinic – the Department has embarked on an e-clinic for managing benign seborrhoeic warts. A double vet process has been adopted, to provide added governance for this model. Patients identified at photovetting with a classic seborrhoeic wart receive a copy of a standardised letter with the diagnosis which is sent to GPs within a week of vetting and signposting them to the BAD website (www.bad.org.uk). GPs are offered the caveat to re-refer if there are any ongoing concerns. This model provides rapid reassurance for GPs and patients, and provides an educational resource for GPs as the referral will be fresh in their minds. It promotes the tenets of Realistic Medicine and Modernising Outpatients. GP and patient feedback is in progress, and audit is ongoing.
- Straight to Surgeon – a new pathway which allows patients with large skin
tumours to be redirected at phototriage to Plastic Surgery, without the need for a clinic visit to Dermatology. This allows a more rapid patient journey and supports Getting It Right First Time (GIRFT) models. Audit is currently ongoing.
Expansion of the teledermatology service to include referrals for all lesions and not just skin cancer will allow better use of resources and provide opportunities for expanding the e-clinic for other diagnoses in the future.
- S Mehrtens and S. Halpern. Changing use and attitudes towards teledermatology in the UK over 10 years: results of the 2016 national survey. BJD 2017 (suppl. 1), 177. 185-189.
- Quality standards for teledermatology : using 'store and forward' images. BAD 2013
- C Edwards and C Macedo. A pilot study to investigate the potential for teledermatology triage of 2 week wait new skin cancer referrals at Chelsea and Westminster Hospital. BJD 2017 (suppl. 1), 177. 185-189.
- Tan E, Yung A, Jameson M et al. Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial). Br J Dermatol 2010; 162(4):803-11.
Just received news of a newly-released Dermatology Resource for those working in Primary Care.
The RCGP and Primary Care Dermatology Society (PCDS) have collaborated to produce a very user-friendly electronic resource, available at https://www.rcgp.org.uk/dermatologytoolkit.
This has links to summaries about how to start using Dermoscopy and how to ensure a mobile device used for taking Dermoscopic and other clinical pictures is compliant with data protection and security guidelines.
It also links in to various other high quality resources such as the PCDS Diagnostic Tables for skin conditions, where the starting point is symptoms and presentation, rather than a diagnosis- very helpful for the non-specialist. Links to Dermatology Patient Leaflets and advice about how to apply treatments are there too.
Worth checking out.
Chronic venous insufficiency (CVI) affects between 20% and 40% of the adult population. Venous leg ulcers (VLU) are chronic wounds, caused by venous insufficiency and are the most common type of leg ulcer, affecting around 1% of the population and 3% of people over 80 years. The main risk factors for VLUs include family history, deep venous thrombosis, age and obesity. Specific groups affected by VLU include:
- People with reduced mobility
- Multiple co-morbidities e.g. obesity, diabetes
- People who inject drugs (PWID)
- Homeless/Chaotic lifestyles
VLU most often occur in the gaiter region of the lower leg, from mid-calf to just below the ankle. A VLU is defined as an open lesion between the knee and the ankle joint that occurs in the presence of venous disease and takes more than two weeks to heal or occurs in someone with a previous history of venous leg ulceration.
It is estimated that 93% of VLUs will heal in 12 months and that 7% remain unhealed after five years. Repeated cycles of ulceration, healing and recurrence are common and recurrence rate within three months of healing can be as high as 70%.
In a recent study from the UK which included over 500 patients with VLU, it was noted that:
- Patients with a VLU were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians
- Up to 30% of all the VLUs may have been clinically infected at the time of presentation
- Only 22% of patients had an ankle brachial pressure index recorded in their records
- 53% of all VLUs healed within 12 months
- Mean time to healing was 3months
- 13% of patients were never prescribed any recognised compression system and 78% of their wounds healed
- In comparison 87% of patients were prescribed arecognised compression system and 52% of their wounds healed.
- The VLU healing rate was lower in patients with a putative infection, and the mean time to healing was longer. Furthermore, the cost of wound management of an uninfected VLU was at least 69% less than that of a wound with a putative infection
Assessment and Treatment
NICE and International guidelines agree that all patients with a wound on the lower leg should have a holistic assessment, including Doppler APBI, to assess arterial supply. Once the assessment is complete the decision will be made dependent of findings:
- If the limb has poor arterial supply, e.g. ABPI below 0.8 or above 1; the patient will be referred to vascular surgeons for full assessment for suitability for surgery.
- If there is sufficient arterial supply, e.g. ABPI between 0.8 and 1.3; then ‘Gold Standard’ treatment of full compression therapy can be prescribed.
- Ulcers with ‘mixed’ aetiology, e.g. ABPI between 0.6 and 0.8 and increased pain; will require referral to vascular for assessment but may be suitable for modified compression.
Compression therapy aims to support venous return and prevent the build-up of fluid and toxins in the tissues to support wound healing. Compression therapy can be provided by multi-layer bandage kits, hosiery kits or stockings or compression wraps. Most systems cover the foot but provide a graduated compression from ankle to below the knee.
As well as assessment for the appropriate compression therapy system there needs to be:
- Assessment and maintenance of skin condition of the leg
- Assessment of oedema
- Wound (ulcer) assessment
- Wound bed preparation. Wound bed preparation may involve removing devitalised tissue and reducing bacterial biofilms to support healing.
- Appropriate dressing to protect the wound bed and manage the level of exudate is required. Exudate levels should reduce once compression therapy starts and the venous return is improved.
- Once healed then long term prevention in the form of compression hosiery is required to prevent the risk of recurrence.
If a patient is not suitable for compression therapy or is non-concordant with treatment then long term management may be the aim of treatment rather than healing.
Experience of patients with Leg ulcers
Patient’s experience a range of concerns related to VLU these include painful, wet, malodorous wounds. They are often distressing and have a considerable impact on quality of life. What matters most to people with ulcers is complete wound healing.
The challenges of patients not having access to correct assessment and management leads to sub optimal care. This can be due to a long wait for assessment with a risk of deterioration of the ulcer leading to a longer time to healing and increased risk of cellulitis and/or sepsis.
VLUs have been found to have a significant impact on patients’ quality of life, with associated personal, social and psychological effects; this also has a considerable financial impact on healthcare providers, as well as a wider social and economic impact.
Resources and costs including Community Nursing
Across the UK it is estimated that total costs to the NHS for VLU is up to £600 million per year. One study showed that the mean NHS cost of wound care over 12months was an estimated £7600 per VLU, with the cost of managing an unhealed VLU being 4⋅5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU, 2015-16 prices)
Patients with CVI account for between 35-65% of District Nursing caseloads, those who require management of VLU, account for 61-64% of costs of community nursing visits. These include the wound (ulcer) dressings required as well as the compression therapy systems.
Patients with long term leg ulceration are more likely to develop cellulitis and require hospital admissions for IV antibiotics adding to the hidden costs of care related to VLU.
The burden of CVI is likely to increase with changing demographics, with a growing number of people with VLU. The main challenges are around:
- Lack of awareness by general public about prevention e.g. Legs Matter campaign www.legsmatter.org
- Lack of skilled community staff to undertake first line Doppler ABPI assessment and start compression therapy
- Long waiting times for referral to Vascular for full assessment for surgery or other treatments
- Long waiting times for referral to Dermatology for leg ulcer patch testing for allergies/sensitivities
- Variation in care provided from one area to another.
- Non-healing wounds due to underlying co-morbidities
- Non-concordance of patients with compression bandages or therapies
- Lack of follow up to prevent recurrence of VLU
Gold Standard Service for VLU
A ‘Gold Standard’ service for prevention and management of VLU would include:
1stline- General nurses (hospital/community) trained to assess VLU and start treatment of those which fit the criteria for full compression, normal limb shape and no challenges. Also referral to Vascular to assess for surgical intervention to improve healing rates.
2ndLine- Centralised Leg Ulcer or Lower limb Service for each Health Board - run by Clinical Nurse Specialist plus registered nurse(s) to assess and manage more complex VLU or those not suitable for compression and/or redirect to other services dependent on needs. For example linking directly to Lymphoedema services, Vascular surgery, Dermatology and Diabetic clinics.
3rdline- Leg Clubs in each locality/area to support prevention of VLU and maintenance of healed ulcer.
There is a clear need for evidence-based strategies and services to prevent and treat VLUs. Educating health care workers and developing their skills and competencies is essential with centralised services and local support groups to maintain and prevent long term problems.
Author: Ruth Ropper, Lead Nurse Tissue Viability, NHS Lothian, Oct 2019
- Dr. Alison Coull, Nursing Dept. Napier University
- Janice Bianchi, Medical Education Specialist/Honorary Lecturer, Glasgow University.