Dermatology pilots. Ram Patel GPwSI Dermatology Gateway lead for Dermatology.

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1 Dermatology pilots Ram Patel GPwSI Dermatology Gateway lead for Dermatology

2 Assessing needs Extent of skin disease: Study of 1500 people age 15 years and over 54% reported a skin condition 14% seek advice from GP (rest self manage or see pharmacist) Around 24% of the population consult their GP with a skin problem per annum 94% of these managed in primary care 6% referred to secondary care

3 Basal Cell Carcinomas Review of Rushcliffe 2WW BCC referrals 29 to 44% were cancer. BCCs are slow growing tumours and very rarely metastasize. BCCs are excluded from the 2WW targets nationally Variance in Principia practices is 0.8 to 10.9 per 1000 patients. The low referrers are as worrying as the high referrers. The burden of skin cancer, especially Non-melanoma Skin Cancer (NMSC) is rising and is expected to do so for the next decade. Rushcliffe has a higher incidence of melanoma

4 Aims of training/pilot Raise GP skills in member practices to: Improve confidence in diagnosing BCC and benign lesions Reduce referral of benign lesions via 2WW BCC pathway Pick up BCCs early, thereby improving outcome Pick up other skin cancers early Reducing long term risk of all skin cancers by preventive advice and promoting sun protection

5 Pilot Train at least one GP from each practice in Rushcliffe Each practice provided with dermatoscope and dermoscopy guide Initial lecture to GPs wanting training All 2WW BCC referrals sent to triage clinic Each GP attended 3 clinics for practical training Training focused on assessment of skin lesions and use of dermoscopy Follow up lecture and support GPs to triage 2WW BCC referrals in their practice Audit

6 Dermoscopy

7 Costs The cost of the training was 39,408. Included: purchasing dermatoscopes and supporting text books for 18 surgeries 33 training clinics, and the associated administration 2 training events. These costs are non-recurrent and were met through a Transformational Fund investment.

8 Outcome of clinic 247 patients seen 135 referred on via skin cancer pathway 99 via BCC pathway 36 via SCC/Melanoma 43 referred to community GPwSI clinic Biopsy or follow up Treatment of actinic keratosis, Bowen s 69 Discharged back to GP

9 Of the 139 referred to 2WW cancer pathway: 108 have known outcome 73 (68%) confirmed BCC 13 (12%) other skin cancer 22 (20%) had actinic keratosis/bowen s or benign Of the patients discharged back to GP only one on subsequent follow has developed a skin cancer in a different part of the body!

10 Patient survey Patient satisfaction was high 95 patient survey returns Overall opinion of service: 76 excellent and 17 good 86 very likely to recommend service to friends and family

11 GP survey 100% of GPs felt it was worth their time invested in attending the training 100% feel more confident in diagnosing BCC 95% more confident in diagnosing benign lesions. 80% of GPs were confident to start triaging in their own practice

12 Pre Training: Audit of BCC referrals Pre and post training 44% of referrals confirmed skin cancer 35% discharged with no biopsy or excision Comparison of practices who have submitted post training figures: Confirmed skin cancer 54% pre and 52% post No biopsy or excision: 29% pre and 14% post

13 Dermatology Advice Pilot GPs asked to or text me for advice before referral preferably with photos 35 referrals Outcome: 23 completed as advice 6 triaged to community dermatology clinic 3 triaged to secondary care clinic 2 triaged to paediatric dermatology 1 triaged to 2WW melanoma pathway

14 Teledermatology Visual education for GPs Establish closer links between GP and secondary care Models of care includes: Triaging to direct patients to appropriate service Alternative to face to face Hybrid of above Factors that may affect cost effectiveness: cost of equipment GP time nurse cost double charging

15 Conclusion Triage of skin cancer referrals is cost effective and can be achieved with no added risk to the patient GP feedback supports clinic based training Upskilling GPs will raise standard of care of patients presenting with skin problems and reduce referrals Support through teledermatology can be cost effective and educational for referring GP

16 Recommendations Consider triage of all 2WW BCC referrals Consider community BCC excision service Explore Teledermatology Teaching clinics Community based integrated dermatology based service