Summary
Since 2014 the Isle of Wight has had a fully integrated dermatology service, incorporating Tiers 2 and 3 seamlessly. The Lighthouse Clinic service provides community and secondary NHS care to island residents, reducing the need to travel to the mainland for specialist care. The service is run efficiently and is a national leader with its innovative ways of delivering care. There are two visiting locum consultants supervising a close team of experienced GPwSIs, ANPs and HCAs. The clinical work is run hand in hand with a small, efficient administrative team, with the backing of collaborative contracting with the local NHS trust and CCG.
Method
Both of the Lighthouse Clinic’s consultant dermatologists are visiting sessional doctors who work alongside the very experienced GPwSIs and ANPs. The clinics are co-run, including working from one shared list, with each member taking the appropriate patients and using the consultant or GPwSI next door for advice and collaborative support, as needed. During the pandemic, face-to-face two-week wait (2WW) cancer assessments were maintained, even when the consultants were self-isolating, thanks to the teledermatology system. This allowed the ANPs to take real-time images, including dermatoscopic ones, and share them securely to the mainland, where the consultant was able to direct biopsy, or other action, as necessary. High performance on the NHS targets was maintained throughout the pandemic thanks to careful clinic setups and the willingness of the small team to work in new ways to provide care.
Results
The ‘small and beautifully formed’ team supports greater flexibility in clinic types and enables rapid change in response to evolving demands. Most of the administrative staff are dual trained to be able to assist the clinicians as chaperones and minor surgical procedure assistants. This has been a huge help in enabling clinics to continue when members of the workforce had to stay away because of COVID-19. Good communication between administrative and clinical staff enables the best outcomes for patients, with queries being dealt with promptly and clinic slots kept filled. Waiting times for all types of appointment are consistently among the best in the country, leading to very low levels of urgent referrals. The Teledermatology Assessment Service runs a combined routine and 2WW lesion pathway, where patients’ images are taken in primary care and booked directly to biopsy, face-to-face appointment, or have reassurance information provided. Efficient use of personnel and clinic variability delivers reduced waiting times for new referrals and simple, patient-initiated follow up (PIFU) improves access to help for long-term skin conditions. PIFU has been in place for years with routine and urgent pathways. This gives more control to the patient and frees appointments for new patients to be seen sooner. Patients are empowered to choose telephone/video or a face-to-face contact if they feel their condition needs to be re-examined. This provides options that reduce travel time and time off work. Over 60% of referrals are for skin cancer and 25% of biopsies are done as a ‘one stop’. The Teledermatology Assessment Service commenced just prior to the pandemic and is a game-changer for delivering this aspect of care. Over 50% of referrals are reassured directly, with the remainder being booked straight in for biopsy or face-to-face assessment.
Sustainability and Spread
There are few integrated dermatology units in the UK and, hearing from patients and seeing how bigger units have struggled with service delivery through the pandemic, there is a lot to be learned from the flexible, small team working practices of the Lighthouse Clinic. The team has presented its model of PIFU during a national webinar for the National Outpatient Transformation Programme. It also features on the NHSX Digital Playbook under the cancer section as a new model of delivering skin cancer care. The Teledermatology service has featured on BBC South and in Building Better Healthcare, Health Europa, Pulse, Digital Health, HSJ, as well as on local press and radio. Integrated care units show how effective a close relationship between the two tiers of care can be, enabling high quality and responsive care for patients close to their homes.
