Summary
The Aneurin Bevan University Health Board (ABUHB) teledermoscopy service was established by dermatology consultant, Dr Caroline Mills, 10 years ago and has grown into an exemplary service. Eleven clinical photographers hold 16 teledermoscopy clinics at six hubs across the region per week. High quality dermatoscopic photographs are reviewed by consultants with 24 patients’ photographs seen per session. A total of 7,435 patients used this pathway in 2022 and more than 43,000 have used it over the last 10 years. A 2019 review showed 86.3% of patients were steered away from an initial face-to-face clinic appointment using this model and waiting lists have been significantly reduced.
Method
Skin lesion referrals comprise more than 60% of the ABUHB dermatology workload. More than half of these are urgent suspected cancer (USC) referrals. The vast majority of these (around 80%) are either benign or non-urgent. This huge demand adds significant strain on capacity and impacts negatively on waiting times. The goals were to reduce referral waiting times, prioritise high-risk skin cancers with hospital clinics and reduce patient travel, while providing an accurate diagnostic service. Planning involved working closely with clinical photographers and local GPs. GPs from sites across the region were trained to remove small, low-risk lesions. These lesions, identified via the teledermoscopy photographs, were referred directly to the GPs for removal within primary care, close to patients’ homes (local enhanced service). Triaged referrals were sent electronically to the medical illustration team through the patient administration system (PAS) and the patients were booked in to a teledermoscopy clinic. Macroscopic images of anatomical site and detailed dermoscopic photographs were taken using an Opticlar 8DS dermatoscope attached to a Nikon D300s/D7000 camera body. Further kit at all the sites included Bowens 500 DX flash heads with wafer soft boxes as back lights and softlite reflector dishes. Referral waiting times and number of patients needing to subsequently attend hospital were recorded and measured. Diagnostic accuracy, based on histology, was logged by individual clinicians.
Results
The teledermoscopy service meant patients were diagnosed and triaged effectively. A study by the team, published in 2021, showed that 53% of all lesion referrals could be discharged without an outpatient appointment. This meant these appointments could be offered to patients with clinical need. Further positive impacts of this service included: medical photography hubs, located across the health board region, allowed patients to be seen closer to home, avoiding unnecessary travel and minimising carbon footprint; providing a remote diagnostic service enabled better use of hospital appointments; patients were seen more quickly and skin cancers were identified sooner; robust management of patient pathways, allowing patients to be booked directly for minor surgery or referred to other specialities; the service met Welsh Government recommendations for virtual clinics, plus it improved dermoscopy and teledermatology teaching for registrars.
Sustainability and Spread
This year the service has been introduced at an ‘All Wales’ level, allowing colleagues across Wales to access to the same level of quality images and teledermatology clinics, helping to free up budgets and bring down waiting lists. Only one board in the north is yet to activate this. In the ABUHB, the photography department has commenced services in the maxillofacial and ear, nose and throat departments, working alongside the new model in the same way. The Telelid programme, launched in 2016, that looks at growths on eyelids, is already experienced in delivering ophthalmological services. The team is passionate that this is the approach for many diagnoses with a visual element and believes the service can be extrapolated to other specialities easily.
