Summary
Around 24% of the population attend their GP for a skin complaint in a year, which generates around 1.3 million referrals for England and Wales, including 500,000 higher risk 2WW cancer cases with low cancer diagnosed conversion (8-12%). Many of these cases can be reassured and discharged, or dealt with in primary care with advice and guidance. Higher priority cases need to be identified and escalated. Teledermatology offers this opportunity, but it also has its limitations. A teledermatology service was in place at a medium sized CCG, but ScreenCancerDermoSight recognised its limitations and wanted to improve it.
Method
There was dissatisfaction with the national electronic referral system (eRS) that was being used so an alternative was sought. The main issues were: inconsistent quality of images, with significant rejection of cases; multiple steps/a lot of time required in recording then uploading photographs, consent and history, plus downloading and saving basic reports;
variations in kit used across different sites and replacement costs, plus limitations on reporting as the eRS relied on NHS-specific hardware and software, with consequent repeated extended periods of lost activity. Patients were consulted at the start and GPs and practice staff were engaged without pressure during conversion to the new system. The six-month pilot was extended as COVID-19 limited the trial. By the end of the pilot, surgeries requested to join/remain on the new system rather than reverting. The goal was to assess ease of implementation and use, the stability of the system, and track patient outcomes. A pilot was proposed during 2020 but the pandemic meant face-to-face appointments were paused and teledermatology was suspended. With the easing of restrictions a single site introduced the system and further sites joined over time. The pilot has been continued as the ongoing active service. Sites feed back to the historic CCG lead and no service concerns have been expressed. A tracking and monitoring facility provides live activity and outcomes for assessment. Additional information cross-referenced to pathology is serially assessed as well.
Results
Results were compiled in late 2021. Over its 15 months of operation, 1,561 patients accessed the service, with 2,066 scans uploaded in total. Of these, 1,609 of the referrals were for lesion analysis and 457 were for opinions on skin conditions. Of the 2,066 scans, 74% required no referral and management advice was provided, and 88% of referrals were assessed as appropriate for management in the community. Only three submitted scans had to be rejected based on quality, lighting or perceived error/possible mismatch in the demographic information relating to the attached photographs. The previous system had a rejection rate of around 10% and several periods of downtime, sometimes lasting several weeks and impacting access and reporting. All submissions were assessed and returned within 72 hours. More recent data are available, but these have not been signed off since dissolution of the local CCGs. The percentage outcomes remain similar although the numbers approximately doubled between January 2021 and March 2022 (when this submission was prepared). Approximately 3,000 patients were assessed through the system across nine surgeries, about 2,500 patients were assessed for skin lesions (some multiple), and about 500 patients were assessed for skin disease.
Sustainability and Spread
Feedback is obtained directly from GPs and clinical staff communicating via the system or email. Patient feedback was planned via practice patient groups, but these were suspended because of the pandemic. No GPs reported any patient concerns, but the system is voluntary and patients may choose to wait and have a face-to-face consultation instead.
