Summary

The Strategic Planning and Performance Group, Department of Health NI dermatology photo triage e-referral pathway enables the capture and transfer of images alongside clinical information from primary and community care to dermatology teams in secondary care for patients with suspected skin cancer and urgent basal cell carcinoma (BCC). This pathway supports reform strategy by addressing waiting times, expanding capacity and capability in primary care, improving direct access between primary and secondary care and enabling secondary care to meet patient demand. It improves the accuracy of the e-triage process, maximising existing systems. The pathway was launched on the charity Action Cancer Big Bus in 2023.

Method

GPs and Action Cancer were given an iPod preloaded with the SMARTDERM app, enabling the safe capture and transfer of photographs. Dermatology teams were provided with both core clinical information and photographs to enable a clinical decision to be made within 72 hours at the point of triage. Patients were provided with advice or support, negating the need for a traditional outpatient appointment and enabling those who required plastics input to be referred directly to this team at the point of triage. Implementing the pathway on the Action Cancer Big Bus in 2023 was the first time a charitable organisation had had access to the GP clinical system to make a referral for patients in rural or hard-to-reach areas, further enhancing the care offered to patients with a suspected skin cancer diagnosis. There are over 50,000 dermatology referrals annually, half of which are for suspected skin cancer. Dermatology services face challenges from demand pressures, recruitment, retention, skill mix challenges and delivery of core capacity. Regional engagement was undertaken with stakeholders prior to implementation, and ongoing training support and engagement continues to ensure uptake. Regional expansion was implemented in December 2022 through a phased approach, with full implementation achieved in July 2023. An official launch was held in April 2023, with extensive engagement undertaken to raise awareness of the pathway. The goal is to reduce the need for traditional outpatient appointments, supporting the management of patients within primary care and enabling direct referral to plastics when required. The project was managed using PRINCE 2 methodology. A project initiation document and project plan were developed and approved by the Department of Health (DH). A communication and engagement plan included regional workshops, webinars and events held across Northern Ireland (NI). A regional dashboard was developed to capture referrals, triage times and outcomes, and monthly progress reports were produced and widely disseminated to the DH and cancer policy colleagues.

Results

An initial pilot of the pathway demonstrated that of those referred via the e-Referral pathway, 20% required an outpatient appointment, 43% required no appointment and were returned to their GP, 33% were booked straight to surgery and 4% required further specialist opinion. As of March 2024, almost 12,000 referrals had been made. A total of 94% of all GPs across NI had contracted to the pathway, with 82% of those actively referring. Almost 10% of referrals were downgraded following triage, 13% were discharged with advice back to their GP, and 5% were booked straight to surgery. The core project team engaged with primary and secondary care to enable collaborative working to improve image and referral quality, thus improving patient care and outcomes. Further work is ongoing to expand the app across dermatology and other specialities. Feedback is routinely collected from patients, GPs and secondary care teams through feedback surveys, plus on-site practice and trust visits.

Sustainability and Spread

Initially implemented as a Red Flag Suspect Cancer Pathway, the pathway has been expanded to the Action Cancer Big Bus and now includes referrals for suspected BCC. The photo triage programme team reviewed NI GP cancer referral guidance and revised it to enable all BCC referrals via photo triage to be prioritised as urgent, avoiding some of the longest wait times for dermatology. The pathway has been shared with Health Service Executive Ireland planning teams and NHS Forth Valley, who have adopted the pathway concept. The pathway has been expanded to all 316 GP practices and five Trusts across NI and has been endorsed by the NIGPC and Department of Health NI. Regional and national engagement has been undertaken by the programme team and the photo triage model was showcased at the Irish Association of Dermatology international conference in April 2024.