Commissioning and Delivering Dermatology (and surgical) Services
Overview
The gold standard of care is for patients to be seen within agreed time frames, by the most appropriate health professional, and ideally in a local setting. When developing / reconfiguring a service it is important to note that there is no single dermatology model that works best across all localities.
This page provides an insight into referral pathways, and should be read in conjunction with the section on referral guidance and the case studies of service models.
The most recent guidance from NHS England includes:
Lateral thinking - skin services, not just dermatology
Patient with skin conditions are managed by a large array of health professionals including:
Pharmacists
GPs, practice nurses, district nurses and tissue viability teams, health visitors (eczema), and podiatrists
GPwERs in Dermatology and Skin Lesion Management (including skin surgery)
Consultants - Dermatologists, Plastics Surgeons, Oncologists, others (eg some cases of skin cancer are managed by Ophthalmologists and Oral & Maxillofacial surgeons)
Understanding different levels of care
While referral pathways can help join up different levels of care provision, they will need to include consultant-led services to help manage the more complex skin conditions
Numbers of new patients seen in clinic, new to follow-up ratio, and outcomes (eg complete BCC excision rates) need to take in to consideration that Secondary Care work is likely to have a more complex case-load than Primary and Intermediate Care
The difference between GPs performing skin (minor) surgery under contracts such as DES/LES, and GPs with Extended Roles (GPwERs):
GPs providing surgical services - manage benign skin lesions and small low-risk BCC beneath the clavicle. They are first and foremost surgical services. GPs would be expected to have an understanding of lesion recognition appropriate to their surgical remit but they have not undertaken specialist training and competency based assessment in skin lesion recognition and management. In essence, skin surgery services such as DES or LES only cover clinical remits that are within the normal scope of General Practice; as such the RCGP does not consider that such roles warrant extended role accreditation. It remains good practice to make certain that the premises used are fit for purpose, and that the GP has their surgical competencies assessed (for example using a Direct Observation of Practical Procedure assessment tool) and periodically reviews their quality of their care
GPwERs – work as an integrated team with commissioned secondary care services. GPwERs have undertaken formal specialist training and assessment in the diagnosis (clinical and dermoscopic) of skin lesions, enabling the GPwER to be commissioned to provide skin lesion clinics (excluding 2-week waits). Groups 2 and 3 GPwER can also provide surgical services with a wider remit, which may include certain BCC on the head and neck (refer to Annex C in the 2018 RCGP framework Guidance and Competencies for GPwER – Dermatology and Skin Surgery). The remit described is broad and so formal accreditation is required
Integrated, mapped care
It is important to bring together the different providers of 'skin care' in order to ascertain which individuals/groups are best equipped to deliver different aspects of care - such discussions are often best instigated through Primary Care commissioning groups. Once established, referral pathways can then be mapped out. One provider group should not control the overall process as this increases the potential for conflict of interests
Skin lesions can be used as one clear example as to how referral pathways can best be mapped:
Lesion diagnosis is best done through health professionals experienced in dermoscopy, resulting in fewer unnecessary excisions, less patient anxiety, fewer scars and considerable costs savings
For those patients requiring skin surgery, this is best done by health professionals able to demonstrate good outcomes in terms of high rates of complete excisions and cosmetic outcomes
Which practices are high referrers? look at education to address such matters
If needed, audit can help establish facts
Exclusions - low-priority framework
Mechanisms should be put in place for making sure that cosmetic / other skin lesions not suitable for treatment on the NHS do not get through the net - this should be built into agreed referrals pathways
Teledermatology (including teledermoscopy)
Should not be regarded as the solution, rather to complement the delivery of care
Teledermatology can be for skin lesions (teledermoscopy) and/or medical dermatology (rashes and so forth)
One model of teledermatology does not fit all localities, the proportion of teledermatology used locally ranges from:
Advice and guidance
Diagnostic only
Diagnosis and management;
In some localities all referrals have to be submitted with an image
There are several reasons as to why teledermatology is not on its own the solution:
Clear evidence that lowering the threshold for referral increases referral rates (paper as per link) - this makes common sense in that if a Primary Care health professional can get a specialist opinion in a matter of days as opposed to waiting weeks / months, then they are less likely to tackle the problem themselves, and instead refer, resulting in increased referrals and de-skilling
If a Primary Care health professional is confident the patient needs to be seen in clinic, then imaging all such patients is likely to be time consuming - in any case the gold standard of care for such patients is a face to face clinic appointment
Whichever level of teledermatology is used, it must be aligned with effective care pathways, good clinical services and appropriately targeted education
The attached teledermatology roadmap sets out what systems can do now to optimise teledermatology triage and advice and guidance to support the delivery of integrated dermatology services.
The following links have been developed to support patients and Primary Care with teledermatology as part of the Dermatology National Outpatients Transformation Programme. The videos are available on the NHSE/I you tube account and the patient video is also being hosted as part of the National Health and Care video library, alongside other health-related videos. All the videos have British Sign Language equivalent videos and captions (click on the captions button to turn them on/off – it’s the little box with a “CC” on the bottom right) :
Getting patients into the correct level of care can be aided by properly targeted education - not only of clinical matters but also of care pathways and signposting to educational resources.
Perhaps the two biggest areas to focus on are self-care and Primary Care, which are the most cost-effective, and where the majority of patients receive their dermatology/skin care
The main barrier in Primary Care is the lack of dermatology education - there is a huge mismatch given that some 30% of GP consultations contain some element of skin, while most medical students receive only six days of dermatology education, and most GPs have limited exposure to dermatology training beyond this time
This mismatch results can result in:
Substandard diagnostics with multiple visits to different practitioners with the same problem, and/or delayed diagnosis of potentially life-threatening skin conditions
Substandard treatment
High levels of unnecessary referrals, be this face-to-face appointments or teledermatology
Much can be done to address the educational needs of Primary Care:
Communicate to all Primary Care health professionals (including GP training schemes), pharmacists and other allied health care professionals the benefits of the diagnostic tools, concise management guidance and A-Z chapters on this website
Use time out sessions to teach larger numbers of Primary Care health professionals on common skin conditions (eg acne, eczema, actinic keratoses), and discuss local care pathways
Have a local skin club to upskill one GP / practice nurse either per practice or PCN (using that individual as a magnet for skin conditions). Such upskilling could also include dermoscopy, especially for those lesions that result in high referrals and don't require too much upskilling eg seborrhoeic keratoses, dermatofibromas and angiomas
Use local specialists (consultants and GPwERs) to help deliver local education, which should form part of the provider contract
Ultimately, more patients managed effectively in the bottom two tiers of the pyramid results in more cost-effective care
The PCDS provides 30 educational meetings across the UK per year on a wide range of dermatology subjects aimed at Primary Care health professionals
Submit your models of care with images of where you work - please email all such information to pcds@pcds.org.uk using the attached template, checking for grammar, as we won't be doing this for you
Other resources
General guidance
Several sites provide general guidance on commissioning:
