Teledermatology and e-Referral Service advice and guidance

The triage service was set up in collaboration with the local clinical commissioning groups (CCGs). All GP practices were provided with dermoscopes and equipment to take photos (funded by a local cancer charity) and GPs were invited to attend training sessions on use of the equipment and how to take good images.

Situation

At the point the services were set up, York Teaching Hospital NHS Foundation Trust was carrying three whole time equivalent consultant vacancies. The hope was that diagnosing patients by teledermatology would support a reduction in the number of patients needing to attend clinic for a face-to-face consultation. Whilst the two-week wait conversion figures in York have always been comparable to national figures (10-12%) it was also hoped that this could be improved. Local audits suggest that 60-70% of patients sent for an advice and guidance opinion (for all diagnoses) are able to be managed (at least initially) without a face to-face consultation.

Aspiration

That the majority of secondary care referrals have been reviewed remotely prior to being seen in clinic. This would allow preliminary treatments to be offered to patients pending review in clinic and to track changes in skin lesions / rashes, from photos taken at referral with those seen in clinic.

Solution and impact

Since April 2016, several teledermatology-based innovations have been introduced to the service. These include teledermatology triage for both two-week wait and general referrals and also integration of e-Referral Service (e-RS) advice and guidance into the Trust database system to allow a rapid advice service. The triage service was set up in collaboration with the local CCGs. All GP practices were provided with dermatoscopes and equipment to take photos (funded by a local cancer charity) and GPs were invited to attend training sessions on use of the equipment and how to take good images.

All referrals were reviewed by a consultant dermatologist with options to offer diagnosis and advice based on images or to arrange face-to-face appointments (either as two-week wait or downgraded) in either dermatology or straight to a surgical clinic. Based on the improved image quality the two-week wait clock can be stopped at the point of triage if a diagnosis is possible at this stage.

The teledermatology advice and guidance service has gradually increased in popularity with GP colleagues. Referrals are made through e-RS advice and guidance but then uploaded to thelocal core patient database which allows easy cross-referencing to previous letters, images and results and allows requests and responses to be accessed easily at a later date. Many GPs in the area now choose to send patients through initial advice and guidance prior to referral. More than 6,000 cases of teledermatology advice and guidance were given by the department in 2018 (usually 120-150 a week).

Functionality

The NHS e-Referral Service (e-RS) advice and guidance function allows a clinician (eg GP) to seek advice from another (eg consultant) before, or instead of, making a referral
If, as part of the advice, the specialist provider recommends referral, then the decision and responsibility to refer remains with the GP
New e-RS functionality in 2021 will allow providers to directly convert an A&G request into a referral if the GP has given pre-authorization
Advice and guidance should run in parallel with referral services and is recommended to supplement, but not replace, referral services
Enabling access to specialist opinion helps GPs or other referrers to manage patients in the community and avoids unnecessary referrals

Capabilities

Provide digital communication between two clinicians
Ask another clinician or specialist for their advice on a treatment plan and/or the ongoing management of a patient
Clarification (or advice) regarding a patient’s test results
Seek advice on the appropriateness of a referral for their patient (eg whether to refer, or what the most appropriate alternative care pathway might be)
Identify the most clinically appropriate service to which to refer a patient

Scope

The referrer can attach documents to the advice request, which may include diagnostic results, clinical photos, scanned images or previous correspondence relating to the patient
The provider is then able to review the request (along with any attachments) and respond to the query, adding their own attachments, if required. These attachments could include a proposed treatment plan or links to external documents and websites
The referrer is able to convert the advice request into a referral or appointment request, linking the advice information (and any attachments) to the referral. This ensures that the receiving provider has all the relevant referral information and negates the need for a new referral being created
NHS e‐RS is available to all GPs, dermatologists and hospital trusts in England, with no set‐up costs, providing the potential to rapidly and cost‐effectively reduce face‐to‐face referrals and provide care closer to home

Key figures/quotes

Prior to the introduction of two-week wait triage, department audits all gave conversion rate figures of 10-12%. Since this service has been introduced, conversion rates have been between 15.5% and 17%. Around 10% of two-week wait referrals are diagnosed without a clinic appointment. Whilst this is relatively low, many patients are now initially sent via the advice and guidance service and therefore two-week wait has been recommended for many by the team. Many patients therefore do not reach the point of referral. There are plans to integrate the arms of the teledermatology service more fully so that all patients are initially sent via the advice and guidance route which would then allow more appropriate direct booking for an appointment, investigations or treatment if required.

Find out more

Download the case study from the British Association of Dermatologists outpatient case studies paper (pg 14) (PDF, 315KB)

Elective Care Community of Practice. This platform hosts tools and resources to support local health systems implement advice and guidance services. To request access to this, please email ECDC-manager@future.nhs.uk.

Additional resource:

Elective care transformation programme

Advice and guidance toolkit for the NHS e-Referral service

Key contact

Dr Kathryn Thomson, York Teaching Hospital NHS Foundation Trust: Kathryn.Thomson@york.nhs.uk

Disclaimer

Any virtual teledermatology 2 week wait pathway will require:

the use of high-quality macroscopic and dermoscopic images as the ‘reasonable diagnostics’ required to exclude cancer
a triage outcome that permits the specialist clinician to request to see the patient face-to-face if required
the facility to communicate directly with the patient and their GP

Outcomes from the virtual teledermatology 2 week wait pathway

The clock can be stopped in 2 ways:

if the macroscopic and dermoscopic images are taken by a member of the specialist dermatology team (for example, a medical photographer or a nurse), this counts as ‘1st diagnostic test’ so the clock can be stopped at the time the image is taken
if the images are taken by the primary care team or in a primary care-led community hub and then reviewed by the specialist, the clock stops when ‘an appropriate member of the specialist team’ contacts the patient by telephone, video or face-to-face consultation. Determining who is ‘an appropriate member of the specialist team’ is a decision for the specialist department who have the overall clinical accountability or responsibility for this part of the pathway

For more information, read the guidance: suspected skin cancer 2 week wait pathway optimisation on the Dermatology Future NHS site.

Please note the full legal disclaimer - NHSX playbook disclaimer