Transformation Directorate

Teledermatology using e-Referral Service Advice and Guidance (e-RS A&G) at the Royal Devon and Exeter Hospital

The Royal Devon and Exeter Foundation Trust provides integrated health and care services to around 450,000 people in Exeter and across East and Mid-Devon.

The Exeter dermatology department provides a wide variety of services.

This includes:

  • teledermatology Advice and Guidance (A&G) provided remotely to GPs
  • outpatient clinics
  • skin surgery
  • phototherapy


Increasing referral volumes to the dermatology outpatient clinic and long waiting times for routine outpatient review.


Using e-RS A&G to make the most of clinic capacity and digitally provide specialist care where appropriate.

Solution and impact

The department has been providing a teledermatology A&G service since 2011 using the e-RS.

The service received approximately 150 A&G requests a month prior to the COVID-19 pandemic, but has been receiving 250 to 300 requests a month since June 2020.

Six consultants provide the teledermatology service; each provides A&G on one day a week and has allocated time in their job plan. All reporting consultants have been allocated a Trust laptop to allow remote access. A&G requests are responded to within two working days (most within 24 hours). The teledermatology service accepts A&G requests for all skin conditions in adults and children with the exception of pigmented lesions and two-week-wait requests. The majority of A&G requests relate to inflammatory skin disease and pre-cancerous skin lesions.

A&G provides a valuable educational teledermatology image bank for teaching healthcare professionals. The department provides a parallel e-RS Referral Assessment Service (RAS), allowing referred patients to be triaged to the correct subspecialty clinic (phone, video or face-to-face), or direct to surgery with a pre-operative phone consultation.

Since February 2021, e-RS A&G enhancements have allowed consultants to convert A&G requests to referrals where appropriate (if authorised by the referring GP). This has streamlined patient care.

Interim advice can be given to the GP to support patients on the waiting list before their outpatient appointment. This is a significant advantage over the Referral Assessment Service (RAS) functionality.


Mobilisation of the teledermatology A&G service has followed the principles of the NHS A&G toolkit. Wider roll-out of A&G across other specialities (including cardiology, gastroenterology, neurology, endocrinology and gynaecology) formed a key workstream for the Trust in April 2018/19 following the national CQUIN for A&G.

The Consultant Connect PhotoSAF app has been commissioned across Devon to allow primary care clinicians to use their own smartphones as secure cameras to photograph and upload patient images to e-RS.

Dermatoscopes with mobile phone attachments have been supplied to all GP practices since the start of the pandemic. Dermoscopic images can be attached to A&G requests and referrals alongside macroscopic images.

Teledermatology A&G provides secure, rapid, two-way digital communication between GPs and the dermatology team, and provides a safety net for patient care during COVID-19 recovery. The Trust and clinical commissioning group (CCG) collect monthly data on:

  • the number of A&G requests from each GP practice and in total
  • the number of A&G responses from each clinician and in total
  • the number of patients seen in the dermatology department for a face-to-face consultation within six months of their A&G
  • the conversion to referral percentage for each clinician

A&G teledermatology has:

  • reduced unnecessary hospital outpatient referrals (<20% of A&G requests result in the patient being referred to outpatients within six months of their A&G)
  • helped ensure that patients requiring face-to-face appointments are seen in the right place at the right time by the right person
  • improved communication and education between primary and secondary care

Main barriers to change

To encourage GP engagement the CCG allocated a senior information analyst from an existing primary care commissioning role to visit local GP practices that required additional support to start using the A&G facility of e-RS (this support is now available via the A&G national toolkit).

A&G usage among GP practices varies according to the availability of digital technology and their willingness to use it. Before the release of the Consultant Connect photoSAF app, rapid access to cameras was a barrier for GPs.

New application programming interfaces will support future integration of e-RS A&G and RAS in the electronic patient record.


  • Allows a clinician (such as a GP) to seek advice from another (such as a consultant) before, or instead of, making a referral
  • New e-RS functionality in 2021 allows providers to directly convert an A&G request into a referral if the GP has given pre-authorization
  • Enabling access to specialist opinion helps GPs or other referrers to manage patients in the community and avoid unnecessary referrals


  • Provide digital communication between two clinicians
  • Ask other clinicians or specialists for their advice on a treatment plan and/or ongoing patient management
  • Gain clarification or advice regarding a patient’s test results
  • Seek advice on the appropriateness of a referral for their patient (for example, whether to refer, or what alternative care pathways exist)
  • Identify the most clinically appropriate service into which to refer a patient


  • A referrer can send advice requests and attach documents such as diagnostic results, clinical photos, scanned images or previous correspondence relating to the patient
  • A provider is then able to review the request and its attachments before responding to the query, with more attachments of their own. These attachments could include a proposed treatment plan or links to external documents and websites
  • The referrer or provider 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 eliminates the need for a new referral to be 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 and quotes 

The service received approximately 150 A&G requests a month prior to the COVID-19 pandemic, but has been receiving 250 to 300 requests a month since June 2020.

Find out more

Find out more on the Consultant Connect PhotoSAF app website

The Future NHS Outpatient Transformation Platform has a range of tools and resources. These help to support local health systems and increase utilisation of services that provide specialist advice like those enabled through e-RS A&G

Additional resources

Elective Care Transformation Programme

Future NHS Outpatient Transformation platform  

Advice and guidance toolkit for the NHS e-Referral Service

Key contact

Dr Carolyn Charman, Consultant Dermatologist, Clinical Advisor for NHSX and e-Referral Service