Dermatology Clinical Assessment and Treatment Service: NW Hertfordshire (St Albans, Harpenden and Hertsmere) Dr. Simon Dawe Consultant Dermatologist West Hertfordshire NHS trust Clinical Lead of CATS

CATS service Due to be decommissioned in Nov 2011 Patients to be repatriated to primary care Patients to be referred via secondary care Some clinics may continue in the community but under secondary care

What’s happening in secondary care 16% reduction in referrals in service level agreement estimated by PCT leading to reduced income (not evidence based) Decommisioning of CATS for providing accessibility and low waiting times for patients Probable redundancies and reduced working hours Training Gp’s and provision of educational clinics unlikely Restructuring of our service Likelihood of increased waiting times

How to reduce referrals?

I Don’t Know ??

How Could you do it Restrict the type of referrals Provide services in the community that might reduce the need of onward referral Better diagnosis and management the role of education? New technology? Use alternative services Private healthcare e.t.c

What are you up against BCC is the commonest type of cancer in the UK, with an average of 48,000 new cases registered each year in England between 2004 and 2006 (Some figures nearer 100,000) The incidence of BCC is rising annual percentage increase of 1.4% for males and 1.9% for females between 1992 and 2003 The rise in incidence is predicted to be particularly great up to 2030 because of the large increase in the elderly population that will arise as the ‘baby boom’ population ages Studies from Scotland suggest that the risk of developing a second BCC within 3 years of the first presentation is approximately 44% NICE Guidance on Cancer Services Improving Outcomes for People with Skin Tumours including Melanoma (update): The Management of Low-risk Basal Cell Carcinomas in the Community May 2010

Melanoma Incidence Unlike most malignancies, malignant melanoma is more common in women than men with a M:F ratio of 4:5 In 2006 it was the sixth most common cancer in females and the eighth in males For both sexes combined it was the sixth most common cancer. 1 Almost a third (31%) of all cases occur in people aged less than 50 years and in the age-group malignant melanoma is the most common cancer (when NMSCs are excluded) On average, about 20 years of life are lost for each melanoma death 1) Statistical Information Team, Cancer Research UK, 2009

Trends in malignant melanoma incidence Over the last thirty years, the incidence of malignant melanoma has increased more than for any other common cancer in the UK The male rates have increased more than five times from around 2.5 in 1975 to 14.3 in 2006, while the female rates have more than tripled from 3.9 to 15.4 over the same period in Great Britain Statistical Information Team Cancer Research UK

Mortality due to Melanoma In 2007, 117 people aged under 40 died from malignant melanoma and over half of all deaths were in people aged under 70. The age-standardised mortality rates in the UK show a continuous rise for men from around 1.2 per 100,000 in the early 1970s to 3.1 in Female rates in the early 1970s at 1.4 per 100,000 but have remained at around 2.0 per 100,000

Restrict the type of referrals

Conditions expected to be treated within Primary Care Skin tags, Molluscum and Viral Warts Continuing treatment of skin conditions that have been diagnosed Removal of benign lesions that are causing significant problems Urticaria Acne (low grade) Leg Ulcers Eczema Psoriasis uncomplicated

Reducing referrals ? Solutions Designated Eczema Nurse Re-institution of Cryotherapy /Efudix Minor surgery capacity Apply for LPF funding prior to onward referral Better lesion recognition Dedicated GP for dermatology

Education does it help? Skin lesion courses Dermatology MSC Cardiff Diploma Special case meetings Consensus opinion In house case review e.t.c Dermatoscopy

Education does it help? Not necessarily if your primary end point is reduced referrals rather than improved patient care and management Education needs to be targeted at those who need it

Teledermatology is it the answer? Piloted teledermatology software for accuracy in the triage of a subset of 2 week wait (2ww) 110 cases were analysed over a period of 6 months There was 86 (78%) and 80 (73%) cases with complete concordance respectively between the telediagnosis made by each consultant and the face-to-face diagnosis in the outpatient clinic No melanoma’s were missed 14 (13%) and 17 (15%) of the telediagnosis were graded as no onward referral necessary respectively A teledermatology pilot in Hertfordshire. Triage of 2 week wait referrals. Bataille V, Hargest E, Brown V, Dawe S, Blackwell V, Cooper A and Hamp J. West Herts NHS Trust, Hertfordshire, TeleHealth Diagnostics, UK.

Teledermatology is it the answer? Our pilot showed that with teledermatology the referral pathway could be managed more efficiently with non urgent cases being seen in the correct clinics It reduced total referrals by between 13-15% Not cost effective Software worked well but requires significant IT support and cost to implement

Alternative providers CATS has been decommissioned Other options private vs alternative community model ? Clinical governance and quality assurance Unlikely to provide solution no example in UK to suggest it is a working

Thank you