BMJ Awards 2019: Dermatology Team of the YearBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1229 (Published 19 March 2019) Cite this as: BMJ 2019;364:l1229
Establishing a national xeroderma pigmentosum service
Patients with the rare inherited disorder xeroderma pigmentosum can’t repair the normal damage that occurs from exposure to ultraviolet light. As a consequence, they develop skin cancers from early childhood, severe eye disease, and neurological degeneration. Their mean lifespan is only 32 years, with most patients dying from skin cancer.
There are only 100 people with the condition in the UK. Because patients tended to be seen by consultants who had never seen the condition before, they were given poor care with unnecessary, inappropriate investigations and surgery, says Robert Sarkany, consultant dermatologist at Guy’s and St Thomas’ NHS Foundation Trust.
Sarkany set up a national xeroderma pigmentosum service in 2010 with input from the patient support group. Patients come annually to a multidisciplinary clinic where they can see a dermatologist, dermatological surgeon, ophthalmologist, neurologist, neuropsychologist, geneticist, and specialist nurse. “The nurses supervise the outreach programme and liaise with the patient’s GP. They act as a glue to bind the service together,” says Sarkany.
The specialist nurse also visits the patient at home and gives advice—for example on fitting ultraviolet protective window films as a preventative measure. These window films are now fitted in 94% of patient’s homes (up from 82%), in 88% of cars (up from 45%), and 94% of schools (up from 78%). The service has also reduced the number of appointments and the amount of unnecessary surgery—saving the NHS £80 000 (€93 000; $106 000) a year.
Changing dermatology referrals
Leeds Teaching Hospitals NHS trust provides an all hours on-call dermatology service with referrals coming from three separate hospital sites. Historically, 100% of acute inpatient dermatology referrals came from telephone calls. There was little photography available to help triage referrals and it wasn’t always easy to pop in to see the referrals because they were at a different site, says Kaderina Stylianou, dermatology registrar.
In September 2018 the inpatient referral system was digitalised in order to improve information governance, operational transparency, and continuity of patient care. “We have seen many improvements,” says Stylianou. “The system is streamlined with more accurate, efficient triage. We are now paperless, so there are no bits of paper with patient details on. There is transparency for people taking over out of hours. Dermatological advice can be given remotely and this can be subsequently seen by anyone following up the patient.”
An audit shows that 35% of e-referrals had unprompted accompanying medical illustration so could be triaged immediately; previously, getting images needed prompting in all cases. The new system has improved efficiency with a 90% reduction in handover of cases to out of hours cover. Referral rates have stayed roughly the same but 30% are now unaccompanied by a phone call. “Telephone calls can be inefficient and disruptive to clinic,” says Stylianou.
Introducing a teledermatology service
There is a national shortage of dermatologists and north east Lincolnshire, as a rural area, has particular difficulties in attracting consultants. There is also a high dermatology workload because of the geography and the large population of retired people, says Javed Mohungoo, consultant dermatologist at Virgin Care Dermatology.
The solution was to set up a teledermatology service so that a GP wanting a second opinion can upload an image to the NHS Cloud service. The image is reviewed by the consultant within three days and often the same day, says Mohungoo. And whereas most teledermatology services focus on lesions and moles, this one covers all skin conditions apart from genital images and those involving children.
The service now has 20 000 patient contacts a year with 40% of referrals now coming through the teledermatology system; of those patients, 59% could be managed in primary care. Another advantage is that if a consultant appointment is needed it can be booked straight onto the correct procedure list—for example, to have a mole removed or an allergy test. “This bypasses the first consultant appointment and gets an outcome quicker,” says Mohungoo.
Within the first six months of the project, waiting times in north east Lincolnshire went down to two weeks for urgent cases and four weeks for routine cases. The results show that 99% of potential cancer cases are seen within two weeks, versus 93% nationally.
Successful digital innovation
Lack of space and facilities at the main Luton and Dunstable University Hospital meant that the dermatology department moved off site in June 2018. This was a double edged sword, says Bernadette De Silva, consultant dermatologist. On the plus side there was a purpose built site with more space but on the other hand it wasn’t easy for consultants to review patients on the ward because it is an hour round trip between sites.
The team put in a bespoke teledermatology solution with trained dermatology nurses to run the inpatient and outpatient hubs. All the uploaded images are assessed by a trained consultant dermatologist who can access them and make a triage decision wherever they are.
Results from the initial three month pilot scheme showed positive results. Outpatient data from the teledermatology clinics showed that there were no skin cancer breaches—patients were all seen within the two week wait target. Automatically generated clinic letters were sent to GPs and patients, including macroscopic and dermoscopic images, in 100% of cases within 72 hours of patient attendance whereas previously it took 5.4 days. For inpatients, an expert dermatology assessment was available on average within 5.67 hours of the referral being made whereas previously it was 24 hours.
“It seems the telederm consultation is actually better than the face to face clinic. We think it is because we have really good dermoscopic images and information so we can make an accurate clinical diagnosis,” says de Silva.
The Dermatology Team of the Year award is sponsored by LEO Pharma. The winners will be announced at the awards ceremony on 24 April 2019 at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.bmj.com