Dermatology Clinical Assessment and Dermatology Clinical Assessment and Treatment Service: 2007-2011Treatment Service: 2007-2011

NW Hertfordshire (St Albans, Harpenden and Hertsmere)NW Hertfordshire (St Albans, Harpenden and Hertsmere)

Dr. Simon Dawe Consultant Dermatologist

West Hertfordshire NHS trust

Clinical Lead of CATS

CATS serviceCATS service

Due to be decommissioned in Nov 2011Patients to be repatriated to primary carePatients to be referred via secondary careSome clinics may continue in the

community but under secondary care

What’s happening in secondary What’s happening in secondary carecare

16% reduction in referrals in service level agreement 2011-2012 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 How to reduce referrals?referrals?

I Don’t Know ??I Don’t Know ??

How Could you do itHow Could you do it

Restrict the type of referralsProvide services in the community that

might reduce the need of onward referralBetter diagnosis and management the role

of education?New technology?Use alternative services Private healthcare

e.t.c

What are you up againstWhat 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 IncidenceMelanoma 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 15-34 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

Persons1975-19771976-19781977-19791978-19801979-1981 1980-1982 1981-1983 1982-1984 1983-1985 1984-1986 1985-1987 1986-1988 1987-1989

15-34 1.7 1.7 1.8 1.9 1.9 2.0 2.1 2.2 2.4 2.6 2.9 3.3 3.435-59 5.0 5.2 5.5 5.8 6.3 6.7 7.0 7.3 8.3 8.9 9.9 10.4 10.860-79 6.6 7.1 7.6 8.4 9.0 9.5 10.2 10.4 11.4 12.5 13.9 15.4 16.180+ 11.7 11.4 10.8 11.2 11.2 12.2 13.0 13.9 14.3 14.6 16.7 18.3 19.7

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Figure 1.9: Age specific incidence rates of malignant melanoma in persons, adults only, Great Britain, from 1975-2006 and projected to 2024

Cancer SiteIncidence Rate - 1997-1999

Incidence Rate - 2006-2008

Percentage Change in Incidence Rates

All Cancers (Excl. NMSC) 413 420.3 1.8

Bladder 27.5 19.2 -30

Bone and Connective Tissue 3.4 3.6 5.8

Brain and Central Nervous System 8.5 8.3 -2.8

Colorectum* 57.9 57.7 -0.3

Hodgkin Lymphoma 2.7 3 10.4

Kidney 12.3 14.9 20.7

Leukaemia 12.9 12.6 -2.6

Liver 4.4 6.1 37.8

Lung 74.2 61.2 -17.6

Malignant Melanoma 8.9 15.1 69.7

Mesothelioma 4.7 5.3 14.7

Multiple Myeloma 5.8 6.4 9.6

Non-Hodgkin Lymphoma 15.6 17.2 10.7

Oesophagus 13.4 14.5 8.7

Oral 9 11.2 23.7

Pancreas 10.5 10.6 1

Prostate 73.4 99.9 36

Stomach 19.6 13.2 -32.7

Testis 6.6 6.9 5.5

20 Most Common Cancers, Percentage Change in European Age-Standardised Incidence Rates per 100,000 Population, Males, UK, 1997-1999 and 2006-2008

* Colorectum including anus (C18-C21)

* Colorectum including anus (C18-C21)

4. N. Ireland Cancer Registry. www.qub.ac.uk/nicr.

Prepared by Cancer Research UKOriginal data sources:1. Office for National Statistics. Cancer Statistics: Registrations Series MB1. http://www.statistics.gov.uk/statbase/Product.asp?vlnk=8843.2. Welsh Cancer Intelligence and Surveillance Unit. http://www.wcisu.wales.nhs.uk.3. Information Services Division Scotland. Cancer Information Programme. www.isdscotland.org/cancer.

Trends in malignant melanoma incidenceTrends 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 MelanomaMortality 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 2007. 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 referralsRestrict the type of referrals

Conditions expected to be Conditions expected to be treated within Primary Caretreated 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 ? SolutionsReducing referrals ? Solutions

Designated Eczema NurseRe-institution of Cryotherapy /Efudix Minor surgery capacityApply for LPF funding prior to onward

referralBetter lesion recognitionDedicated GP for dermatology

Education does it help?Education does it help?

Skin lesion coursesDermatology MSC Cardiff DiplomaSpecial case meetingsConsensus opinion In house case review

e.t.cDermatoscopy

Education does it help?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 Teledermatology is it the answer?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 Teledermatology is it the answer?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 providersAlternative providers

CATS has been decommissionedOther options private vs alternative

community model? Clinical governance and quality assuranceUnlikely to provide solution no example in

UK to suggest it is a working

Thank you