GP Dr Stephanie Gallard shares her tips after helping to launch a tech solution that has dramatically reduced dermatology hospital referrals
In 2019, Cheshire and Merseyside Health and Care Partnership (now part of the local ICS) began a collaborative process to design and pilot a pioneering teledermatology service that streamlined the triaging and referral of patients.
The Partnership is a group of NHS, local authority, voluntary, community, faith and social enterprise organisations from across nine local authority areas, all working together to improve public health and reduce health inequalities.
The ultimate goals of the new teledermatology service were to support the region’s 228 GP practices in the delivery of timely, effective and collaborative dermatology care; and to reduce the high number of benign moles and skin lesions being referred into secondary care via the Two Week Wait (2WW) cancer pathway.
The initiative involved four acute trusts in Liverpool, Wirral, and Cheshire (including Liverpool University Hospital NHS Foundation Trust). The end result was the creation of a clinically led, fully IT-integrated solution bringing together primary care and secondary care colleagues.
The pilot project involving six GP practices within the South Liverpool area has, since March 2022, been converted into a permanent scheme and has expanded to cover all 228 GP practices in the region.
Overview of the project and what it involved
The project received National Teledermatology Investment Programme (NTIP) funding, and, following a procurement process, Cinapsis SmartReferrals was chosen as the technology partner.
The participating GPs are provided with dermatoscopes and a universal adaptor that attaches to any smartphone camera. This enables them to use their own phones to safely capture high-quality clinical images of moles and other skin lesions in a secure, data-compliant manner, with no images being stored on their personal phones but instead uploaded immediately into a secure data cloud. These images can then be easily attached to an Advice and Guidance (A&G) request made directly through a fully integrated app.
On the Cinapsis desktop or mobile platform, a secondary care specialist will review the case and suggest the best course of treatment or next steps for the patient, whether that be a 2WW clinic, a routine or urgent outpatient clinic appointment, or primary care management or self-care. The images and the outcomes of the A&G request are automatically updated in the patient record via full EMIS integration.
Project benefits and outcomes
A key advantage of this initiative is that it is reducing the (previously high) number of benign moles and skin lesions being referred into secondary care via the 2WW cancer pathway.
Prior to the technology rollout, at least 30% of dermatology 2WW referrals were being referred unnecessarily – around 7,000 every year, at a cost of over £1 million. This proportion is similar nationwide. Apart from draining resources and putting extra strain on the system and clinicians involved, these referrals also cause needless anxiety and worry for patients where lesions are subsequently shown to be benign.
Since the launch of the teledermatology project, at least 49% of teledermatology cases are successfully managed with either A&G alone, or a simple discharge as no action is required.
All patients entering the cancer-suspected 2WW pathway are correctly referred into onward treatment pathways using technology integrated with the eRS system, so no additional action is needed by the referrer. This prevents any further delay and eliminates the risk of a patient being lost to follow-up.
Patients who do have clinically worrying lesions are being redirected into the appropriate clinic earlier on, while those with benign lesions are screened out and saved from a journey to hospital.
Other benefits include clinician resources and time being freed up to tackle waiting times for other dermatological conditions, such as inflammatory dermatoses. In addition, organisations are being supported to reach NHSX metrics and local improvement targets.
There is also an educational benefit from working in this joined-up way: GPs and other referrers benefit from access to rapid 48-hour feedback from secondary care specialists, which has consistently been shown to be an excellent aid to upskilling clinicians.
What are the main steps to launching your own Telederm service?
1. Find funding
Our service received a share of the £5m NHSX National Teledermatology Investment Programme (NTIP) funding. We secured £496k in total, which was split 3 ways: £161k for Software and Licences, £180k for programme management, and £155k for dermatoscopes and equipment. The funding was initially for one year only, but by carefully setting out our ambitions and plan, we managed to negotiate a two-year programme.
2. Identify what your users want from the system
Having clear goals and non-negotiables will make the service design and tech procurement process much easier. Consulting with the clinicians who will be using the system is key here. Concerns likely to be raised are usability in practice, ease of use by all clinicians and end-to-end data integration with all clinical systems. To engage with GPs:
- We forged close relationships with PCNs and asked for volunteers
- We communicated via the LMC and gained its support
- We held a launch night and asked for representation from all practices across Liverpool.
At Cheshire and Merseyside ICS, our priorities were that we wanted GPs to be able to use their own phones (iPhone or Android) to capture images with a dermatoscope; that they could easily and securely upload those into EMIS and a secure server and they would be free from data protection issues or risks, with no images being needed to be stored on their personal phones.
We also wanted to make sure that cases would be triaged by local secondary care clinicians rather than a more remote service, and that there would not be potential issues over locum referrals becoming lost in the system.
3. Choose a tech solution provider that meets your criteria
A benchmarking exercise was undertaken to identify three potential providers of teledermatology platforms. A panel was established consisting of primary and secondary care clinical leads, digital experts and potential primary care system users to evaluate each solution.
Find out whether the solution you are considering has been successfully used elsewhere. Also check that:
- It is fully integrated with your primary care clinical systems and e-Referral service.
- It meets Digital Technology Assessment Criteria (DTAC) for health and social care. This ensures that digital health tools meet clinical safety, data protection, technical security, interoperability and usability and accessibility standards.
- It allows for cloud-based secure data transfer.
- It has a good user experience and user interface design and is easily customisable so can be adapted to meet local demand and issues.
4. Create an inclusive project team to implement the service
We appointed both a primary and secondary care lead, as well as a programme manager. This ensured that clinical and operational issues could be accounted for across both sides of the healthcare system, which is vital for smooth implementation of any new service. It’s important not to underestimate the importance of having both primary and secondary care leads working together. We were also very keen that this initiative didn’t feel as if it were imposed and went to great lengths to ensure all levels of IT/tech-savviness were represented in the group.
As primary care lead, my role was vital in ensuring that local GPs felt represented and their views and patterns of working were being taken into account.
5. Run a pilot with a PCN partner
Pilots with volunteer practices and early champions mean you have an invaluable way to prove the new concept works. It also means you can iron out teething problems or issues, prior to starting any tender process by NHS procurement. We ran a pilot with six GP practices within the South Liverpool area. Each practice received a dermatoscope, access to the Cinapsis SmartReferrals platform via both an app on the mobile phone, and a floating widget linked to their desktop EMIS computer system. The software and equipment were provided by the suppliers free of charge for the duration of the pilot.
During the pilot, challenges with the equipment were identified (including the adaptor that fixed the dermatoscope to the smartphone). This was useful because it allowed the project team to address such problems before rolling out further within the ICS. The model piloted in Liverpool was later expanded across Wirral and Cheshire.
Dr Stephanie Gallard is a Dermatology GPSI for the Liverpool Intermediate Community Assessment and Treatment Service (ICATS) at Liverpool University NHS Foundation Trust, and Primary Care Lead for Elective Dermatology within Cheshire and Merseyside Health and Care Partnership
