Transcript Dermatology CATS decommissioning - Dr Simon Dawe

Dermatology Clinical Assessment and
Treatment Service: 2007-2011
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 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
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 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
Persons
1975-19771976-19781977-19791978-19801979-1981 1980-1982 1981-1983 1982-1984 1983-1985 1984-1986 1985-1987 1986-1988 1987-1989
1.7
1.7
1.8
1.9
1.9
2.0
2.1
2.2
2.4
2.6
2.9
3.3
3.4
5.0
5.2
5.5
5.8
6.3
6.7
7.0
7.3
8.3
8.9
9.9
10.4
10.8
6.6
7.1
7.6
8.4
9.0
9.5
10.2
10.4
11.4
12.5
13.9
15.4
16.1
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
Figure 1.9: Age specific incidence rates of malignant melanoma in persons,
adults only, Great Britain, from 1975-2006 and projected to 2024
120
15-34
100
35-59
60-79
80
80+
60
40
20
Year of diagnosis
2020-24
2015-19
2010-14
2004-2006
2002-2004
2000-2001
1998-2000
1996-1998
1994-1996
1992-1994
1990-1992
1988-1990
1986-1988
1984-1986
1982-1984
1980-1982
1978-1980
0
1975-1977
Rate per 100,000 population
15-34
35-59
60-79
80+
20 Most Common Cancers, Percentage Change in European AgeStandardised Incidence Rates per 100,000 Population, Males, UK, 19971999 and 2006-2008
Cancer Site
All Cancers (Excl. NMSC)
Bladder
Bone and Connective Tissue
Brain and Central Nervous System
Colorectum*
Hodgkin Lymphoma
Kidney
Leukaemia
Liver
Lung
Malignant Melanoma
Mesothelioma
Multiple Myeloma
Non-Hodgkin Lymphoma
Oesophagus
Oral
Pancreas
Prostate
Stomach
Testis
Incidence Rate 1997-1999
413
27.5
3.4
8.5
57.9
2.7
12.3
12.9
4.4
74.2
8.9
4.7
5.8
15.6
13.4
9
10.5
73.4
19.6
6.6
Incidence Rate Percentage Change
2006-2008
in Incidence Rates
420.3
1.8
19.2
-30
3.6
5.8
8.3
-2.8
57.7
-0.3
3
10.4
14.9
20.7
12.6
-2.6
6.1
37.8
61.2
-17.6
15.1
69.7
5.3
14.7
6.4
9.6
17.2
10.7
14.5
8.7
11.2
23.7
10.6
1
99.9
36
13.2
-32.7
6.9
5.5
* Colorectum including anus (C18-C21)
* Colorectum including anus (C18-C21)
Prepared by Cancer Research UK
Original data sources:
1. Office for National Statis tics . Cancer Statis tics : Regis trations Series MB1. http://www.s tatis tics .gov.uk/s tatbas e/Product.as p?vlnk=8843.
2. Wels h Cancer Intelligence and Surveillance Unit. http://www.wcis u.wales .nhs .uk.
3. Inform ation Services Divis ion Scotland. Cancer Inform ation Program m e. www.is ds cotland.org/cancer.
4. N. Ireland Cancer Regis try. www.qub.ac.uk/nicr.
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 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 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