Teledermatology: improving patient and clinician experiences of care for long-term skin conditions

Gemma Dakin, Project Support Officer at the Health Innovation Network and Digital Pioneer Fellow, shares the latest on the Dermatology Improvement Collaborative and how it is helping to improve dermatology services for patients and clinicians.

Dermatology

The landscape of healthcare has changed, accelerated through Covid. We have seen a shift in the way we interact, use and access healthcare services. The workforce has moved on from older technology, such as referrals being sent via fax machines, to digital tools that aim to provide easier access to services, faster communication between patient and clinician, and help patients to safely manage their health more independently. This is supported by the Digital First Agenda, which is part of the NHS Long Term Plan to embed digital more and more into our day-to-day practice.

Dermatology is an area of medicine where people with inflammatory skin conditions and particularly chronic skin conditions, such as psoriasis, atopic eczema, urticaria and acne, often suffer due to poor and slow access to the right treatment. The “diagnostic bottleneck” and the unsatisfactory management of skin conditions have been amplified due to Covid preventing patients getting treated in the right place at the right time within the 18-week Referral To Treatment timeframe (RTT), which is the maximum accepted timeframe in the NHS within which a patient should receive treatment following a referral. For example, the acute trusts in SWL were experiencing an increase in dermatology appointment backlog up to 16% above the 18-week RTT performance marker in March 2020, with 71% of appointments allocated to follow-ups. As a result of COVID – 19, this backlog was further increased.  In August 2020, the Association of the British Pharmaceutical Industry (ABPI) Improvement Dermatology Initiative (IDI) commissioned the Health Innovation Network (HIN) to deliver a Quality Improvement (QI) programme. The HIN set up the Dermatology Improvement Collaborative to improve dermatology services with practical solutions that could positively impact the patient and clinician experience and relieve the burden on the NHS.

The Dermatology Improvement Collaborative has provided Trusts across the South-East of England (London, Kent, Surrey, Sussex) with an opportunity to explore how to use technologies, such as tele-dermatology to deliver NICE-compliant dermatology services that are consistently accessible, high quality and cost effective. The areas of focus are described below.

Improving the referral pathway between primary and secondary care by attaching a photograph to the e-Referral System (e-RS):

The direct capture of images helps to provide more information to the dermatology referral when it is transmitted from Patient Portal to acute dermatology setting. This aims to improve the remote clinical triage of patients by a secondary care clinician, help patients to be seen in the most appropriate setting (e.g. secondary care appointment or advice and guidance), reduce waiting times and use clinical resources more efficiently. This will also enable clinicians to work more effectively on other pathways (e.g. suspected skin cancer two-week pathway) due to the improved efficiency of the inflammatory skin condition pathway.

Patient and clinician education to support the early detection and treatment of inflammatory and long-term skin conditions:

The development of four online educational videos in South-West London is to support patient and GP education on the treatment and management of common skin conditions such as psoriasis, eczema and skin cancer, so clinical decisions can be made effectively, within shorter time periods and ensure patients are seen in the most suitable place. Over time, the videos will help to reduce the number of face-to-face appointments and therefore reduce the overall demand on the service, first seen in primary care and subsequently in secondary care. This workstream also hopes to provide a wider and quicker access to care for patients by sharing the videos Nationally online. Specifically, the video on “how to take a good quality photo” will help patients to be able to take an image of their skin that they can send into the patient portal that can effectively be uploaded with the referral and used to triage.

Improving digital communication to enable multiple trusts and different healthcare sectors in a region to work together as a network:

South-East London focused on a network approach using Medical Photographers to capture out-of-clinic, anatomical, macroscopic and dermatoscopic images of lesions deemed necessary for review in secondary care. Images are then bundled with a referral and a patient questionnaire and presented to Consultant Dermatologists in dedicated Teledermatology clinics for a clinical virtual review and a decision on whether to accept or reject the referral and refer the patient onto the right clinical pathway. This network approach aims to release capacity across South-East London by regrouping their consultant dermatologists’ clinical expertise to clinically triage safely and ensure that patients’ time to treatment is reduced.

Exploring the use of dermatoscopes in Primary Care and Artificial Intelligence (AI) decision support tools (e.g. skin analytics):

In particular, the transformation team at Ashford and St Peter’s Hospitals NHS Foundation Trust explored a number of AI solutions, remote diagnostic platforms, and image sharing tools looking at solutions to reduce waiting times for patients on two-week referral pathway, reduce unnecessary secondary care referrals and potentially provide faster intervention in malignant cancers. Although there was positive clinical engagement to support the recommended AI solutions it was agreed that procurement and implementation would be paused until guidance from their professional body, British Association for Dermatologists, was clarified in favour of adoption or other indication that adoption would be appropriate (i.e. acceptance onto a nationally supported programme such as the Accelerated Access Collaborative AI fund).      

Soon to “Go Live” in SWL will be the patient portal (Zesty) for secondary care appointments where patients will be able to fill in an assessment form prior to their appointment with additional information about themselves and their condition to support the dermatology referral from primary care. This is due to start in late Autumn 2021. 

A full report and set of case studies will soon be available, and ultimately these service improvement projects could be used as case studies for other NHS dermatology services to learn from, follow good practice within a quality improvement methodology to reduce waiting times for patients in accessing high quality dermatology care and improve the patient and clinician experience using teledermatology solutions.


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