ABSTRACT
Managing the increasing number of 2-week wait (2WW) suspected skin cancer referrals to specialist National Health Service (NHS) dermatology services is challenging. Currently, once received, these referrals cannot be redirected back to the referrer and data show that around only 6% of these referrals are relevant skin cancers. The use of teledermatology, including dermoscopic images, for pre-2WW triage has therefore been advocated. Current recommendations expect that these images will be taken in a primary care setting by a member of the primary care team as part of a face-to-face interaction. In response to the COVID-19 pandemic, NHS England now recommends that all general practices should be using a total triage model, using telephone or online consultation systems for all patients contacting the practice, to reduce footfall and thereby protect patients and staff. It is speculated that this change in primary care practice will continue for the foreseeable future. The aim of this study was to review the impact of primary care remote consultation activity on 2WW skin cancer referrals. A simple questionnaire was designed to ask patients attending a 2WW appointment of the nature of their interaction in primary care prior to their 2WW referral, including the type of consultation and the responsible healthcare professional. Data were obtained from 347 consecutive patients, and 206 (59 4%) had been seen face to face. Of these, 135 (65 5%) were seen by a doctor and 71 (34 5%) by a nurse. The remaining 141 (40 6%) did not have a face-to-face consultation prior to referral. Of these 86 (61 0) were referred based on either a video consultation with an image from the patient and 55 (39 0%) following a telephone consultation only. These data are important as they show that the increasing emphasis on remote consultations in primary care means that large numbers of patients with suspected skin cancer are being referred without a face-to-face interaction and one in six were referred based on a telephone consultation only. There are two important potential implications of this. Firstly, this is likely to lead to an increase in 2WW referrals and, secondly, proposed models of pre-2WW triage using teledermatology with appropriate images (including dermoscopic) that currently require patients to attend a general practice surgery for appropriate image taking may need to be rethought. Alternative innovative approaches such as the use of community hubs for image taking or rapid-access community-based skin lesion diagnosis clinics ('spot clinics') may need to be considered.