Dr Rabi Nambi, Consultant Dermatologist at University Hospitals of Derby and Burton NHS Foundation Trust is part of the consultant team that uses Consultant Connect to offer teledermatology to practices in the NHS Derby and Derbyshire ICB area, covering over 1 million NHS patients in Derbyshire. Dr Nambi is also part of the National Consultant Network for Teledermatology.
In this article, we share some of the questions we put to Dr Nambi during our recent webinar ‘Enabling dermoscopy in Primary Care’. Dr Nambi shares his experience of how dermatology pathways and practices have evolved over the last 12 months, and how the Consultant Connect teledermatology service together with dermoscopy has helped improve the quality of referrals, whilst reducing demand on secondary care throughout the pandemic.
How have dermatology pathways and practices been impacted, particularly over the last 12 months? How have they evolved throughout this time?
‘Due to the pandemic, we moved a sizeable amount of dermatology work to teledermatology. Using Consultant Connect for teledermatology, facilitates a joint and efficient communication system between primary care and secondary care teams. It is improving patient care by allowing patients to receive care not only closer to home, and primary care, but also in a more immediate and appropriate setting.
As an example, when a GP sees a patient with a mild, moderate, or severe rash and contacts us via Consultant Connect teledermatology:
- The GP will receive a response within 24 hours, enabling them to treat the patient in the appropriate manner, quickly.
- A patient with a severe rash will get the correct treatment faster, as their GP will be advised that their patient needs to be seen in secondary care quicker. In this situation, urgent treatment advice given can help the patient immensely alleviating the disease impact before being seen urgently in secondary care.
- Finally, there might be situations where the patient’s moderate rash may rapidly change to severe if not treated appropriately. Specialist advice on these patients will be received faster via Consultant Connect, enabling the patients to be treated in the most appropriate care setting – whether that be, that their care can remain in primary care or that they need to be seen in secondary care.’
With fewer in-person appointments due to the pandemic, has the quality of the referrals been impacted in any way?
‘We aim to ensure that clinicians seeking teledermatology advice via Consultant Connect provide specific information about the patient they are with, alongside the images of the patient’s condition. So, if they fill in the requested information in a standardised protocol correctly, the quality and detail of the information provided should be sufficient for us to respond with appropriate advice.
With regards to images included in teledermatology requests, their quality generally improves over time, with more clinicians using the service. In addition, I think dermoscopy is very useful both in primary care and secondary care. One of the key things we find is that many GPs attend primary care dermatology and dermoscopy courses and then once back in their practice, they might see a patient and think “Is that something that I should be worried about? Is that something that needs this treatment?” When they send an image to a consultant via Consultant Connect, they get answers to their concerns almost immediately. This reinforces the immediacy of the education for dermoscopy. It’s a collaborative approach, rather than a GP going on a course, then coming back to their practice and treating the patient on their own feeling unsupported – they have our support, and that support builds their training and education and ultimately helps them handle patients more confidently in the future.’
Would you say that it is more of a dialogue between you and the clinician submitting the teledermatology advice query?
‘Absolutely. Sometimes, following sending the advice, the GP comes back asking for clarification as to why I think it’s a basal cell carcinoma for example. Questions are also asked about why this treatment is given as opposed to another. Feedback is given and how tweaking treatments makes a huge impact. Simply increasing the potency of the topical steroids will help in some situations.
The only way to help improve or reduce referrals is to treat the patient like a consultant would, and the immediacy of feedback and communication via Consultant Connect helps immensely in that matter.’
Would you say that GPs in your area are learning from the referrals that they would have made initially, and that they are starting to try their own treatment before seeking advice?
‘Yes, so in Derby and Burton we’ve got two pathways available via Consultant Connect:
Both pathways have separate questions and we, as consultants take turns every day to answer the lesion queries. There’s a wide variety of types of lesions and rashes coming in, and this educates the GPs who learn how to use each pathway over time, and we have found that the queries coming through are improving with time.’
What are the benefits of using dermoscopy alongside Consultant Connect?
‘A key thing when using the Consultant Connect App is that none of the images taken are stored on the clinician’s phone. They are automatically stored in an IG-secure and GDPR-compliant cloud.
With the dermoscopy aspect, clinicians just need a good smartphone and most smartphones these days are quite adaptable. Dermoscopy is very valuable, if you think it’s a melanoma then obviously you should be using the two-week wait pathway. And, in general, if you want to refer a patient, it’s very good practice to attach a dermoscopy image to help consultants triage better, and for the GPs to learn as well.’
Does having an image and a dermatoscopic image to review, prior to accepting a referral, help you direct those urgent cases and less serious cases to the right place, faster?
‘Yes. With the referrals that come to me, I’m able to review the images and say, “This is a basal cell carcinoma, or this is a dermatofibroma, or it’s very symptomatic so refer to the community clinic, or this is actually a large basal cell carcinoma close to the eye, and it needs a plastic surgeon to look at it, please refer to the plastic surgeon”.
We are usually able to triage the referrals into different settings which helps the patient get the most appropriate treatment. There is also a mental health benefit to the patients themselves in that their treatment can either be expedited or they can be reassured sooner.’
What do you think we can expect from teledermatology over the next 12 months?
‘Teledermatology will contribute towards dermatology in general. I think it’s going to be an expansion of the services that we provide teledermatology-wise, but there’s also going to be a role for face-to-face consultations. It’s always going to be a hybrid system, we’re never going to go back to what existed before, and that’s for the best. I can count any number of examples where there was a patient with bad eczema or even moderate eczema, we gave the treatment advice, and within a week the patient was better. In the past, those patients would have been referred in a routine way, meaning that often they would have waited for quite some time before being seen.
Thanks to teledermatology, the treatment options can be given almost immediately to the patient and the next time the GP sees a patient with a similar condition, they’ll have a better idea of what steps to take before referring.
It has become more of a collaborative exercise between the consultant and the GP, and the patients benefit from this collaboration through getting treatment for their condition faster.’
There are a limited number of Consultant Dermatologists in the country, you’re under more pressure than you have been, having to cope with a massive change in practice, particularly throughout COVID. Is there an efficiency element to teledermatology that you’ve seen?
‘Yes, certainly because clinically we may see around 10 to 15 patients in a clinic, but with teledermatology you can easily review 25 to 30 patients. A ballpark figure is roughly around 60% of these queries result in a referral being avoided. And more importantly, around 10% are referred for a two-week wait. So, a significant proportion of patients do not actually need to be seen in secondary care and appropriate two-week referrals are made. So, these patients will be seen faster when they might have been sitting longer waiting for an appointment.’
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