Advice & Guidance and guidelines

Advice & Guidance (also known as Teledermatology)

The Dermatology A and G services have seen a huge increase in requests for advice over recent years and have struggled with the resources required to match the level of demand. This is a recognised national problem. Secondary care clinicians are working hard to keep on top of this work, but there may be delay  in receiving a response.

Please only use A and G if absolutely necessary for non-urgent skin problems where a referral may be prevented. It may still be the best and quickest route for getting advice on how to best manage your patients.

Please do not use A and G for pigmented lesions or other lesions meeting 2WW referral criteria.

The team is asking for support from GPs to help set realistic expectations with your patients. They also request that any outstanding A and G requests that have not received a response should be reviewed to decide if advice is still required.

Response times. The waiting time tool for BNSSG GP practices includes a section on A and G waiting times. You will need to download the document and follow the instructions to access the latest information (updated monthly). Please see the Hospital waiting times page.

We have agreed essential criteria that you should adhere to when seeking Dermatology A&G

Please consider using online tools and guidelines to help decisions about management in primary care and when to request A and G or referral (see resource section at bottom of the page) 

• I have checked that photographs are of sufficient quality and in focus, to aid appropriate advice. NOTE: Providing blurred or poor quality images will result in your A&G request being returned. Through AccuRx you can link to this video to help ensure good quality images are returned to you by your patients.

• I have attached an appropriate number of photographs (no more than 5) to assist the receiving clinician. Dermatoscopic images are attached if appropriate (usually lesions only). 

• I have already consulted available resources (e.g. clinical knowledge summaries, PCDS and REMEDY information) and still despite this need A&G. 

• I have discussed this enquiry with a senior or most appropriate GP within the practice before submitting my enquiry via eRS A&G.

Please also consider the inclusion and exclusion criteria below. 

Dermatology advice and guidance is available across BNSSG via eRS.  Referrers can obtain advice and guidance from UHBW or NBT on diagnosis and management of skin conditions in primary care, for patients who would otherwise have been referred into secondary care.

Inclusion criteria:

• A patient is registered with a GP practice in BNSSG and is 16 years old or over.
• There is diagnostic or management uncertainty and would normally be referred to secondary care. However, please note that this is not a back door route to a referral and should not be used if a referral is necessary or more appropriate.
• Referrals must include a concise history and a clear clinical question.
• Good quality images of rashes and lesions should be provided (no more than 5 pictures please) - see above.

Exclusion criteria:

• If malignancy is suspected then please use then suspected skin cancer 2 week pathway if criteria are met - see also pigmented lesion advice below.
• Dermatological problems affecting the genital area should not be referred via A and G.
• Benign skin lesions should be managed in primary care unless diagnostic uncertainty - see the Benign skin lesion page or use the PCDS website for guidance.

Please note that requests for advice may be returned if the criteria above are not met so please take care to check before sending.

If the reply from A and G advises referral then please refer to the same trust unless otherwise instructed, as this improves continuity and consistency in care of the patient.

The service is not currently available for children <16 years old. See the paediatric dermatology A and G section.

Pigmented lesions

Please note that the Advice and Guidance service does not accept referrals for patients with pigmented skin lesions.

Practices are encouraged to use dermatoscopes in primary care where available as this can help in the diagnosis of pigmented lesions and can help to avoid unnecessary 2WW referrals. The Weighted 7 Point Check List (NICE cancer guidelines 2015) can also be a useful guide on when to refer. Patients with pigmented lesions where malignancy cannot be excluded should be sent via the Suspected Skin Cancer 2WW pathway.

UHBW Dermatology Advice & Guidance

General Dermatology Advice & Guidance at UHBW

Referrals require:

• Good quality clinical images - see quick reference guide (include dermoscopy images if possible - particularly for pigmented lesions)  Patients should be advised to view this video to help ensure good quality images are returned. A written guide is also available How to Photograph your skin from home (also available on the ICB website for sending link to patients: https://bnssg.icb.nhs.uk/library/how-photograph-your-skin-home/)
• Referrers should ask the patient for consent to share photographs with other healthcare professionals and this should be recorded in the patient record. Please follow the data protection act requirements. A consent form can also be used (see resources section below).
• A referral letter or dermatology referral form (should be available as an EMIS template). Please ensure a detailed history of the condition and if possible ask a specific question

Please see Dermatology A&G Steps - UHB for further guidance on how to submit a request via e-Referral.

Please process via eRS bypassing the Referral Service

• Dermatology Routine Advice - University Hospitals Bristol - RA7

Priority - Routine
Specialty - Dermatology
Clinic - Not Otherwise Specified

Urgent On Call Advice & Guidance at UHBW

If you are concerned that a patient is acutely unwell and needs admitting, then the route of referral is via the Medical admissions Team. Dermatology do not have an acute inpatient service but patients will be reviewed following admission if required.

If admission is not required but urgent advice is needed then UHBristol offer access to a Dermatology on-call advice service via e-RS* (dermatology on call service) or email. You can also contact UHB Switchboard who will divert you to a voicemail service (please leave a message and they will call you back by the end of the working day).

The criteria for urgent on call advice service are as follows:

• Advice is needed urgently to care for a patient.
• The care is needed to avoid serious health risk.
• Photos should be attached to the referral if possible.

Please see the attached UHB Dermatology On Call Services document for further information. At the discretion of the on-call registrar, a HOT clinic appointment may be available if urgent review is clinically indicated. There is no equivalent urgent service at NBT (by phone or eRS).

• *Dermatology On Call Advice - University Hospitals Bristol - RA7

Priority - URGENT only
Specialty - Dermatology
Clinic - Not Otherwise Specified

NBT Dermatology Advice & Guidance

Referrals require:

• Good quality clinical images - see quick reference guide (include dermoscopy images if possible - particularly for pigmented lesions)  Patients should be advised to view this video to help ensure good quality images are returned. A written guide is also available How to Photograph your skin from home (also available on the ICB website for sending link to patients: How to photograph your skin from home)
• Referrers should ask the patient for consent to share photographs with other healthcare professionals and this should be recorded in the patient record. Please follow the data protection act requirements. A consent form can also be used (see resources section below).
• A referral letter or dermatology referral form (should be available as an EMIS template). Please ensure a detailed history of the condition and if possible ask a specific question

Please see the Dermatology A&G Steps - NBT (word doc) for further guidance on how to submit a request via e-Referral.

Please process through eRS bypassing the Referral Service.

• General Dermatology Advice & Guidance - Southmead - RVJ

Priority - Routine
Specialty - Dermatology
Clinic - Not Otherwise Specified

Dermatology secretaries can be contacted by e-mail on dermatologysecretaries@nbt.nhs.uk

Email responses will be returned within 7 calendar days.

If a response has not been received within 7 calendar days please escalate this via Outpatients.Appointments@nbt.nhs.uk

Sirona Community Dermatology Advice & Guidance Service

The Sirona community dermatology team have set up an advice and guidance service for community HCPs /AHPs and primary care practitioners across BNSSG. 

This service offers treatment advice and guidance for management of service users with a diagnosed chronic skin condition which is not being effectively managed and specialist dermatology input may be of benefit. 

Information regarding this service can be found on the Community Dermatology Services page.

Tips on making a Dermatology A&G Referral

Taking photos on personal mobile phones has been approved as long as following the agreed information governance policies. GPs may wish to download the Pando app  which can be used to take photos securely and email them on to your practice secretary via NHS.net.

Patients should be advised to view this video to help ensure good quality images are returned. A written guide is also available How to Photograph your skin from home (also available on the ICB website for sending link to patients: https://bnssg.icb.nhs.uk/library/how-photograph-your-skin-home/)

There are separate EMIS templates for both lesions and rashes that have been sent to practices to assist with the recording of consultations and auto-population of your skin referral.

David DeBerker has shared a useful presentation with information about different dermatoscopes and tips on taking images

Tips for patients on taking images

Photography for the patient - how to take a good photograph of a skin condition / skin lesion- PCDS

Resources

The following websites may also be useful in deciding whether referral or A and G or management in primary care  is appropriate:

• Primary Care Dermatology Society website - diagnostic tool and A-Z of dermatology conditions with pictures and management advice
• British Association of Dermatologists referral tool - A brief clinical algorithm for some of the most common skin conditions seen in primary, community and secondary care services
• DermnetNZ

Taking and sharing photos - consent

Referrers should ask the patient for consent to share photographs with other healthcare professionals and this should be recorded in the patient record. Please follow the data protection act requirements. Written consent  can also be obtained but this is not compulsory if images are only to be used for the purposes of direct clinical care.

If images are to be used for education or teaching purposes then written consent should be obtained (1).

All clinicians sending photos should be aware of the following:

'If using my own smartphone camera I agree to managing this data securely in accordance with the Data Protection Act requirements. This includes using nhs.net, deactivating cloud photo sharing and deleting the images from my device afterwards. All data and images will be held confidentially and only used for clinical care. The patient has the right to object or withdraw consent at any time by advising me of this.'

An optional consent form can be used such as the one below:

• Dermatology Advice and Guidance Consent Form

Guidance from British Association of Dermatologists

(1) UK-GUIDANCE-ON-THE-USE-OF-MOBILE-PHOTOGRAPHIC-DEVICES-IN-DERMATOLOGY.pdf

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.