When a solution has to be more than skin deep

In December 2014 Neath Port Talbot Hospital faced a situation where over 800 dermatology patients were breaching the Welsh referral to treatment target of 26 weeks.

Despite funding being available, the hospital was unable to recruit a further consultant or a locum and waiting list initiatives would not have made a significant impact on such a large number of patients.

There is a national shortage of dermatologists in the UK, with no prospect of an increase in training places. At Neath our team devised a reproducible method of seeing and treating up to 250 new dermatology referrals to secondary care in a single day, using only one consultant, while maintaining excellent patient feedback and preserving the principle of a senior specialist opinion for every patient.

We set up a dermatology screening clinic in which we offered new patients a brief consultation of around 60 seconds. We had five rooms, running simultaneously with patients escorted by a health care assistant or staff nurse throughout their journey. I rotated around the five rooms making a diagnosis and advising on treatment.

There is a national shortage of dermatologists in the UK, with no prospect of an increase in training places

Allowing for some patients needing longer than 60 seconds and the time spent moving between rooms we were able to see 50 patients per hour and 250 patients per day quite comfortably.

The patients were prepared for the concept of this clinic with a letter sent out before their appointment, which explained the nature of the screening and the very limited time that would be available to discuss their condition. They were given the option of turning down this appointment in favour of remaining on the waiting list in their current position.

They were also told they could be reinstated to the waiting list if, for any reason, they felt the screening clinic did not meet their needs.

Instantaneous diagnosis

There are some patients for whom it is obvious from the GP referral that their skin condition will not benefit from a very quick visit and those letters can be screened out in advance. For example, childhood eczema, acne and patients with multiple problems remained on the list for a normal clinic appointment.

The initial aim of the clinic was to provide reassurance to those with benign lesions and to pick up more serious conditions that might not have been diagnosed in primary care.

However, an experienced consultant dermatologist can make an almost instantaneous diagnosis of many simple conditions and it quickly became apparent that a diagnosis and treatment plan could be given to the patient in the vast majority of cases.

All patients were given one of 14 pre-prepared letters based on the outcome of their consultation (see box below). To this standard letter a diagnosis and treatment plan was added by a specialist nurse or medical secretary while the consultant was talking to the patient.

Self treatment of inflamed skin	Cryotherapy
Inflamed skin, refer for allergy testing	Return to nurse led cryotherapy clinic
Day Unit treatment of inflamed skin	5-Fluorouracil treatment
Benign lesion	Laser treatment
Lesion for surgical removal	Chondrodermatitis nodularis
Lesion for referral to plastic surgeon	Unable to help-offer normal appointment
Lesion for radiotherapy	Other

A copy of this letter was sent to the GP and the patient’s notes and a further copy retained for post clinic administration. The letters all contained a link to the New Zealand dermatology website www.dermnetnz.org which has a comprehensive range of patient information leaflets.

The patients’ medical notes were not provided but the GP referral was available and that contained the patient’s medical history and current medications.

In a very small number of cases (less than 2 per cent) I felt it was not possible to provide a diagnosis and/or treatment in a brief consultation. In those cases patients received an apology and the promise of a normal appointment the following week. Some clinic slots had deliberately been kept open to provide for this eventuality. In addition four undiagnosed, and potentially metastatic, skin cancers were picked up and numerous patients whose condition had deteriorated since the original referral were fast tracked to treatment. Many patients required cryotherapy treatment on the day so a second specialist nurse was available to perform this treatment in a dedicated room.

Conclusions

Service manager Kim Beddow says: “Feedback from patients has been overwhelmingly positive. The first 450 patients were given an anonymous feedback form asking how happy they were with their clinic visit.

“Written comments were also invited and only three out of 450 patients gave any negative feedback. Two thought the consultation was too quick and one suggested that wheelchair access could be improved.

“After seeing 1,450 patients with this method, only seven have telephoned to request a conventional follow-up. In addition all the staff involved enjoyed the format of the clinic and the positive response from patients.”

The first 450 patients were given an anonymous feedback form asking how happy they were with their clinic visit

All dermatologists will be familiar with the large number of patients referred with straightforward conditions and incorporating a screening clinic into their timetable would greatly increase their efficiency. For this innovation to be successful they must be experienced enough to make good decisions quickly and be motivated to drastically reduce their waiting list. Their communication skills must be good enough to explain the diagnosis and treatment in a very limited time.

A pilot clinic of 50 patients in one hour will serve as a practice run and as an assessment of their ability to cope in this situation. I would welcome enquiries from managers or clinicians who might like to try this innovation in their own hospitals. It could easily be replicated and has the potential to have a transformative effect on dermatology waiting times throughout the NHS.

Alun Evans is a consultant dermatologist at Abertawe Bro Morgannwg University Health Board.