2.2.2 Telemedicine: See Primary Assessment Information - IT requirements

2.2.3 Diagnostic biopsy: See NICE Guidelines - Improving outcomes for people with skin tumours including melanoma. GPs biopsy and treat SCC in situ or prefer to refer to Community Skin Cancer clinic or LSMDT Hospital clinic (working within NICE IOG guidance)

WORKFORCE FUNCTIONS
2.2.1 & 2: Telemedicine & Diagnostic Biopsy
- Enable individuals to make health choices and decisions regarding their own health or the health of others
- Receive and pass on messages and information
- Capture visual images for transmission to another location
- Determine an individuals state of physical health and fitness
- Prioritise treatment and care for individuals according to their health status and needs
- Provide information and advice to individuals/carers on managing health care needs
- Obtain specimens invasively
- Obtain specimens non-invasively

2.3 Primary Treatment thresholds & Decision Aids
- Undertake a risk assessment in relation to a defined health need
- Assess an individuals needs arising from their health status
- Assess an individuals suitability to undergo planned actions
- Determine a diagnosis and prognosis for an individual
- Refer individuals to specialist services for treatment and care

SERVICE IMPROVEMENT
A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information.

COMMISSIONING AND CONTRACTING
Generic Patient Reported Outcome Measures exist for this pathway (EQ5D). Currently clinical consensus has not been reached for a condition specific measure.

3.2.2 Diagnostic biopsy: LSMDT members may consider diagnostic biopsy for suspected Bowens disease and BCC

3.2.3 Dermoscopy: LSMDT members and trained GpwSI

WORKFORCE FUNCTIONS
3.2.2 Biopsy
- Determine an individuals state of physical health and fitness
- Prioritise treatment and care for individuals according to their health status and needs
- Provide information and advice to individuals/carers on managing health care needs
- Obtain specimens invasively
- Obtain specimens non-invasively

3.2.3 Dermoscopy
- Obtain images of organs and tissues using light sensitive film and digital imaging equipment
- Interpret and report on the findings of investigations
- Prepare individual for healthcare actions
- Support individuals to prepare for, adapt to and manage change

3.3 Primary Treatment Thesholds
- Undertake a risk assessment in relation to a defined health need
- Assess an individuals needs arising from their health status
- Assess an individuals suitability to undergo planned actions
- Determine a diagnosis and prognosis for an individual
- Refer individuals to specialist services for treatment and care

SERVICE IMPROVEMENT
A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information.

Change in size shape or colour, new mole, scaly, scabbing, bleeding, crusting, changing moles should all be referred into primary care for review
Workforce and Equipment: Dermoscopy, provided the clinician in suitably trained, may be a service provided in primary care
IT Requirements: Telemedicine links may be considered in some geographical areas. There is little evidence to date that telemedicine is a useful addition to pathways. In a recent study on the efficiency of resource allocation in teledermatology it took one consultant session and 2 sessions of specialist dermatology nurses to see 18 patients. 60% of these were then required to attend the hospital. This compares poorly with normal clinic allocation of resources. It applies to the model of teledermatology as "substitute for consultation" rather than as "supplement to telephone". (Source: British Teledermatology Society 2007)

Catching on clothes, painful, itching. Non-healing, enlarging skin lesion.

In the UK 8000 Malignant Melanoma (MM) diagnosed per year (in 2001 6432 new MM in England + Wales with 1500
deaths). GPs will see 1 malignant melanoma approximately every 5 years. Data from 2001 for NMSC: 65 per 100,000 in females and 96 per 100,000 in males.
BCC to SCC ratio of 4:1. 400 deaths /year from NMSC in UK
Possible malignant melanoma or squamous cell carcinoma require rapid referral via the 2 week skin cancer pathway

WORKFORCE FUNCTIONS
- Support individuals to undertake and monitor their own healthcare
- Support individuals to undertake and monitor their own healthcare
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Receive and direct requests for health care assistance using protocols and guidelines

Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page.

WORKFORCE FUNCTIONS
- Receive and direct requests for health care assistance using protocols and guidelines
- Refer individuals to specialist services for treatment and care

Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page.

Referral Thresholds: Suspected BCCs / symptomatic benign lesion must be managed by an LSMDT member, either a Community Skin Cancer Clinician or Hospital clinic, in order to meet the NICE IOG.
Consider direct referral to Plastic Surgery / Oculoplastic surgery where appropriate. This will depend on availability of local specialties

Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page.

WORKFORCE FUNCTIONS
- Receive and direct requests for health care assistance using protocols and guidelines
- Prioritise treatment and care for individuals according to their health status and needs
- Refer individuals to specialist services for treatment and care
- Advise and support others pending the attendance of a healthcare practitioner
- Refer individuals to specialist services for treatment and care

TECHNOLOGY

Oldham Community PAS system for recording 18 week journeys through ICATs or other intermediate services.

The Dermatology Department at the West Suffolk Hospital, redesigned the pathway for referral of possible basal cell carcinoma into secondary care which gave GPs information about where to direct their referral dependent on the nature and location of the lesion. This avoided Consultant to Consultant referrals causing delay. Read the case study here.

COMMISSIONING AND CONTRACTING
Can the quality of primary care be improved to help referrals?

Referral Thresholds: Symptomatic benign skin lesion where outside capacity of specialist assessment teams. Complex BCCs and rare tumours. These are likely to be cases requiring complicated surgery/treatment e.g. Mohs micrographic surgery.
Consider direct referral to Plastic Surgery / Oculoplastic surgery where appropriate. This will depend on availability of local specialties. Consider Mohs - if head and neck ill defined lesions, recurrent BCC

Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page.

WORKFORCE FUNCTIONS
- Receive and direct requests for health care assistance using protocols and guidelines
- Prioritise treatment and care for individuals according to their health status and needs
- Refer individuals to specialist services for treatment and care
- Advise and support others pending the attendance of a healthcare practitioner
- Refer individuals to specialist services for treatment and care

WORKFORCE FUNCTIONS
4.2.2 Biopsy
- Determine an individuals state of physical health and fitness
- Prioritise treatment and care for individuals according to their health status and needs
- Provide information and advice to individuals/carers on managing health care needs
- Obtain specimens invasively
- Obtain specimens non-invasively


4.3 Treatment Thresholds
- Undertake a risk assessment in relation to a defined health need
- Assess an individuals needs arising from their health status
- Assess an individuals suitability to undergo planned actions
- Determine a diagnosis and prognosis for an individual
- Refer individuals to specialist services for treatment and care

WORKFORCE
- Assess an individuals needs arising from their health status
- Arrange access to resources needed to support planned health care/lifestyle programmes
- Evaluate treatment plans with individuals and those involved in their care
- Reflect on and evaluate your own values, priorities, interests and effectiveness
- Audit your own clinical practice

WORKFORCE
-Assess an individuals needs arising from their health status
- Arrange access to resources needed to support planned health care/lifestyle programmes
- Evaluate treatment plans with individuals and those involved in their care
- Reflect on and evaluate your own values, priorities, interests and effectiveness
- Audit your own clinical practice

WORKFORCE
- Assess an individuals needs arising from their health status
- Arrange access to resources needed to support planned health care/lifestyle programmes
- Evaluate treatment plans with individuals and those involved in their care
- Reflect on and evaluate your own values, priorities, interests and effectiveness
- Audit your own clinical practice

Examination: Pigmented lesions, Glasgow 7-point checklist
Major features
Change in size
Irregular shape
Irregular colour
Minor features
Diameter >7mm
Inflammation
Oozing
Change in sensation
Clinical features of BCC, SCC, Bowens disease

WORKFORCE FUNCTIONS
2.0 Primary Assessment
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Undertake routine clinical measurements
- Assess an individual with a suspected health condition
- Determine an individuals state of physical health and fitness

2.1 Primary Diagnostic Thresholds and Decision Aids
- Agree the nature and purpose of assessment and investigation into an individuals health status
- Plan assessment and investigation into an individuals health status
- Select assessment and investigative techniques/procedures for use
- Agree courses of action following assessment

SERVICE IMPROVEMENT
Key documents to be considered along this pathway are located here .

Middlesborough PCT addressed long wiats in secondary care for patients with skin lesions by setting up the Middlesborough Primary Skin Care Service. Read more about the service by clicking on the hyperlink above.

There is also a link to the CCH website where there is a practical example of Surgical Care Practitioners providing minor surgery from Leeds PCT.

COMMISSIONING AND CONTRACTING
See the Contractual Levers for 18 week Pathways for more detailed directions and guidance that underpin primary care contracting. Before starting commissioning consider existing primary care medical contracts. Are you already paying for this work? Is it more appropriate to commission this stage of the pathway from primary care contractors? Have your Practice Based Commissioning (PBC) groups considered this pathway for any service redesign? Have you considered the contractual options to commission the pathway at primary care level?
Is the current primary care contract fully utilised? Is there capacity to commission additional activity under additional or enhanced service arrangements?

Where Community Cancer Clinicians are managing low risk BCCs as per IOG Guidance see the Guidance and competencies for the provision services using GP with Special interests (GPwSI)- Dermatology and Skin Surgery. The guidelines have been developed at two levels. The first is a generic document Implementing Care Closer to Home Providing Convenient Quality Care for Patients, which has been developed by the Practitioner with a Special Interest
National Accreditation Steering Group. This document is broken into three parts:
Part 1: Introduction to commissioning more specialised care closer to home
Part 2: Step by Step guide to commissioning more specialised care delivered by accredited Practitioners with Special Interests in community settings
Part 3: National Guidelines for the Accreditation of GPs and Pharmacists with Special Interests
The second set of documents are specialty specific guidelines for dermatology & skin surgery. The steps needed for specialty specific accreditation link into the generic accreditation requirements. The full title for the specialty specific work on skin is Guidance and competencies for the provision services using GP with Special interests (GPwSI)- Dermatology and Skin Surgery.
The generic document can be found on www.pcc.nhs.uk/173.php
www.pcc.nhs.uk/uploads/pwsis/gpwsis_dermatology.pdf
High risk BCC should be managed by appropriately trained specialist who is member of the LSMDT
Workforce and Equipment: Unless only treating benign skin lesions all clinicians involved in the specialist assessment will be members of the local skin cancer MDT (LSMDT). GPwSIs involved in the assessment and management of skin lesions need to fulfil the mandatory DH guidance and the requirements for community cancer clinicians. See link to the new GPwSI guidance (generic and speciality specific at: Implementing care closer to home convenient quality care for patients Parts 1-3 http://www.pcc.nhs.uk/173.php and National Guidelines for the accreditation of GPwSIs: Dermatology and skin surgery,
http://www.pcc.nhs.uk/uploads/pwsis/gpwsis_dermatology.pdf and IOG Guidance http://www.nice.org.uk/page.aspx?o=csgstim&c=skin

WORKFORCE FUNCTIONS
3.0 Specialist Assessment
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Undertake routine clinical measurements
- Assess an individual with a suspected health condition
- Determine an individuals state of physical health and fitness

3.1 Specialist Diagnostic Thresholds
- Agree the nature and purpose of assessment and investigation into an individuals health status
- Plan assessment and investigation into an individuals health status
- Select assessment and investigative techniques/procedures for use
- Agree courses of action following assessment

Key documents to be considerd along this pathway are located here

WORKFORCE FUNCTIONS
4.0 Supra specialist assessment
- Obtain information from individuals to support assessment of their health status and needs (History Taking)
- Undertake routine clinical measurements
- Assess an individual with a suspected health condition
- Determine an individuals state of physical health and fitness

4.1 Supraspecialist Diagnostic Thresholds
- Agree the nature and purpose of assessment and investigation into an individuals health status
- Plan assessment and investigation into an individuals health status
- Select assessment and investigative techniques/procedures for use
- Agree courses of action following assessment

Key documents to be considerd along this pathway are located here

Changing skin growth/lesion causing concern. Worrying skin lesion as identified by patient health professional relative or friend.

2.4.1 Reassurance, Information & Self-Help: Information may include: checking your moles: what to look out for, how to reduce your risk of skin cancer, sun protection advice

2.4.2 Active Monitoring: Consider photograph now and at review

2.4.4 Non-Surgical Tx: Acinitic Kerastoses (AKs): 5-Fluorouracil cream (Efudix), 3% diclofenac sodium gel (Solaraze) or cryotherapy.
Bowens disease: 5-Fluorouracil cream (Efudix), or cryotherapy
Superficial BCCs: Consider 5% Imiquimod cream (Aldara) , 5-Fluorouracil cream (Efudix), or cryotherapy. Manage only if approved member of LSMDT

2.4.6 Surgical Tx: Straight forward benign symptomatic lesions eg small lesions on low risk sites, or those that can be removed by shave excision and/or curettage and cautery can be removed by health care professionals that have demonstrated competencies within the framework detailed in the National Guidelines for the accreditation of GPwSIs: Dermatology and skin surgery. http://www.pcc.nhs.uk/uploads/pwsis/gpwsis_dermatology.pdf. More complicated benign skin lesions eg larger cysts, lipomas and lesions on higher risk sites such as face and keloid prone areas, should be referred to practitioners that have demonstrated the appropriate level of competencies to manage such patients and are working within robust clinical governance framework.
Process Planning Events: For simple benign skin lesions being excised within local priority frameworks aim for one-stop shop assessment and surgical excision service where appropriate. Patients must have enough time to give informed consent about their surgery

WORKFORCE FUNCTIONS
- Provide information and advice to individuals/carers on managing health care needs
- Support individuals to access and use services and facilities
- Discharge individuals

2.4.2 Active Monitoring
- Determine an individuals state of physical health and fitness
- Support individuals to prepare for, adapt to and manage change
- Support individuals to undertake and monitor their own health care
- Support individuals to access and use services and facilities
- Provide information and advice to individuals/carers on managing health care needs

2.4.4 Medication +/- Cryotherapy
- Prescribe pharmaceuticals to achieve specified health goals
- Manage an individuals medication to achieve optimum outcomes
- Administer medication to individuals
- Support individuals to self medicate
- Support individuals to prepare for, adapt to and manage change
- Other relevant functions in development/to be identified

2.4.6 Surgical Treatments
- All aspects of surgery and the surgical environment are relevant this area is still in development

SERVICE IMPROVEMENT
For good practice pre-operative assessment guidance, use the hyperlink above or see the website

3.4.1 Reassurance, Information & Self-Help: Lesion may need no intervention, patient discharged

3.4.2 Active Monitoring: May advise no action at present. For multiple atypical naevi considered at low risk, will need access to high quality medical photography and storage of digital images (with copies supplied to patients for self monitoring). For those with higher risk e.g. with positive family or personal history of malignant melanoma, consider long term monitoring. Review as clinically appropriate and denote by self, GP, specialist

3.4.3 Psychological Treatment: Psychological treatment and support, patient information as per NICE IOG. Access to skin cancer nurse where appropriate.
Minimum requirement to manage the patient is approved member of LSMDT

3.4.4 Non-Surgical Tx:
Cryotherapy, topical treatments (5-Fluorouracil cream [Efudix], 5% Imiquimod cream [Aldara], 3% Diclofenac sodium gel [Solaraze]) , Photodynamic therapy provided by suitably trained clinicians as per NICE IOG

3.4.5 Pre-op Assessment: Check PMH/Current drug therapy / allergies / resp function

3.4.6 Surgical Tx: For management of basal cell carcinomas and benign lesions causing functional impairment. LA DC or Procedure room. All equipment and facilities to be accredited to meet national standards
Specialist Assessment Definitive Treatments (with agreed treatment thresholds)
Specialist Assessment (e.g. Interface services - ICATS & CATS; Outpatient Services)

WORKFORCE FUNCTIONS
3.4.1 Reassurance, Information, Self-help
- Provide information and advice to individuals/carers on managing health care needs
- Support individuals to access and use services and facilities
- Discharge individuals

3.4.2 Active Monitoring
-Determine an individuals state of physical health and fitness
- Support individuals to prepare for, adapt to and manage change
- Support individuals to undertake and monitor their own health care
- Support individuals to access and use services and facilities
- Provide information and advice to individuals/carers on managing health care needs

3.4.3 Psychological
- Support individuals to prepare for, adapt to and manage change
- Other relevant functions in development

3.4.4 Non-Surgical
- Prescribe pharmaceuticals to achieve specified health goals
- Manage an individuals medication to achieve optimum outcomes
- Administer medication to individuals
- Support individuals to self medicate
- Plan activities, interventions and treatments to achieve specified health goals
- Produce treatment parameters for clinical/therapeutic interventions

3.4.6 Excision, curettage and cautery
- All aspects of invasive surgery and the surgical environment are relevant - this area is still subject to development

SERVICE IMPROVEMENT
For good practice pre-operative assessment guidance, use the hyperlink above or see the website

4.4.3 Physical/Psychological Treatment: NICE Interventional Procedure Guidance 155 - Photodynamic therapy for non-melanoma skin tumours (including premalignant and primary non-metastatic skin lesions). Psychological treatment and support, patient information as per NICE IOG. Access to skin cancer nurse where appropriate

4.4.4 Non-Surgical Treatment: Photodynamic therapy where beyond the remit of LSMDT. Radiotherapy as required

4.4.6 Surgical Treatment: NICE Guidance on Cancer services Feb 2006 Improving Outcomes for People with Skin Tumours including Melanoma p163
http://guidance.nice.org.uk/csgstim

WORKFORCE FUNCTIONS
4.3.3 Psychological
- Support individuals to prepare for, adapt to and manage change
- Other relevant functions in development

4.4.4 Non-surgical
- Prescribe pharmaceuticals to achieve specified health goals
- Manage an individuals medication to achieve optimum outcomes
- Administer medication to individuals
- Support individuals to self medicate
- Plan activities, interventions and treatments to achieve specified health goals
- Produce treatment parameters for clinical/therapeutic interventions

4.4.5 Pre Operative Assessment
- Assess an individuals suitability to undergo planned actions
- Provide information and advice to individuals/carers on managing health care needs

4.4.6 Surgical Treatment
- All aspects of invasive surgery and the surgical environment are relevant - this area is still subject to development