Dr Jonathan Engler discusses a teledermatology pilot in Bristol that has resulted in a significant number of patients being treated in the community and avoiding a hospital visit
- NHS Bristol piloted Vantage Teledermatology in 18 GP practices to help address the demand of dermatology care
- Images were sent electronically to the dermatology department of University Hospitals Bristol, and in most cases received a response from secondary care within 48 hours
- 68% of cases were triaged to be managed in primary care settings or in the community. Patients who required a hospital appointment were triaged to the appropriate specialist and waiting list, which helped reduce ‘door-to-door needle times’ and unnecessary consultant-to-consultant referrals
- The service achieved estimated savings of nearly £65,000 in the 9-month period of the pilot; this does not include cost savings made through the shift of minor surgery activity from hospital to primary care
- Following the pilot, a teledermatology service was formally commissioned and implemented in 85 practices across Bristol and North Somerset.
Increasing numbers of referrals to hospital, lengthy waiting times, and cost pressures are all significant barriers to the effective provision of dermatology services. In 2006, 24% of the population in England and Wales sought medical advice for a skin condition, and approximately 6% of patients presenting with a skin problem are referred for specialist advice each year.1 Commissioners in primary and secondary care are therefore looking at ways of managing demand while at the same time ensuring high-quality patient care and cost savings. The Department of Health Operating Framework 2011/2012 encourages the use of digital technology in key areas to support delivery of the quality, innovation, productivity, and prevention (QIPP) agenda.2 This includes the introduction of digital or online services to deliver greater convenience for patients and to free up face-to-face clinical time for individuals who really need it.
Teledermatology is an innovative solution that provides GPs with simple and rapid access to specialist triage and advice. In essence, the system enables primary care clinicians to capture images of routine dermatological conditions using high-quality digital imaging equipment. These images are then sent directly to specialists as part of an electronic referral. The use of teledermatology can allow referrals to be made to secondary care for a face-to-face consultation, if appropriate; however, the aim of teledermatology is to allow the majority of patients to be treated by their own GP following a suitable management plan suggested by the specialist, but without having to attend hospital. This technological solution therefore helps optimise resources in the community and secondary care.
In 2010, the GP lead for dermatology in South Bristol Consortium, Dr Barbara Compitus, conducted an investigation into the current use and benefits of teledermatology in the UK. She became aware of an independent audit by PricewaterhouseCoopers (PwC),3 which highlighted significant clinical and financial benefits of a large-scale pilot of Vantage Teledermatology (VTD) in NHS Hampshire. According to Dr Compitus: ‘It was good timing … Bristol was looking at costs, and I gained support from the local commissioning team and clinicians. It helped that I could always come up with documents or evidence from the Hampshire project to answer their questions or issues … it made sense and seemed intuitive using modern [information technology] systems.’
A business case was soon approved, and a pilot of VTD was implemented across 18 general practices in the South Bristol Consortium in collaboration with the consultant dermatology team based at University Hospitals Bristol (UH Bristol). A project team comprising a dedicated manager from Vantage Diagnostics and stakeholders from the consortium, NHS Bristol, and UH Bristol, including specialists, was set up at the start. This group worked together to:
- confirm protocols
- establish the key performance indicators (KPIs) against which the project would be measured
- develop a communication plan.
Implementation workshops gave GPs the opportunity to see a demonstration of the VTD software, ask questions about the pilot, and suggest ways in which the service would operate most effectively at their practices. Nominated clinicians were appropriately trained in how to capture photographs of skin conditions using the camera and dermatoscope provided. Comprehensive training materials were made available as hard copies, as well as online for later reference; additional resources such as patient consent forms and information sheets were also included. Consultants from UH Bristol were given secure access to the VTD reporting system.
A series of group training sessions led by a local consultant at UH Bristol gave clinicians the opportunity to share their experiences of the service and to receive further guidance on the clinical and technical aspects of teledermatology.
The project team met regularly to review the progress of the pilot. In addition, stakeholders had access to real-time activity data, via the Vantage Analytics portal, which allowed them to:
- ascertain whether the service was meeting the agreed KPIs
- audit activities
- identify areas for improvement in the provision of dermatology care more generally within the community.
After 9 months, NHS Bristol undertook a comprehensive evaluation of the pilot. The findings showed that the teledermatology service was effective in preventing a high proportion of avoidable outpatient appointments in secondary care and had also achieved the expected financial savings. These outcomes, along with positive feedback from clinicians and patients, were also outlined in a recently published QIPP-focused paper on the pilot.4
The advice provided by UH Bristol consultant dermatologists via VTD, resulted in 68% of the 347 patients avoiding a hospital visit and being treated in the community. Routine and urgent cases were triaged directly to the appropriate specialist and waiting list, which helped reduce ‘door-to-needle times’ and unnecessary consultant-to-consultant referrals. In most cases, the management plans were received within 48 hours, which helped facilitate prompt treatment and enhanced the patient experience. In addition, several suspect melanomas were picked up by the system, even though these were formally excluded from the pathway. In effect, the teledermatology service was acting as an additional safety net, permitting such cases to be detected immediately, even though the referring GP had not considered a 2-week wait referral necessary. Steve Rae, who was Commissioning Manager for NHS Bristol during the pilot, was impressed by the service, stating: ‘We are proud of the system, we’ve had very good patient feedback. It’s a simple service, it’s close to home, they don’t have to venture into the hospital, and local care is something we’re very keen on.’
Recording high levels of clinician satisfaction (>90%), the rapid access to expert advice empowered GPs, and provided an ongoing educational framework. The reduction in the number of outpatient appointments in secondary care through management of patients in the community was estimated to have saved nearly £65,000 in the 9-month period of the pilot. After taking into consideration the operating costs and initial set-up commitments for the cameras and training, net savings were calculated at about £28,000;5 however, this does not take into account further potential savings—for example, the shift in minor surgery activity from hospital to primary care and the future benefits that would accrue from GPs’ improved knowledge of dermatology.
Following the success of the pilot, NHS Bristol subsequently procured the service via a formal tendering exercise and VTD is now available to all 56 practices in Bristol and a further 29 practices in North Somerset. At a national level, the Vantage system is widely integrated within the NHS and is used by hundreds of GP practices and several hospital trusts.
A number of challenges were faced during the teledermatology pilot, which provided lessons for future implementation. A degree of ‘pilot mentality’ was evident, with some GPs preferring to wait until the end of the trial and formal commissioning before fully engaging with the service. According to Dr Compitus, it takes time to achieve ‘buy in’ from clinicians, especially when introducing a new pathway and technology; she commented that: ‘Some GPs were sceptical about the efficacy and efficiency of the system. There were also technophobes and traditionalists in some practices, and, in some instances, this is still the case. However, when adopted well, they enjoy using the system a lot.’
It also became apparent that general practices differ widely and often require individually tailored protocols that take into consideration their resources, physical layout, and capabilities. Following feedback from clinicians, a number of technical enhancements and new modules were implemented in the VTD system during the pilot, including a reflective practice log that allows GPs to improve performance by reviewing cases after they have passed through the diagnosis and treatment cycle.
As the Vantage platform may be used to manage and control a wide range of patient data and images, the digital cameras provided for teledermatology could also be used in the fields of podiatry and wound care. Moreover, a secure clinical data communication platform such as that used in the pilot can clearly bring benefits even in areas that do not require images to be sent. A good example is managing the workflow of orthopaedic consultations (secondary care specialists are able to work with primary care even before the patient is seen in hospital), and Vantage is currently trialling such a system in a number of major hospitals.
The potential of innovative technologies to help optimise resources, save money, and improve care is significant. However, the key to realising these benefits is largely contingent on adoption and enthusiasm from stakeholders. The Bristol teledermatology pilot highlighted the importance of gaining clinical ‘buy-in’ from GPs, nurses, and specialists along with the ongoing support of CCG, PCT, and hospital trust leads. This solid infrastructure allowed for effective implementation of the solution, and contributed to the delivery of positive clinical and financial outcomes.
- The evaluation of the teledermatology service described in this article suggests that similar services could be both cost effective and practical for wider roll-out by CCGs
- However, CCGs should seek to define a local business plan for such a service and define what costings would be required to achieve savings over the PbR tariff
- It is important to define whether suspected melanomas are to be excluded from such a service, and to redefine pathways for such cases (a discussion should be held with the NHS Commissioning Board, which will be responsible for commissioning melanoma services via the Specialist Clinical Networks from 1 April 2013)
- A teledermatology service could represent one of the locally commissioned services that practices may be incentivised to use, via the proposed new direct enhanced service in the GMS Contract (if imposed as expected)
- CCGs should consider how to procure such a service, for example:
- rolled out by an existing provider
- a new tendered service
- provided under Any Qualified Provider programme.
- Schofield J, Grindlay D, Williams H. Skin conditions in the UK: a health care needs assessment. Nottingham: Centre of Evidence Based Dermatology, University of Nottingham, 2009.
- Department of Health. The operating framework for the NHS in England 2011/12. London: DH, 2010. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122736.pdf
- PricewaterhouseCoopers. NHS Hampshire: evaluation of Vantage Teledermatology pilot in Hampshire. London: PricewaterhouseCoopers, 2010.
- NHS Bristol. Teledermatology: diagnosis, triage and effective care of dermatology (ID11/0038). London: NHS Evidence, 2012. Available at: www.networks.nhs.uk/news/teledermatology-diagnosis-triage-and-effective-care-of-dermatology
- NHS Bristol. 9-month review of the teledermatology service in south Bristol provided by Vantage Diagnostics. Bristol: NHS Bristol, 2011.G