Healthcare must be delivered in an equitable and inclusive way to everyone. When redesigning dermatology pathways, systems and services must consider the potential for widening health inequality locally and how they can mitigate against this; and use pathway redesign as an opportunity to reduce existing inequalities.

This guidance describes current inequity in accessing dermatology services and considers the potential for service redesign, particularly teledermatology and remote consultations, to further reduce access to care for some people with skin conditions; and suggests actions to provide equitable access.

This resource is not an equalities health impact assessment. Developed by dermatology stakeholders, its purpose is to inform local assessment for pathway redesign, and systems must consider their own population make up in this.

Current challenges and areas of inequality

People with skin conditions face a range of inequalities in care; some appear to be widening. The starting point when redesigning pathways for dermatology services should be a baseline assessment of inequalities in care.

1. Inequity of access to specialist dermatology services

The Getting it Right First Time (GIRFT) report 2021 identified wide variation in access to specialist dermatology services in the UK, driven in large part by workforce issues. The report’s recommendations for new models of care stress the importance of developing regional or sub-regional strategic plans for sustainable partnerships between local trusts to eliminate single-handed working and support smaller units. Other recommendations link to the redesign of pathways and have been taken forward by the National Outpatient Recovery and Transformation Programme.

2. Inequity of access to regional dermatology services

The GIRFT report also identified variation in access to regional services, in particular specialist skin cancer services such as Moh’s micrographic surgery and melanoma oncology services. National and regional specialist commissioners need to work together to ensure equity of access to these specialist services to improve outcomes for people with skin cancer.

3. Skin tone

The look of some conditions can depend on a person’s skin tone, and some skin conditions are more common or unique in people with brown or black skin. In 2019/20 10% of all specialist dermatology consultations in England and Wales were with people with brown or black skin (NHS data), but this proportion will vary across the country. Local systems need to look carefully at their local population needs in relation to delivering appropriate specialist dermatology services for people with brown or black skin.

To serve our diverse society equally and efficiently, it is essential that clinicians are familiar with conditions that are unique, more frequent or clinically variable in different skin tones. The appendix lists resources and image galleries to support managing the specific challenges in the diagnosis and management of skin conditions in people with different skin tones.

4. Psychological support

Many people with long-term skin conditions need psychological support. A large study (Dalgard et al 2015) reviewed the psychological burden of skin disease and identified a clear link between depression, anxiety and suicidal ideation in people with skin conditions. Other patients may have mental health disorders that manifest in skin disease.

The All Party Parliamentary Group on Skin’s 2020 report included a survey which found that 98% of people reported their skin condition affected their emotional and psychological wellbeing. People working with patients with skin conditions have also highlighted the likely negative impact of the COVID-19 pandemic on mental health.

Holistic assessment and person-centred care to ascertain the psychological and social impact of skin conditions is vital, together with signposting and referral to appropriately resourced mental health services. Pathway redesign provides the opportunity for dermatology services to develop links to psychological support services. The appendix identifies resources to support this.

5. Digital exclusion

The introduction of digital solutions, such as teledermatology and remote consultations, in service design must not limit access for those who do not have a smart phone/device, computer or internet connection, or are not digitally literate. The likely age of the patient group is an important consideration; those with skin cancer may be disproportionately older and they may not be digitally literate. People living in areas of deprivation may be less likely to have access to the necessary digital equipment. The development of inclusive alternatives needs to be considered; for example, a hub in the community where a person can get an image of their skin condition taken or a video conferencing centre.

Research shows that remote consultations are more acceptable to younger patients, and more suited to ‘simple’ problems that do not require such an ‘information rich’ consultation as achieved by face to face appointments.

Digital access to healthcare does not equate to equitable access; reasonable adjustment is needed for those who are excluded when assessing the place for teledermatology and remote consultations in dermatology. This NHS Digital resource gives guidance on how to create an inclusive service online, including information on accessibility software and design principles, and further resources are listed in the appendix.

Potential inequalities introduced with dermatology pathway redesign

This section considers the possible inequalities that could arise when implementing the new pathways of care, and suggests ways that systems/providers can mitigate against these.

1. Teledermatology

This involves asking patients, their carers or primary care healthcare professionals to send images to support advice and guidance, specialist triage, clinical prioritisation and implementation of a virtual 2-week wait skin cancer pathway. Further information can be found in the teledermatology roadmap.

Potential adverse impacts and actions to mitigate them:

• Patients may not have access to image-taking equipment and/or be able to send good quality images, meaning teledermatology care pathways are unavailable to them.

• Images of skin rashes may not show the severity and extent of the rash, so the patient is not triaged with the appropriate urgency.

• Rashes and lesions in patients with brown and black skin types or hard to see body sites, eg the scalp, may be more challenging to assess and diagnose.
  Skin conditions affecting intimate areas of the body (breasts, genitalia, perianal area) may not be suitable for teledermatology.

• Substituting a face-to-face consultation with an exchange of images and text may miss important points in the history and examination, with attendant clinical risk.

• Without direct communication between the specialist and patient (communication is via the primary care clinician), there is the potential that the diagnosis and management are not as well explained to the patient.

• Reduction in face-to-face interactions and move towards ‘single lesion’ diagnostic services will reduce the number of skin cancers discovered as incidental findings.

2. Remote consultations

This involves patients having a telephone or video consultation instead of a face-to-face consultation to review their skin condition.

Potential adverse impacts and actions to mitigate them:

• Patients and clinicians may not have access to the required technology for a video consultation, eg laptop/tablet/internet connection. Although their carers or relatives may be able to help, patients may prefer not to involve others in their care.

• The quality of video reception and images may be poor, and it may be difficult to assess the skin properly unless images are taken in good light and with a good quality camera.

• Rashes and lesions in patients with brown and black skin types or hard to see body sites, eg scalp, may be more challenging to assess and diagnose.
  
  Skin conditions affecting intimate areas of the body (breasts, genitalia, perianal area) may not be suitable for remote consultations.
  
  Chaperones (appropriately trained healthcare professional) are not available.

• More difficult for the patient to express and for the healthcare professional to assess the psychological impact of the skin condition.
  
  More difficult for the patient and the healthcare professional to develop a relationship.

• No opportunity to show the patient how they should apply topical treatment and give them a choice of emollient; likely to reduce treatment efficacy.

• Lack of access to printed resources to support the consultation and access to prescriptions.

3. Patient initiated follow-up (PIFU)

Patients on a PIFU pathway can book a review appointment when they need it.

Potential adverse impacts and actions to mitigate:

• Patients may not understand the system and be reluctant to re-access care.

• Patients may not recognise when specialist help and advice may benefit their care.

• The service may not be accessible to those who do not have self-determination and have to use gatekeepers, eg prison, care homes, disabled, etc.

• Ensuring that patients see the correct member of the team in a timely fashion may be a challenge.
  
  Risk that those ‘in the system’ will be prioritised and those trying to re-access the service may lose out.

4. Referral optimisation for dermatology

This is the process whereby a primary care healthcare professional seeks specialist advice from another provider. It usually requires images to be sent.

Potential adverse impacts and actions to mitigate them:

• Specialist advice is dependent on high quality images and a good history from the patient.

• The use of pre-referral specialist advice, using teledermatology, as the ‘front door’ to services requires a new model of care for specialist providers; systems may be overwhelmed when this approach is introduced and delays may occur.

5. Potential impact on health inequalities when introducing the 2-week wait skin cancer pathway

Potential adverse impacts and actions to mitigate:

• The new virtual pathway requires high quality dermoscopic images to be sent with the referral. Lack of access to suitable image-taking services will mean patients have to attend hospital appointments.

Acknowledgements

We are grateful to the following members of the advisory group for their involvement in the development of this guidance.

• British Association of Dermatologists: Dr Tanya Bleiker; Tania Von Hospenthal
• British Association of Dermatologists Teledermatology Committee: Dr Carolyn Charman
• Patient representatives and organisations: Amanda Roberts – BAD patient group; Emma Rush – BAD patient group and Vitiligo Support UK; Andy Proctor – National Eczema Society; Helen McAteer – Psoriasis Association UK
• Primary Care Dermatology Society: Dr Angelika Razzaque to 30 June, then Dr Timothy Cunliffe; Dr Naomi Kemp
• British Dermatological Nursing Group: Rebecca Penzer-Hick (Chair BDNG)
• Getting It Right First Time: Dr Nick Levell – Dermatology Clinical Lead

Appendix: Resources

Skin tone: mitigation and image galleries

• Centre of Evidence Based Dermatology (CEBD) Skin of colour resource: complied by Dr Douglas Grindlay and Dr Sharon Belmo, brings together up to date evidence-based information including systematic reviews, review articles, guidelines and patient information on topics of relevance to skin of colour.
• British Association of Dermatologists Skin of colour in dermatology: lists educational resources for clinicians looking to learn more about skin disease in skin of colour
• Dermnet NZ Dermatological conditions in skin of colour: collation of links to clinical information about a range of skin conditions affecting skin of colour.
• Skin Deep (sub-section of a paediatric website): ‘Don’t forget the bubbles’ provides an extensive bank of high quality paediatric skin of colour images.
• VisualDx: a diagnostic clinical support tool available on subscription. Subscription gives access to an extensive skin of colour image bank. With the Skin of Colour Society and NEJM Group, VisualDx has also produced a series of webinars about skin of colour.
• Journal of Drugs in Dermatology: the website’s skin of colour section offers a wide range of skin of colour publications as well as updates on conferences, webinars and CME.

Psychodermatology

• Find an NHS psychological therapies service (IAPT): Patients can self-refer to local IAPT services for depression and anxiety, and this NHS website gives details of how they can do so. It is important to use this link when signposting patient displaying potential mental health distress.
• British Association of Dermatologists Skin Support: website provides comprehensive resources to support the wellbeing of people suffering from skin conditions alongside links to national, regional and local support groups.
• Changing Faces: a charity for people with scar, marks or conditions on their face or body that makes them look different.

Digital exclusion

• NHS Digital: What we mean by digital inclusion
• NHS Digital: Why digital inclusion matters to health and social care
• Office for National Statistics: Exploring the UK’s digital divide
• Rogers M, Raine G, Thomas S, Harden M, Eastwood A (2019) Informing NHS policy in ‘digital-first primary care’: a rapid evidence synthesis