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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Melanoma

Warning

Cutaneous Melanoma: A skin cancer of the melanocytes in the skin. Melanoma is the third most common skin cancer in the UK. It accounts for more cancer deaths than all other skin cancers combined. Although melanoma is more often diagnosed in older people, it is increasingly affecting younger people. It is the second most common cancer in adults aged between 25 and 49. Most melanomas occur in people with pale skin. Precursor lesions include acquired and large congenital melanocytic naevi (moles), and dysplastic naevi but at least 50% appear with no preceding lesion. Several histologic variants have been recognized, including superficial spreading melanoma, acral lentiginous melanoma, nodular melanoma, and lentigo maligna melanoma.  

 

Please see key messages with scenarios outlining common situations where people have benign lesions that cause some concern and need additional evaluation over time. 

 

Scottish Referral Guidelines for suspected cancer are available at the following link - https://www.cancerreferral.scot.nhs.uk/Home 

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Benign: 

Referral is not usually required for obviously benign lesions, Features which are generally reassuring and suggest a benign lesion include: 

  • Regularity of colour, surface, and border. 
  • Rapid growth over days rather than weeks – common with trauma or inflammation. 
  • 'Stuck on' appearance with keratotic plugs on the surface (suggests a seborrhoeic keratosis). 
  • A pigmented lesion in a child (melanoma is very rare in this age group). 

Risk evaluation: 

Risk evaluation indicating at risk people includes the following: 

  • A personal history of skin cancer.  
  • A family history of skin cancer.  
  • Pale skin (Fitzpatrick Skin Type I and II) that burns easily.  
  • Red, blonde or light-coloured hair. 
  • Blue or green eyes. 
  • History of sunburn, particularly blistering sunburn in childhood. 
  • A large number of moles. 
  • Unusually high sun exposure (living or spending frequent periods in hot countries). 
  • Use of tanning beds or sun beds, particularly if 10 or more sessions.  
  • Increasing age.  
  • Immunosuppression 
  • Pigmented lesions which 'stand out from the crowd' because they are different (the 'Ugly Duckling sign') are a cause for concern, especially if they are changing.  

The Weighted 7-point checklist may be used to assess pigmented skin lesions, and determine referral:  

o Major features of the lesion (2 points each): change in size, irregular shape or border, irregular colour. 

o Minor features of the lesion (1 point each): largest diameter 7 mm or more, inflammation, oozing or crusting of the lesion, change in sensation (including itch). 

o Suspicion is greater for lesions scoring 3 points or more. However, if there are strong concerns about cancer, any one feature is adequate to prompt urgent referral under Urgent Suspicion Of Cancer (USOC) arrangements.

The ABCD(E) system can also be used for pigmented lesion assessment (http://www.pcds.org.uk/clinical-guidance/melanoma-an-overview1) 

 

Refer using a Routine priority (as long as there is no index lesion of concern, where USOC needed) for risk estimation if people are at higher risk of melanoma, such as those with: 

  • Giant congenital pigmented naevi (risk is highest for those measuring 20 cm in diameter or more). 
  • A family history of 3 or more cases of melanoma and/or family history of pancreatic cancer— Those with two cases in the family may also benefit, especially if one of the cases had multiple primary melanomas or the atypical mole phenotype.  
  • More than 100 normal moles. 

Atypical moles, see: https://www.pcds.org.uk/clinical-guidance/atypical-dysplastic-melanocytic-naevus  (particularly if multiple). 

Possible malignant: 

Urgently refer (using USOC, or similar, urgent pathway) to a dermatologist, plastic surgeon, or other suitable specialist with experience of melanoma diagnosis if: 

  • The lesion is suggestive of malignant melanoma (including nodular and amelanotic melanoma). For example: 
  • Lesions scoring 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each) on the 7-point checklist. However, any one feature is adequate to prompt urgent referral. 
  • New nodules which are pigmented or vascular in appearance. 
  • Nail changes, such as a new pigmented line in the nail or pigmentation under the nail that differs from other nails. 
  • A skin condition is persistent or slowly evolving and unresponsive, with an uncertain diagnosis, and melanoma is a possibility. 
  • A biopsy has confirmed the diagnosis of malignant melanoma. Note: normally such patients would be referred prior to excision. 

A copy of the pathology report should be sent with the referral correspondence, as there may be details (such as tumour thickness, excision margin) that will specifically influence further management.

Scottish Referral Guidelines for suspected cancer are available at the following link - https://www.cancerreferral.scot.nhs.uk/Home 

Referral Management

Benign: 

Manage in primary care. Consider scenarios 1 to 3 in Key messages. Review access to alternative providers for patient access to benign lesion treatments outside the NHS. 

Risk evaluation: 

 

Possible malignant: 

Refer using the USOC pathway for skin cancer. 

 

Scottish Referral Guidelines for suspected cancer are available at the following link - https://www.cancerreferral.scot.nhs.uk/Home 

Clinical tips

  • Lesions change over time and a benign diagnosis at initial assessment may need to be reviewed if the lesion changes. Initial safety netting by check in 3 months against baseline photos is current NICE guidance for lesions with some measure of uncertainty. For itchy benign-appearing lesions causing uncertainty, see scenario 2 in Key Messages. 
  • Photography is key for monitoring of lesions, sharing the diagnostic process and helping patients self-monitor. It improves the quality of the GP record and can be used for teledermatology. See scenarios below illustrating common dilemmas 

Scenario 1  

Low suspicion of malignancy: teledermatology may be used outside the USOC process, where locally available. Include a stable non-changing clinically benign skin lesion, but where the clinical diagnosis is uncertain and doesn’t satisfy 7 point checklist. Suitable photos are essential: 

take at least 3 images of the lesion, once indicated with an inked arrow or circle, including:  

  • regional photograph with lesion indicated with ink.  
  • macro image plane and at an angle.  
  • dermoscopic image with and without gel/polarisation.  

Include core history: 

  • see Risk Evaluation: e.g. evolution, symptoms, skin type, family history, eye colour, episodes of burning, high mole count.  

Scenario 2 

For a pigmented lesion which does not satisfy criteria for referral but is difficult to evaluate, consider the following: 

  • Take a photograph (see scenario 1)  
  • Ask a senior colleague with additional expertise/dermoscopy skills.  
  • Where the lesion is itchy and suspicious for seborrhoeic keratosis take a photo, use emollient and moderate potency steroid for 3 weeks and review to ensure return to previous appearance. 

Scenario 3  

For someone with multiple pigmented lesions which appear benign but give rise to uncertainty: 

  • Highlight with ink (number and arrow) those that warrant monitoring or assessment and take regional /macro/dermoscopy photos. Suggest patient participates in self-monitoring with Apps (review NHS Apps). Failure to number them in regional photo will risk misidentification. 
  • If atypical see “risk evaluation” 

ICD search categories

Malignant 

ICD11 code - 2C30 

Editorial Information

Last reviewed: 24/05/2023

Next review date: 24/05/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society