A dermatologist checks for skin cancer. Photo: Joe Raedle/Getty Images
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Worried about your moles? GPs are here to help – except they’re not allowed

A deluge of mole-owners have put pressure on health services.

A letter arrived this past week from our local dermatology department, telling us that it is closed to new patients. Actually, that’s not quite true: the department will still see suspected cases of the two most serious forms of skin cancer, but everyone else will have to go elsewhere. Except that there isn’t anywhere else to go. GPs manage the vast bulk of skin problems but there is a range of conditions that need consultant input. For the time being, that service is not available.

There are a few factors behind this, not least the government’s 18-week referral-to-treatment target. If a hospital isn’t able to see patients within that timescale then it gets a big slap on the wrist. The immediate solution for a department facing imminent breaches is to stop taking referrals, giving itself breathing space in which to deal with the backlog.

Where has the backlog come from? The dermatologists believe it’s a direct result of the Be Clear on Cancer campaign, the skin cancer component of which was piloted in our area last year, advising people to get moles checked if they’d noticed any change in them. The problem is that a) virtually everyone has moles, and b) invariably over time they change. Most often they are harmless. The problem with cancer campaigns is they push these issues to the forefront of people’s minds, so when a small change occurs it becomes disproportionately worrying. This has led to a surge in the numbers of people consulting their GPs with pigmented skin lesions. While dermatology would like to blame the cancer awareness campaign for its present woes, it has, as a specialty, made its own contributions to the crisis.

The problem for GPs is that, although it is usually possible to be sure a mole is harmless, sometimes there is an element of doubt. In the early years of my career, we would solve this dilemma by making a simple excision under local anaesthetic at the surgery and sending the specimen to the lab to ensure it was definitely benign. On rare occasions, the biopsy would show it was an unsuspected melanoma (the most aggressive form of skin cancer), which would require that the patient be referred for wider excision of the problem area, and possibly further cancer treatment.

Over the past decade, however, this practice has come to be frowned upon, largely because dermatologists are mistrustful of GPs doing an adequate job of the primary excision. In fact, most GPs carrying out minor surgery are more than competent – but the dermatologists’ response was to turn the assessment of pigmented lesions into a secondary-care-only service. Any GP these days who performs an excision biopsy of a pigmented lesion that turns out to be an unsuspected melanoma will face an investigation and severe sanction for having dared to deviate from “best practice”.

This same process of the specialisation of skin surgery has extended to encompass even the most indolent form of skin cancer, called basal cell carcinoma. This rarely spreads, and most types are readily treatable in primary care. This was also standard practice in my early years as a GP but again it has now become a specialist-only pursuit. GP minor surgery has gone from being something performed at virtually every practice to something only a minority maintains skills in.

The resultant flow of work to hospitals has been rather good for dermatologists, ensuring a steady expansion of consultant numbers and the general building of empires. Now, however, the chickens are coming home to roost. We are a society increasingly fearful of disease, bombarded on all sides by “Watch Out!” messages.

The recent tidal wave of worried mole-owners could have been managed in primary care but for the deskilling and dismantling of GP minor surgery. We need to restate our confidence in competent GPs being allowed to manage most of these cases without referral. Then dermatologists may again find that they have the capacity to do what only they can properly do. 

This article first appeared in the 13 February 2015 issue of the New Statesman, Assad vs Isis

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There is nothing compassionate about Britain’s Dickensian tolerance of begging

I was called “heartless” for urging police to refer beggars to support services. But funding drug habits to salve a liberal conscience is the truly cruel approach.

In Rochdale, like many other towns across the country, we’re working hard to support small businesses and make our high streets inviting places for people to visit. So it doesn’t help when growing numbers of aggressive street beggars are becoming a regular fixture on the streets, accosting shoppers.

I’ve raised this with the police on several occasions now and when I tweeted that they needed to enforce laws preventing begging and refer them to appropriate services, all hell broke loose on social media. I was condemned as heartless, evil and, of course, the favourite insult of all left-wing trolls, “a Tory”.

An article in the Guardian supported this knee-jerk consensus that I was a typically out-of-touch politician who didn’t understand the underlying reasons for begging and accused me of being “misguided” and showing “open disdain” for the poor. 

The problem is, this isn’t true, as I know plenty about begging.

Before I became an MP, I worked as a researcher for The Big Issue and went on to set up a social research company that carried out significant research on street begging, including a major report that was published by the homeless charity, Crisis.

When I worked at The Big Issue, the strapline on the magazine used to say: “Working not Begging”. This encapsulated its philosophy of dignity in work and empowering people to help themselves. I’ve seen many people’s lives transformed through the work of The Big Issue, but I’ve never seen one person’s life transformed by thrusting small change at them as they beg in the street.

The Big Issue’s founder, John Bird, has argued this position very eloquently over the years. Giving to beggars helps no one, he says. “On the contrary, it locks the beggar in a downward spiral of abject dependency and victimhood, where all self-respect, honesty and hope are lost.”

Even though he’s now doing great work in the House of Lords, much of Bird’s transformative zeal is lost on politicians. Too many on the right have no interest in helping the poor, while too many on the left are more interested in easing their conscience than grappling with the hard solutions required to turn chaotic lives around.

But a good starting point is always to examine the facts.

The Labour leader of Manchester City Council, Richard Leese, has cited evidence that suggests that 80 per cent of street beggars in Manchester are not homeless. And national police figures have shown that fewer than one in five people arrested for begging are homeless.

Further research overwhelmingly shows the most powerful motivating force behind begging is to fund drug addiction. The homeless charity, Thames Reach, estimates that 80 per cent of beggars in London do so to support a drug habit, particularly crack cocaine and heroin, while drug-testing figures by the Metropolitan Police on beggars indicated that between 70 and 80 per cent tested positive for Class A drugs.

It’s important to distinguish that homelessness and begging can be very different sets of circumstances. As Thames Reach puts it, “most rough sleepers don’t beg and most beggars aren’t rough sleepers”.

And this is why they often require different solutions.

In the case of begging, breaking a chaotic drug dependency is hard and the important first step is arrest referral – ie. the police referring beggars on to specialised support services.  The police approach to begging is inconsistent – with action often only coming after local pressure. For example, when West Midlands Police received over 1,000 complaints about street begging, a crackdown was launched. This is not the case everywhere, but only the police have the power to pick beggars up and start a process that can turn their lives around.

With drug-related deaths hitting record levels in England and Wales in recent years, combined with cuts to drug addiction services and a nine per cent cut to local authority health budgets over the next three years, all the conditions are in place for things to get a lot worse.

This week there will be an important homelessness debate in Parliament, as Bob Blackman MP's Homelessness Reduction Bill is due to come back before the House of Commons for report stage. This is welcome legislation, but until we start to properly distinguish the unique set of problems and needs that beggars have, I fear begging on the streets will increase.

Eighteen years ago, I was involved in a report called Drugs at the Sharp End, which called on the government to urgently review its drug strategy. Its findings were presented to the government’s drugs czar Keith Hellawell on Newsnight and there was a sense that the penny was finally dropping.

I feel we’ve gone backwards since then. Not just in the progress that has been undone through services being cut, but also in terms of general attitudes towards begging.

A Dickensian tolerance of begging demonstrates an appalling Victorian attitude that has no place in 21st century Britain. Do we really think it’s acceptable for our fellow citizens to live as beggars with no real way out? And well-meaning displays of “compassion” are losing touch with pragmatic policy. This well-intentioned approach is starting to become symptomatic of the shallow, placard-waving gesture politics of the left, which helps no one and has no connection to meaningful action.

If we’re going make sure begging has no place in modern Britain, then we can’t let misguided sentiment get in the way of a genuine drive to transform lives through evidenced-based effective policy.

Simon Danczuk is MP for Rochdale.