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

Photo: Getty
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Amber Rudd's ignorance isn't just a problem for the laws she writes

Politicians' lack of understanding leads to the wrong laws - and leaves real problems unchecked. 

Amber Rudd’s interview with Andrew Marr yesterday is not going to feature in her highlights reel, that is for certain. Her headline-grabbing howler was her suggesting was that to fight terror “the best people…who understand the necessary hashtags” would stop extremist material “ever being put up, not just taken down”, but the entire performance was riddled with poorly-briefed errors.

During one particularly mystifying exchange, Rudd claimed that she wasn’t asking for permission to “go into the Cloud”, when she is, in fact, asking for permission to go into the Cloud.

That lack of understanding makes itself felt in the misguided attempt to force tech companies to install a backdoor in encrypted communications. I outline some of the problems with that approach here, and Paul Goodman puts it well over at ConservativeHome, the problem with creating a backdoor is that “the security services would indeed be able to travel down it.  So, however, might others – the agencies serving the Chinese and Russian governments, for example, not to mention non-state hackers and criminals”.

But it’s not just in what the government does that makes ministers’ lack of understanding of tech issues a problem. As I’ve written before, there is a problem where hate speech is allowed to flourish freely on new media platforms. After-the-fact enforcement means that jihadist terrorism and white supremacist content can attract a large audience on YouTube and Facebook before it is taken down, while Twitter is notoriously sluggish about removing abuse and hosts a large number of extremists on its site. At time of writing, David Duke, the former head of the Ku Klux Klan, has free use of YouTube to post videos with titles such as “CNN interview on Bannon exposes Jewish bias”, “Will the white race survive?” and “Stop the genocide of European mankind”. It’s somewhat odd, to put it mildly, that WhatsApp is facing more heat for a service that is enjoyed by and protects millions of honest consumers while new media is allowed to be intensely relaxed about hosting hate speech.

Outside of the field of anti-terror, technological illiteracy means that old-fashioned exploitation becomes innovative “disruption” provided it is facilitated by an app. Government and opposition politicians simultaneously decry old businesses’ use of zero-hours contracts and abuse of self-employment status to secure the benefits of a full-time employee without having to bear the costs, while hailing and facilitating the same behaviour provided the company in question was founded after 2007.

As funny as Rudd’s ill-briefed turn on the BBC was, the consequences are anything but funny. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.