A dermatologist checks for skin cancer. Photo: Joe Raedle/Getty Images
Show Hide image

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

Dan Kitwood/Getty
Show Hide image

How can London’s mothers escape the poverty trap?

Despite its booming jobs market, London’s poverty rate is high. What can be done about it?

Why are mothers in London less likely to work than their counterparts across the country, and how can we ensure that having more parents in jobs brings the capital’s high child poverty rates down?

The answers to these two questions, examined in a new CPAG report on parental employment in the capital, may become increasingly nationally significant as policymakers look to ensure jobs growth doesn’t stall and that a job becomes a more much reliable route out of poverty than it is currently – 64 per cent of poor children live in working families.

The choice any parent makes when balancing work and family life is deeply personal.  It’s a choice driven by a wide range of factors but principally by what parents, with their unique viewpoint, regard as best for their families. The man in Whitehall doesn’t know best.

But the personal is also political. Every one of these personal choices is shaped, limited or encouraged by an external context.   Are there suitable jobs out there? Is there childcare available that is affordable and will work for their child(ren)? And what will be the financial gains from working?

In London, 40 per cent of mothers in couples are not working. In the rest of the country, the figure is much lower – 27 per cent. While employment rates amongst lone parents in London have significantly increased in recent years, the proportion of mothers in couples out of work remains stuck at about 12 percentage points higher than the rest of the UK.

The benefits system has played a part in increasing London’s lone parent employment rate. More and more lone parents are expected to seek work. In 2008, there was no obligation on single parents to start looking for work until their youngest child turned 16. Now they need to start looking when their youngest is five (the Welfare Reform and Work Bill would reduce this down to three). But the more stringent “conditionality” regime, while significant, doesn’t wholly explain the higher employment rate. For example, we know more lone parents with much younger children have also moved into jobs.  It also raises the question of what sacrifices families have had to make to meet the new conditionality.  

Mothers in couples in London, who are not mandated to work, have not entered work to the same level as lone parents. So, what is it about the context in London that makes it less likely for mothers in couples to work? Here are four reasons highlighted in our report for policymakers to consider:

1. The higher cost of working in London is likely to play a significant role in this. London parents are much less likely to be able to call on informal (cheaper or free) childcare from family and friends than other parts in the country: only one in nine children in London receives informal childcare compared to an average of one in three for England. And London childcare costs for under 5s dwarf those in the rest of the country, so for many parents support available through tax credits is inadequate.

2. Add to this high housing and transport costs, and parents are left facing a toxic combination of high costs that can mean they see less financial rewards from their work than parents in other parts of the country.

3. Effective employment support can enable parents to enter work, particularly those who might have taken a break from employment while raising children. But whilst workless lone parents and workless couples are be able to access statutory employment support, if you have a working partner, but don’t work yourself, or if you are working on a low wage and want to progress, there is no statutory support available.

4. The nature of the jobs market in London may also be locking mums out. The number of part time jobs in the capital is increasing, but these jobs don’t attract the same London premium as full time work.  That may be partly why London mums who work are more likely to work full time than working mums in other parts of the country. But this leaves London families facing even higher childcare costs.

Parental employment is a thorny issue. Parenting is a 24-hour job in itself which must be balanced with any additional employment and parents’ individual choices should be at the forefront of this debate. Policy must focus on creating the context that enables parents to make positive choices about employment. That means being able to access the right support to help with looking for work, creating a jobs market that works for families, and childcare options that support child development and enable parents to see financial gains from working.

When it comes to helping parents move into jobs they can raise a family on, getting it right for London, may also go a long way to getting it right for the rest of the country.