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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Jeremy Corbyn's Labour conference speech shows how he's grown

The leader's confident address will have impressed even his fiercest foes. 

It is not just Jeremy Corbyn’s mandate that has been improved by his re-election. The Labour leader’s conference speech was, by some distance, the best he has delivered. He spoke with far greater confidence, clarity and energy than previously. From its self-deprecating opening onwards ("Virgin Trains assure me there are 800 empty seats") we saw a leader improved in almost every respect. 

Even Corbyn’s firecest foes will have found less to take issue with than they may have anticipated. He avoided picking a fight on Trident (unlike last year), delivered his most forceful condemnation of anti-Semitism (“an evil”) and, with the exception of the Iraq war, avoided attacks on New Labour’s record. The video which preceded his arrival, and highlighted achievements from the Blair-Brown years, was another olive branch. But deselection, which Corbyn again refused to denounce, will remain a running sore (MPs alleged that Hillsborough campaigner Sheila Coleman, who introduced Corbyn, is seeking to deselect Louise Ellman and backed the rival TUSC last May).

Corbyn is frequently charged with lacking policies. But his lengthy address contained several new ones: the removal of the cap on council borrowing (allowing an extra 60,000 houses to be built), a ban on arms sales to abusive regimes and an arts pupil premium in every primary school.

On policy, Corbyn frequently resembles Ed Miliband in his more radical moments, unrestrained by Ed Balls and other shadow cabinet members. He promised £500bn of infrastructure investment (spread over a decade with £150bn from the private sector), “a real living wage”, the renationalisation of the railways, rent controls and a ban on zero-hours contracts.

Labour’s greatest divisions are not over policy but rules, strategy and culture. Corbyn’s opponents will charge him with doing far too little to appeal to the unconverted - Conservative voters most of all. But he spoke with greater conviction than before of preparing for a general election (acknowledging that Labour faced an arithmetical “mountain”) and successfully delivered the attack lines he has often shunned.

“Even Theresa May gets it, that people want change,” he said. “That’s why she stood on the steps of Downing Street and talked about the inequalities and burning injustices in today’s Britain. She promised a country: ‘that works not for a privileged few but for every one of us’. But even if she manages to talk the talk, she can’t walk the walk. This isn’t a new government, it’s David Cameron’s government repackaged with progressive slogans but with a new harsh right-wing edge, taking the country backwards and dithering before the historic challenges of Brexit.”

After a second landslide victory, Corbyn is, for now, unassailable. Many MPs, having voted no confidence in him, will never serve on the frontbench. But an increasing number, recognising Corbyn’s immovability, speak once again of seeking to “make it work”. For all the ructions of this summer, Corbyn’s speech will have helped to persuade them that they can.

George Eaton is political editor of the New Statesman.