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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After Richmond Park, Labour MPs are haunted by a familiar ghost

Labour MPs in big cities fear the Liberal Democrats, while in the north, they fear Ukip. 

The Liberal Democrats’ victory in Richmond Park has Conservatives nervous, and rightly so. Not only did Sarah Olney take the votes of soft Conservatives who backed a Remain vote on 23 June, she also benefited from tactical voting from Labour voters.

Although Richmond Park is the fifth most pro-Remain constituency won by a Conservative at the 2015 election, the more significant number – for the Liberal Democrats at least – is 15: that’s the number of Tory-held seats they could win if they reduced the Labour vote by the same amount they managed in Richmond Park.

The Tories have two Brexit headaches, electorally speaking. The first is the direct loss of voters who backed David Cameron in 2015 and a Remain vote in 2016 to the Liberal Democrats. The second is that Brexit appears to have made Liberal Democrat candidates palatable to Labour voters who backed the party as the anti-Conservative option in seats where Labour is generally weak from 1992 to 2010, but stayed at home or voted Labour in 2015.

Although local council by-elections are not as dramatic as parliamentary ones, they offer clues as to how national elections may play out, and it’s worth noting that Richmond Park wasn’t the only place where the Liberal Democrats saw a dramatic surge in the party’s fortunes. They also made a dramatic gain in Chichester, which voted to leave.

(That’s the other factor to remember in the “Leave/Remain” divide. In Liberal-Conservative battlegrounds where the majority of voters opted to leave, the third-placed Labour and Green vote tends to be heavily pro-Remain.)

But it’s not just Conservatives with the Liberal Democrats in second who have cause to be nervous.  Labour MPs outside of England's big cities have long been nervous that Ukip will do to them what the SNP did to their Scottish colleagues in 2015. That Ukip is now in second place in many seats that Labour once considered safe only adds to the sense of unease.

In a lot of seats, the closeness of Ukip is overstated. As one MP, who has the Conservatives in second place observed, “All that’s happened is you used to have five or six no-hopers, and all of that vote has gone to Ukip, so colleagues are nervous”. That’s true, to an extent. But it’s worth noting that the same thing could be said for the Liberal Democrats in Conservative seats in 1992. All they had done was to coagulate most of the “anyone but the Conservative” vote under their banner. In 1997, they took Conservative votes – and with it, picked up 28 formerly Tory seats.

Also nervous are the party’s London MPs, albeit for different reasons. They fear that Remain voters will desert them for the Liberal Democrats. (It’s worth noting that Catherine West, who sits for the most pro-Remain seat in the country, has already told constituents that she will vote against Article 50, as has David Lammy, another North London MP.)

A particular cause for alarm is that most of the party’s high command – Jeremy Corbyn, Emily Thornberry, Diane Abbott, and Keir Starmer – all sit for seats that were heavily pro-Remain. Thornberry, in particular, has the particularly dangerous combination of a seat that voted Remain in June but has flirted with the Liberal Democrats in the past, with the shadow foreign secretary finishing just 484 votes ahead of Bridget Fox, the Liberal Democrat candidate, in 2005.

Are they right to be worried? That the referendum allowed the Liberal Democrats to reconfigure the politics of Richmond Park adds credence to a YouGov poll that showed a pro-Brexit Labour party finishing third behind a pro-second referendum Liberal Democrat party, should Labour go into the next election backing Brexit and the Liberal Democrats opt to oppose it.

The difficulty for Labour is the calculation for the Liberal Democrats is easy. They are an unabashedly pro-European party, from their activists to their MPs, and the 22 per cent of voters who back a referendum re-run are a significantly larger group than the eight per cent of the vote that Nick Clegg’s Liberal Democrats got in 2015.

The calculus is more fraught for Labour. In terms of the straight Conservative battle, their best hope is to put the referendum question to bed and focus on issues which don’t divide their coalition in two, as immigration does. But for separate reasons, neither Ukip nor the Liberal Democrats will be keen to let them.

At every point, the referendum question poses difficulties for Labour. Even when neither Ukip nor the Liberal Democrats take seats from them directly, they can hurt them badly, allowing the Conservatives to come through the middle.

The big problem is that the stance that makes sense in terms of maintaining party unity is to try to run on a ticket of moving past the referendum and focussing on the party’s core issues of social justice, better public services and redistribution.

But the trouble with that approach is that it’s alarmingly similar to the one favoured by Kezia Dugdale and Scottish Labour in 2016, who tried to make the election about public services, not the constitution. They came third, behind a Conservative party that ran on an explicitly pro-Union platform. The possibility of an English sequel should not be ruled out.  

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