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

Ukip's Nigel Farage and Paul Nuttall. Photo: Getty
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Is the general election 2017 the end of Ukip?

Ukip led the way to Brexit, but now the party is on less than 10 per cent in the polls. 

Ukip could be finished. Ukip has only ever had two MPs, but it held an outside influence on politics: without it, we’d probably never have had the EU referendum. But Brexit has turned Ukip into a single-issue party without an issue. Ukip’s sole remaining MP, Douglas Carswell, left the party in March 2017, and told Sky News’ Adam Boulton that there was “no point” to the party anymore. 

Not everyone in Ukip has given up, though: Nigel Farage told Peston on Sunday that Ukip “will survive”, and current leader Paul Nuttall will be contesting a seat this year. But Ukip is standing in fewer constituencies than last time thanks to a shortage of both money and people. Who benefits if Ukip is finished? It’s likely to be the Tories. 

Is Ukip finished? 

What are Ukip's poll ratings?

Ukip’s poll ratings peaked in June 2016 at 16 per cent. Since the leave campaign’s success, that has steadily declined so that Ukip is going into the 2017 general election on 4 per cent, according to the latest polls. If the polls can be trusted, that’s a serious collapse.

Can Ukip get anymore MPs?

In the 2015 general election Ukip contested nearly every seat and got 13 per cent of the vote, making it the third biggest party (although is only returned one MP). Now Ukip is reportedly struggling to find candidates and could stand in as few as 100 seats. Ukip leader Paul Nuttall will stand in Boston and Skegness, but both ex-leader Nigel Farage and donor Arron Banks have ruled themselves out of running this time.

How many members does Ukip have?

Ukip’s membership declined from 45,994 at the 2015 general election to 39,000 in 2016. That’s a worrying sign for any political party, which relies on grassroots memberships to put in the campaigning legwork.

What does Ukip's decline mean for Labour and the Conservatives? 

The rise of Ukip took votes from both the Conservatives and Labour, with a nationalist message that appealed to disaffected voters from both right and left. But the decline of Ukip only seems to be helping the Conservatives. Stephen Bush has written about how in Wales voting Ukip seems to have been a gateway drug for traditional Labour voters who are now backing the mainstream right; so the voters Ukip took from the Conservatives are reverting to the Conservatives, and the ones they took from Labour are transferring to the Conservatives too.

Ukip might be finished as an electoral force, but its influence on the rest of British politics will be felt for many years yet. 

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