Skin cancer recognition and urgent referral policy (dermatology)

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users. (Reg 12(2)(i) (shared / transferred responsibility))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations.

3. Purpose

A dermatology service sees skin lesions every day, and a missed melanoma or squamous cell carcinoma can cost a life. This policy sets out how the Service recognises lesions that may be cancer, refers them urgently down the right pathway, and makes sure no patient with a worrying lesion is lost to follow-up.

The Service must verify this policy against current NICE suspected-cancer referral guidance and British Association of Dermatologists guidance before adoption.

4. Sources to verify before adoption

• NICE NG12, Suspected cancer: recognition and referral: https://www.nice.org.uk/guidance/ng12
• NICE NG14, Melanoma: assessment and management: https://www.nice.org.uk/guidance/ng14
• British Association of Dermatologists, clinical guidelines: https://www.bad.org.uk/
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (safe care and treatment): https://www.legislation.gov.uk/uksi/2014/2936/regulation/12

5. Scope

This policy applies to:

• the assessment of any skin lesion the Service sees
• the referral of lesions that may be cancer, and the follow-up of those referrals
• the clinicians who assess lesions and the staff who manage referrals and results

6. Recognising a lesion that may be cancer

Clinicians assess lesions against current criteria, including:

• a pigmented lesion that is changing, asymmetrical, has an irregular border or colour, is growing, or scores on a recognised checklist
• a non-healing, ulcerated, crusting or bleeding lesion
• a new or enlarging lesion in an at-risk patient (sun exposure history, previous skin cancer, immunosuppression, fair skin)
• a patient's own concern about a changing mole, which is taken seriously even when the lesion looks reassuring

The clinician uses dermoscopy where competent (see the dermoscopy and lesion documentation policy) and documents the assessment.

7. Urgent referral

Where a lesion may be cancer, the Service refers it urgently down the right pathway, within the timescale the guidance sets, and does not delay by watching and waiting where the criteria for referral are met. The referral:

• goes to a service that can diagnose and treat skin cancer
• includes the clinical description, the lesion location, any dermoscopy image, and the patient's risk factors
• is made with the patient's understanding of why and what happens next

Where the Service itself excises a lesion that may be cancer, it follows the minor skin surgery and specimen handling policy, including correct specimen handling and acting on the histology result.

8. Safety-netting the patient

The patient is told, in a form they can keep:

• what has been found and what the referral is for
• what to do if symptoms change while they wait
• that they should chase the appointment if they do not hear, and how to contact the Service

The Service does not rely on the patient alone to drive the pathway.

9. Tracking referrals and results

The Service runs a system so no urgent referral or pending result is lost:

• every urgent referral is logged and tracked until the patient is seen or the result is back
• histology and pathology results are checked, acted on and recorded, with a fail-safe so a result that does not arrive is chased
• a malignant result triggers prompt action and clear communication with the patient

10. When something is missed or delayed

A missed or delayed skin-cancer diagnosis is treated as a serious patient-safety matter. It is logged, investigated, and the duty of candour is opened where the threshold is met. The Service reviews how the lesion or result was missed and changes the system to prevent a repeat.

Operational controls to adapt

Roles and responsibilities

• Registered Manager: owns the referral safety system and makes sure urgent referrals, missed referrals and delayed diagnoses are reviewed.
• Assessing clinician: assesses the lesion, applies current referral criteria, explains the concern to the patient, and sends or triggers the urgent referral.
• Referral coordinator or administrator: logs the referral, confirms it has been sent and accepted, chases missing appointments and records outcomes.
• Results lead: checks pathology and specialist letters, escalates malignant or unclear results, and confirms the patient has been told.
• Governance lead: reviews missed or delayed diagnosis incidents, referral delays, themes and improvement actions.

Skin-cancer recognition and referral procedure

1. Assess the lesion systematically. Record history, symptoms, change, risk factors, clinical findings and dermoscopy findings where used.
2. Apply current referral criteria. Use NICE suspected-cancer criteria and local pathway rules, and do not monitor where urgent referral criteria are met.
3. Explain the referral. Tell the patient why urgent referral is needed, what should happen next and what symptoms should prompt immediate contact.
4. Send the referral with evidence. Include lesion site, size, history, risk factors, images, dermoscopy findings and urgency.
5. Track acceptance. Confirm the referral has been sent, received and accepted by the receiving service.
6. Chase missing progress. Chase if the patient has not received an appointment, the result is overdue, or the receiving service asks for missing information.
7. Act on results. Review specialist advice, histology and outcome letters, communicate the result to the patient, and arrange any follow-up.
8. Escalate failures. Open an incident for missed referral, delayed referral, lost result, missed cancer concern, DNA with unresolved risk or failure to communicate a malignant result.

Records and register links

The referral record should include:

• lesion site, size, symptoms, duration, change and patient concern
• risk factors, dermoscopy findings and images relied on
• NICE or local referral criterion used, or the reason referral was not made
• referral date, destination, urgency, attachments and acceptance confirmation
• patient safety-net advice and contact route
• appointment, DNA, result, specialist letter and follow-up outcome
• incident, complaint, risk entry or improvement action where relevant

Missed or delayed referral, lost result and missed cancer concerns are opened on the incident register. Repeated referral or tracking failures are added to the risk register and improvement-actions register.

11. Training

Clinicians who assess skin lesions keep their skin-cancer recognition current, including dermoscopy where they use it, and are refreshed on a stated cadence. The Service records who is competent and the next refresher date.

12. Audit cadence

The Service checks, on a stated cadence, that:

• lesion assessments are documented against current criteria
• urgent referrals are made within the guidance timescale and tracked to the patient being seen
• pathology results are checked, acted on and fail-safed, with none outstanding unnoticed
• missed or delayed diagnoses are investigated and learned from

The Registered Manager and the clinical lead review the results and record the improvement actions that follow.

13. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• NICE suspected cancer referral guidance (NG12)
• NICE melanoma assessment and management guidance (NG14)
• British Association of Dermatologists (BAD) guidance
• CQC Regulation 12: Safe care and treatment
• Local two-week-wait (2WW) suspected skin cancer pathways
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)

Related reading

• Related policy: Dermoscopy and lesion documentation policy
• Related policy: Teledermatology and remote consultation policy
• Related policy: Incident Reporting, Investigation and Learning Policy
• Regulation explainer: Regulation 12 safe care and treatment

14. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

15. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.