Referral
16. Miss A says the lack of care from the Practice was unimaginable, it did not take her skin condition seriously or help to refer her to a dermatologist when she asked for this. She says the Practice ignored the severe pain she was in and the effect it was having on her mental health. She began taking medication for anxiety.
17. Miss A says she went to a private dermatologist on 25 January 2023 and they recommended a prescription steroid cream for longer than the recommended five days, because her eczema was so bad. They also recommended a cream for her body and face. The private dermatologist told her she had atopic eczema (a common type of eczema that affects the skin) but that could change. They recommended she see them again in nine months to check how things were going, as this would be when the eczema would be expected to get worse again.
18. Miss A decided to register with a new GP in March 2023. She says she was referred by them as a priority to an NHS dermatology specialist and was diagnosed with severe atopic eczema and contact dermatitis (a type of eczema triggered by contact with a particular substance). She says her first specialist appointment was in June 2023 and she now sees the specialist regularly.
19. In its complaint response, the Practice apologised that Miss A feels its advice and treatment was not helpful. It says the records show that every clinician she saw offered what they felt to be a good option based on her presentation at that time.
20. The records on 30 December 2022 show Miss A submitted an online consultation request to the GP. She wrote that her face had become red and swollen and she had tried lots of creams and they were not working. She explained this happened every year and she asked for a specialist referral. She also wrote that it was affecting her mental health.
21. The Practice arranged a remote GP consultation for 3 January 2023. By this point Miss A’s skin was improving. The GP did not suggest any change in treatment but advised to call the surgery as she had a rash on her nipple.
22. On 12 January Miss A was seen face to face by the GP. The GP assessed her as having severe eczema with possible infection and a swab test was taken. She was treated with a topical steroid and the swab test confirmed infection. She was prescribed antibiotics for the infection.
23. On 20 January Miss A was again seen face to face by her GP because she had very inflamed skin on her face. She was prescribed a different topical steroid because she was allergic to one of the ingredients in the one prescribed before.
24. On 25 January Miss A saw a private dermatologist. The background section above explains what they said.
25. NICE guidance says:
• ‘At each consultation, the severity of the eczema and the psychological impact should be assessed.
• A stepped approach is recommended for the management of atopic eczema: • Emollients [moisturising treatments] are the first-line treatments during both acute flares and remissions of the condition.
• The use of topical steroids should be considered for red, inflamed skin. The lowest potency [strength] and amount of topical corticosteroid [medication to reduce inflammation] necessary to control symptoms should be prescribed, depending on severity of the flare.
• If there is persistent, severe itch, or urticaria [hives], one-month trial of a non-sedating antihistamine should be considered.
• If itching is severe and affecting sleep, a short course of sedating antihistamine should be considered (if appropriate).
• If there is severe, extensive eczema, a short course of oral corticosteroids should be considered.
• If eczema is weeping, crusted, or there are pustules, with fever or malaise [sickness], secondary bacterial infection should be considered and antibiotic treatment should be prescribed.
26. Refer for a routine dermatology appointment if: • The diagnosis is or has become uncertain.
• Current management has not controlled eczema satisfactorily (for example the person is having one to two flares per month), or the person is reacting adversely to many emollients.
• Facial eczema has not responded to appropriate treatment.
• Treatment (application) advice is needed (for example bandaging techniques).
• Contact allergic dermatitis is suspected (for example if there is persistent eczema or facial, or hand eczema) • There is recurrent secondary infection.
• Eczema is assessed as causing significant social or psychological problems (for example sleep disturbance).’
27. Our adviser says this guidance gives several reasons why Miss A should have been referred to a dermatologist after her appointment on 3 January 2023. She was reacting negatively to many emollients, she had ongoing facial eczema that was not responding to appropriate treatments, she had possible contact dermatitis as she had persistent facial and eyelid eczema and she had significant psychological problems due to the eczema. She had also asked for a referral.
28. Our adviser says the treatment she had from the Practice on 12 and 20 January was in line with this guidance because she was treated with topical steroids and prescribed antibiotics for the infection, but she should also have been referred to dermatology.
29. The NHS maximum waiting time for non-urgent, consultant-led treatments is 18 weeks from the day the appointment is booked through the NHS e-referral service, or when the hospital or service gets the referral letter.
30. We accept there was a failing by the Practice as Miss A should have been referred from 3 January. If Miss A had been referred to an NHS dermatologist then, it is very unlikely she would have been seen before she was seen by the private dermatologist on 25 January.
31. The private dermatologist told Miss A to ask her GP for an NHS referral if her symptoms got worse and to revisit them in nine months.
32. Although the Practice should have referred her, we cannot link the impact Miss A described to this failing because it is unlikely that she would have been seen by an NHS dermatologist before 25 January, when she decided to see a private dermatologist.
Trimovate medication
33. Miss A says the GP prescribed Trimovate cream on 12 January 2023. She says when she picked up the prescription on 17 January, she noticed one of the ingredients was sodium metabisulphite which she is allergic to. She did not use the medication and instead called the Practice to tell it she needed an alternative.
34. She says during this time she was still in pain and her physical and mental health were deteriorating rapidly.
35. In its complaint response, the Practice says the ingredient is not one that is obvious to a GP when prescribing. It is not something like penicillin that can be easily identified as an ingredient. It asked that in future she highlight this allergy at the time of prescribing so the GP can check for this ingredient.
36. While we appreciate Miss A’s frustration at this situation, we cannot see a significant or lasting impact from this. There was a delay between the 12 and 19 of January when she was prescribed a cream she could use. Miss A did not use the prescribed Trimovate cream so did not suffer a negative physical reaction. She was already using her other regularly prescribed creams and within a matter of days had been prescribed an alternative.
37. We think the delay caused distress and was a one-off administrative issue that did not affect her daily routine or standard of life.
38. We are not taking further action on this part of Miss A’s complaint because the impact on her was minimal and the Practice prescribed another cream for her to use.