Dermatology Funding

Edward Leigh Excerpts

Wednesday 4th December 2013 Westminster Hall

[Sir Edward Leigh (Gainsborough) (Con)]

It is a pleasure to serve under your chairmanship, Mr Turner. I am grateful for this opportunity to debate issues relating to the provision of dermatology in the NHS. This area has received little parliamentary attention over the years, given the considerable morbidity and mortality for which skin disease is responsible. Indeed, I think I am right in saying that this is the first debate in the House of Commons in several years on dermatology and how it is treated in the NHS.

I should declare an interest, because we are always supposed to. I have a skin condition called rosacea. It is not that serious; I take antibiotics every day and it is controllable, but it has, of course, led me to take an interest in this subject.

In preparing for this debate, I consulted widely among the different interests in skin disease, and I am grateful for the insights that I was given. It is noteworthy that the same themes emerged from all quarters. Skin disease is extensive and has a great impact. It results in profound psychological consequences for many, especially for those with severe variants of conditions. It is under-treated in the NHS, and there are commissioning issues that relate partly to dermatology’s continuing to be something of a Cinderella disease. Talking to people, I heard the expression “Cinderella disease” time and again.

Most crucially, there is wholly inadequate training, notably among general practitioners, to enable doctors to handle the dermatology cases that will come their way in day-to-day practice. Why is this? There is a view that dermatology does not matter and that it does not kill. This is both complacent and wrong. Many skin diseases have horrendous effects, even when they are not fatal. Skin cancer is a major killer, and there would be benefits from renewed focus on this disease, both to help people avoid it in the first place and to identify and treat it quickly where it occurs.

The statistics on the burden of skin disease are eye-popping. Some 54% of the United Kingdom population experience a skin condition in any 12-month period. Of those, 14% seek medical advice, usually from a doctor or nurse in the community. Some skin conditions will be trivial, but many are not. Skin conditions are the most frequent reason for people to consult their GP with a new problem. Some 24% of the population visit their GP with a skin problem each year.

[Mrs Cheryl Gillan (Chesham and Amersham) (Con)]

I congratulate my hon. Friend on obtaining a debate on a subject that has not been discussed for a long time. I have looked at facts and figures on dermatology services in my constituency. Would it surprise him to hear that, in the first six months of the year, the trust’s dermatology department had 501 day cases, 4,160 new out-patient appointments and 7,951 follow-up out-patient appointments, and undertook more than 3,292 out-patient procedures? Does not that show the demand in the system for dermatological services?

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[Sir Edward Leigh]

I am not surprised. I found similar figures in Lincolnshire. I should think that the same sort of problem will be found anywhere in the England.

The most common reasons for people visiting their GP are skin infections and eczema. Nearly a fifth of all GP consultations relate to a skin disease. Atopic eczema is the most common form of eczema. All my children have had it, and one of my boys suffered badly. Some children suffer grievously from it. It can affect people of all ages, but is primarily seen in children and affects up to 20% of children by the age of seven. Most people grow out of it, but a number of adults continue to show symptoms at a later age, some having the condition for life.

Eczema is typically characterised by red, sore and itchy patches of skin. For those who have it or those, such as parents, who have to care for a child with it, eczema can be highly debilitating. Sleep deprivation is common in children with eczema and, therefore, of course, in their parents. It causes major disruption to family life, not least because of the application of endless amounts of ointment. I know all about that.

Psoriasis, from which my brother and my mother suffered, has serious effects. It affects only 2% to 3% of the population, but often has devastating consequences for those who have it. Its onset is typically at 15 to 24 years, which is such a crucial stage in a person’s development. It is an immune condition that triggers excess replacement skin cells, which can lead to raised plaques on the skin that can be flaky, sore and itchy. It is a serious problem.

Then there is acne—I know all about that, too—a condition most commonly associated with adolescent teenagers. Although the condition is thought to be linked with hormonal changes during puberty, some 80% of young people above the age of 11 will have a degree of it at some point. It can affect people well into their adult lives, and it can be severe. Acne scarring is permanent. About 5% of women and 1% of men have acne over the age of 25. In a not inconsiderable number of cases, acne is widespread and ever-present, producing feelings of shame, despair and even, I am sorry to say, suicide in some cases. Acne is particularly tricky, psychologically, because it is often at its worst when the young emerging adult is feeling at their most self-conscious.

Other common conditions seen by specialists include vitiligo, urticaria, rosacea, herpes simplex, shingles, vascular lesions, benign skin tumours, benign moles, solar keratosis, viral warts, non-malignant skin cancers—I know all about that, too—and malignant melanomas. The list is almost endless, running as it does to a couple of thousand different conditions, each of which can have profound effects on the lives of those who have them. People who suffer from these diseases often do not want to speak about them. I am attempting, in this small debate, to give these people a voice.

It is worth saying that serious psychological effects are sparked by skin disease. We live in a society where we are subjected daily to images of perfection, selling everything from make-up, fashion and holidays to ice-cream. Skin conditions are sometimes very visible, and some people are highly prejudiced against those who have them, and make little attempt to hide that. That can lead to stress, depression, anxiety, and other related problems.

There is a beautiful picture in the Louvre of a child reaching out to an old man, probably their grandfather. The child is beautiful and the old man, who obviously suffers from rosacea, is deformed and hideous. The point of the painting is that beauty lies inside, not on the skin, but that is not often the view of modern society, so skin conditions lead to psychological stress.

Many of these facts—I could go on, but I will not—are set out in detail in the recent report on the psychological effects of skin disease published by the all-party group on skin. I pay tribute to my hon. Friend the Member for Mole Valley (Sir Paul Beresford) who chairs that group and does it well.

Despite the fact that skin disorders are both serious and the most likely reason for someone to go to their GP, training and knowledge of dermatology among primary care health professionals is generally very limited. Perhaps “very” is wrong, but it is certainly limited. Astonishingly, there is no compulsory requirement for dermatology training in undergraduate or postgraduate medical programmes of study. Dermatology is still not included in all undergraduate medical school curriculums; it is optional in some, and untested in others. In five to six years of medical training to become a doctor, the average medical school offers—I found this incredible— less than a fortnight of teaching in dermatology. This is often combined with another so-called minor field of medicine. I am told that many miss this teaching altogether, not regarding it as important, and joke about taking a “dermaholiday”. That is like the NHS employing an army of plumbers who are highly knowledgeable about boilers and blocked drains but who do not know how to trace a leak or mend a pipe. By failing to provide adequate education in dermatology, which is an important field of medicine, we are badly failing to meet the needs of patients.

[Nic Dakin (Scunthorpe) (Lab)]

I congratulate the hon. Gentleman on securing this important debate. He is setting out his stall extremely well. According to the consultant dermatologist at Scunthorpe general hospital who contacted me, 15% of patients presenting to GPs have a skin disorder of one kind or another, which underlines the hon. Gentleman’s point on the importance of including dermatology in GP training.

[Sir Edward Leigh]

In a moment, I will address the fact that skin diseases can have fatal consequences. As GPs often do not have adequate training, they are not able to spot conditions that can be very dangerous.

Training is important. In a 2008 survey of final-year medical students, only 52% of 449 respondents said that they felt they had the necessary skills to manage skin conditions. A lack of education and training may lead to fatal errors, and I stress that point because skin disease is not only about psychological damage. Skin lesions mistakenly taken to be benign can lead to cancer. Conversely, inappropriate referrals to secondary care can be costly and are blocking up big parts of secondary care. As awareness of litigation increases in the NHS, GPs are, unsurprisingly, less and less willing to take risks, so they refer more and more patients to secondary care. I understand that the general hospital in Lincolnshire—this echoes the point raised by my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan)—has seen a 26% rise in dermatology referrals for secondary care in the past year, and it is not alone.

The exploding incidence of skin cancer, an ageing population and side effects from new potent drugs are all driving referral rates. It has been guesstimated that there are 100,000 cases of skin cancer a year in the UK, but the number is not known for sure because the NHS does not collect figures for cancers that are not melanomas. Work this year suggests that the number may be nearer to 700,000; that is what dermatologists tell me, because they are dealing with such a volume of cases, day by day.

Studies show that the skill of GPs in diagnosing skin lesions needs improvement, and other studies raise concerns about the standard of skin surgery offered in primary care. In 2012, the Royal College of General Practitioners updated its curriculum statement on the care of people with skin problems. The statement goes a long way towards recognising dermatology as a key component of a GP’s training. The statement sets out a number of expected key competences within the field, but crucially, dermatology remains an optional component. For undergraduates, the British Association of Dermatologists recommends a two-week full-time attachment to a dermatology unit, with a realistic assessment at the end of the course. The association thinks that dermatology should also be taught when undergraduates work with general practitioners in the community. When trainee GPs are undertaking their two-year hospital placement, a six-month post in dermatology alone, in a combined post such as dermatology and general medicine, or in a combined minor specialty rotation would go a long way towards helping trainee GPs to take a special interest in dermatology, which is what we need.

The GP training period is likely to be lengthened by 12 months. I urge all interested parties—Health Education England, the royal colleges, the General Medical Council and the ultimate employer, NHS England—to use half or all of that extra time on a proper dermatology rotation, which would ensure that the GPs of the future are properly equipped to address their future work load. If that is to happen, funding must be made available to ensure that there is adequate consultant time to train budding GPs and to pay their salary while they undergo the hospital training.

[Mrs Gillan]

My hon. Friend is making a powerful argument. Does he agree that there is a worrying lack of provision for the psychosocial aspects of skin conditions? Is he familiar with Changing Faces, which, among other things, provides skin camouflage clinics? It sent me an e-mail when I was preparing for this debate saying that the King’s Fund has stated that there are only 3.7 posts across the country providing support for the psychosocial aspects of skin conditions, and the funding for those posts is under threat. Does he propose that funding should be found to try to support that vital work?

[Sir Edward Leigh]

I entirely agree. I talked to a doctor recently who said that one of his patients had not dared to go out for 20 years without wearing enormous amounts of special make-up because she was so worried about her condition. We should take that very seriously, because it affects hundreds of thousands of our fellow citizens and their feeling of self-worth.

The lack of dermatology education applies not only to GPs but to nurses and pharmacists, who also play a key role in the management of patients with skin disease. High and ever increasing sales of over-the-counter skin products suggest that people buy many products from pharmacies, yet training of pharmacists in the management of skin problems is limited, and evidence that they are providing appropriate advice is lacking.

There is considerable potential for improving self-care through the provision of high-quality patient information and the development of the knowledge and skills of community pharmacists in skin diseases. That would save the NHS money, as well as improve patient care, and it is a nettle waiting to be grasped.

The General Medical Council, working with the Royal College of General Practitioners, the British Association of Dermatologists, the Royal College of Nursing and the Royal Pharmaceutical Society, plus Health Education England and NHS England, has a duty to ensure that urgent priority is given to the provision of proper dermatological training for all GPs, nurses and pharmacists. That training should surely emphasise that most inflammatory skin diseases are long-term conditions and are likely to need ongoing care, often throughout a patient’s life. Similarly, the psychological effects of skin disease should be considered an integral part of any dermatological training course; I echo my right hon. Friend’s important point on that issue. There is good evidence for the effectiveness of general practitioners with a special interest in dermatology working within appropriate accreditation frameworks. More needs to be done to expand that group of clinicians, which is still all too small.

In addition to poor training at primary care level, there is also an issue with the number of consultant dermatologists. I pay tribute to my consultant, Professor Chris Bunker, who is well known in the field and is president of the British Association of Dermatologists. Compared with mainland Europe, the ratio of consultant dermatologists to the general population remains low in the UK, at 1:130,000. It is estimated that there is a 20% shortfall in consultant numbers in the UK.

Furthermore, there are significant issues related to vacancies in dermatology consultant posts—there were some 180 consultant vacancies at the last count. That is due both to an inability to attract people to posts in remote areas and to the widespread problem of funding being available for a post but the relevant deanery refusing to provide a training number that allows the post to be filled by a trainee.

As well as being unpleasant and demoralising for patients, some skin conditions kill; that must be emphasised. Skin conditions are not just a psychological problem. There were nearly 4,000 deaths due to skin disease in 2005, of which 1,817 were due to malignant melanoma, which is now the UK’s most common cancer. That is against a background of 13,000 malignant melanomas each year, a level that has increased 50% in little more than a decade. Those figures continue to rise, driven by the wide availability of cheap holidays in the sun, the continued fashion for using sunbeds and the inadequate resourcing of awareness campaigns. We must do more about that; improved public funding for awareness campaigns, better training and stronger regulation of the use of sunbeds are some of the most obvious answers to the problem, yet very little, if anything, ever happens. Despite skin disease being very common, the direct cost to the NHS of providing skin care is relatively modest. The overall direct cost to the NHS in England and Wales was some £1.82 billion at the last estimate, in 2006.

As of October 2013, there is no policy lead for dermatology in the Department of Health or NHS England; I put that point directly to the Minister. The majority of dermatology services are commissioned by clinical commissioning groups, but national oversight is necessary to co-ordinate care across the country and to drive the agenda. Prior to the April 2013 switchover, primary care trusts were responsible for commissioning dermatology services, but the Department did at least have a policy lead on overseeing service provision. No similar post now exists in NHS England, so no one—I hope the Minister can reassure us on this—champions this area, spots good practice, or drives change.

Earl Howe recently stated in the other place that dermatology would be spread across the five domains of NHS England, and that it would not, as was previously thought, sit primarily under long-term conditions in domain 2. That surely only heightens the need for a director to co-ordinate policy across the five domains. Even if only a junior post were to be created, patients and health professionals would be given a clear line of accountability and a person to whom they could appeal who was above their local CCG lead for commissioning. Given the prevalence of skin disease, a national clinical director for dermatology, which is what I am calling for, would not look out of place among the long list of such posts at NHS England. I urge it to consider such an appointment.

There is a lack of sources of peer-group, independent advice for people with skin conditions. Patient support organisations are mainly charitable institutions that rely, for the most part, on donations from individuals and pharmaceutical companies. People with skin disease place great value on the information and help provided by dermatology patient support groups. Skin disease is not a well-resourced area, and such groups struggle to make ends meet. There is no group at all, for example, to provide support to people with acne, the previous group having run out of funds some years ago. Given that such charities are almost certainly a cost-effective way to provide what might be life-saving support to patients, perhaps the NHS should consider being a little more generous in its funding.

I thank all those who have helped me to prepare this speech, particularly the British Association of Dermatologists. It is clear that a small number of important steps would make the greatest difference in this area of disease, including the appointment of a national clinical director to co-ordinate learning around the NHS and to drive uptake of new ideas and change. More important, however, is persuading the relevant bodies that I have mentioned to ensure that undergraduates emerge from medical school with a reasonable grasp of dermatology and that newly appointed GPs can recognise a malignant melanoma, which is probably the most important point of all. Those changes alone would have far-reaching, positive consequences for dermatology and for those with skin disease, and I urge the Minister to consider what can be done to make them a reality. I hope that this debate will make some difference.

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[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It is a pleasure to speak under your chairmanship, Mr Turner. I pay tribute to the hon. Members who have spoken today and particularly to my hon. Friend the Member for Gainsborough (Sir Edward Leigh) for securing the debate. As has been illustrated throughout, this is an under-discussed area and it seems to be neglected in other ways, too. The debate has been valuable, and I have certainly learnt a lot during its course and in my preparation for it. Inevitably, there will be some points on which I cannot give a full answer today, but I shall endeavour to follow up with hon. Members if I cannot. I also pay tribute to the all-party parliamentary group on skin. I have looked at the recommendations in its recent report, and I pay tribute to the members of the group who have spoken today.

We have heard from several Members how many people are affected by skin disease and I shall not go over those numbers, which are very large indeed. There is a huge range of skin diseases; some are manageable and others are life-threatening, as we have heard. All have an impact on people’s lives and, in particular, can affect their personal appearance, as Members have highlighted in moving terms. In that way, skin problems perhaps represent more of a day-to-day challenge than many other conditions. They impact on all aspects of life, such as employment and personal relationships. It is, therefore, important to ensure that people with skin disease receive both the treatment and support that they need. As today’s debate has highlighted, considerable challenges remain, many of which we have not necessarily bottomed out during the debate, but we have begun to highlight some.

Let me first plug the national framework. Skin disease is a long-term condition, and through the NHS mandate we have made it clear to NHS England that we want to see the NHS among the best in Europe at supporting people with long-term conditions. We want them to live healthily and independently, with better control over the care that they receive. Those improvements are monitored through the NHS outcomes framework, for which ambitious expectations have been set out. In turn, the NHS will monitor the performance of clinical commissioning groups through the clinical commissioning group outcomes indicator set, on the quality of the services and health outcomes achieved through that commissioning.

As my hon. Friend the Member for Gainsborough highlighted, commissioning for most dermatology services is a matter for CCGs. They are better placed to use their clinical insight, local knowledge and local relationships to do excellent commissioning at a local level than Ministers in Whitehall, but I take on board the challenge about the more specialist areas. We are not leaving CCGs to commission without support. NHS England is working closely with them to ensure high-quality commissioning, and it has established commissioning support units and quality surveillance groups across the country. However, as my hon. Friend the Member for Mole Valley (Sir Paul Beresford) said, it is certainly something that I can raise on appropriate visits when the opportunity arises. As the Public Health Minister, given that so much of my portfolio is localised, I am very keen to draw attention to good practice where we see it.

There is an example in the area of my hon. Friend the Member for Gainsborough, where his local CCG has introduced a teledermatology pathway, which allows patients to be reviewed at their own practice. We also heard of an excellent example from Buckinghamshire, which I was speaking about with my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan) during the break for the Division. The pathway in the area of my hon. Friend the Member for Gainsborough is being implemented across 10 practices from September. If it is successful, it will be rolled out across all the practices in the Lincolnshire West CCG. I am always interested to hear about good practice. A number of kind invitations for visits have been made during the debate and I look forward to following those up with Members so we can highlight people who are being innovative in a way that will help other commissioners.

As has been mentioned, with some highly specialist dermatology services for conditions that cannot be treated locally, it is appropriate for NHS England to commission them directly. NHS England has set out detailed service specifications for the services that it directly commissions. I realise that a number of Members have made points about the national clinical director, and that issue has been raised in other contexts, too. It is a matter for NHS England whether it appoints a national clinical director. I understand, from asking it the question, that there are no current plans to introduce an NCD for dermatology, but it is continuing to discuss with the British Association of Dermatologists the best ways to improve outcomes for patients.

As has been said, aspects of treatment of people with skin conditions can be considered under any of the five domains. That change in the new NHS focuses on people as individuals rather than on their conditions, which is why the patient pathway and not the organisations that treat them is given the closest attention. Many of the national clinical directors have cross-cutting roles—I have come across that in other areas of my portfolio—rather than roles that are related to individual medical conditions, so it is not the case that dermatology is being singled out. Clinical directors often cut across.

There is interest in the research—points have made about it—that is going on to get better results in dermatology and to come up with new treatment, so I shall touch on that. I reassure the Chamber that investment by the National Institute for Health Research in skin research increased from £4.7 million in 2010-11 to £8.7 million in 2012-13. That includes the NIHR investing £2.6 million over five years in the biomedical research centre at Guy’s and St Thomas’s and the King’s College London centre, which is leading the way in research on cutaneous medicine. The NIHR is dedicated to translating these scientific discoveries into improvements in treatment, which we hope will benefit patients at the earliest opportunity.

The NIHR has also awarded nearly £2 million to Salford Royal NHS Foundation Trust to undertake a programme of research on psoriasis. The studies will look at crucial issues, including individual patient experience, difficulties faced by service providers and identifying levels of risk in populations. I hope that the hon. Member for West Lancashire (Rosie Cooper) will take particular comfort from that, and I am sure that she will be interested in the outcome of that programme. The NIHR is also investing nearly £1 million in a trial of silk therapeutic clothing for the long-term management of eczema in children.

My hon. Friend the Member for Gainsborough will know that NICE has also published guidance on a range of dermatological conditions, including atopic eczema in children and psoriasis, and it has issued quality standards on those topics. NHS England is statutorily required to have regard to NICE quality standards, and we expect health and care professionals to take NICE guidance on the treatment of relevant conditions fully into account when deciding how to treat a patient.

NICE has also recommended a number of drugs for the treatment of dermatological conditions such as eczema and psoriasis. Patients have a right in the NHS constitution to access drugs and treatments recommended by NICE technology appraisal guidance that their clinicians want to prescribe.

As I acknowledged earlier, and as has been very much illustrated during the debate, skin disease can have adverse psychological effects on patients. The NICE quality standard on psoriasis recognises that and sets out that people with psoriasis should be offered an assessment of how their physical, psychological and social well-being is affected when they are diagnosed and when they undergo treatment. It is the responsibility of all commissioners, providers and clinicians to ensure that patients receive the psychological and emotional support that they need. Hon. Members may be aware of the IAPT—improving access to psychological therapies —programme, which is an NHS programme rolling out services across England offering interventions for people with depression and anxiety disorders. I understand that as part of that programme, NHS England is looking at how best to support people with psychological problems arising from their physical problems. That issue was raised a number of times during the debate.

I listened carefully to the comments of my hon. Friend the Member for Romsey and Southampton North (Caroline Nokes), who highlighted that the issue of Roaccutane was discussed only yesterday in the Chamber. It is associated with rare, serious side effects and can only be prescribed by or under the supervision of a consultant dermatologist. The BAD has published guidelines for its members about when to prescribe it and how best to monitor patients for adverse effects during treatment. I will certainly make a point of catching up with my hon. Friend the Minister of State, who responded to that debate. I will ensure that we touch base with regard to the important subject that my hon. Friend the Member for Romsey and Southampton North has raised today.

The issue of GPs’ and other health workers’ education and training has come up a lot. My hon. Friend the Member for Mole Valley made it the focus of his speech. It is important that health professionals have the right training. Training and education of health professionals is a matter for Health Education England and the royal colleges. NHS England is statutorily required to have regard to the NICE guidelines, and we expect health professionals to have regard to them, too. I am aware that the BAD has produced toolkits and guidance. They are valuable resources for health professionals and should be promoted widely. NHS England has responsibility to support CCGs, as I said, with commissioning guidance and tools and it can flag up the relevant dermatology guidance and standards.

I understand that NHS England’s domain director for long-term conditions regularly meets the president of the BAD, who is also an adviser to the all-party group on skin. I am sure that the issues about the education of GPs are raised at those meetings.

The current framework for accreditation and re-accreditation of GPs with a special interest remains under review, following the transition to the new arrangements for the NHS in England. NHS England is working with the Royal College of General Practitioners and with dermatologists to produce an improved and consistent accreditation system. It is expected that there will be a report early next year, and I am sure that there will be interest from hon. Members in that.

I am concerned about the point that has been made about the shortcuts being taken on some of the training courses. I thought that what was highlighted today was quite alarming. I have heard that before. It is certainly something that I will put on the agenda for my forthcoming meeting with the Royal College of General Practitioners. I will report back to my hon. Friend the Member for Gainsborough, who raised the matter and said that there was considerable interest in it in the House.

Since 2002, there has been a 40% increase in consultant dermatologists, but I accept that that is from a modest base. It is clear that, although there was an increase of 28% between 2002 and 2012 in the total number of staff, we still have more to do, but things are improving. Health Education England needs to ensure that we have the right dermatological work force. I will ensure that it is aware of the issues that have been raised today and highlight the concerns of hon. Members.

Many of the problems highlighted in the debate have not really been funding issues, which I suppose makes a change in an NHS debate. They have actually come out of a lack of engagement that hon. Members have highlighted. I think that some hon. Members have even alluded to there being a sense of complacency sometimes with regard to skin conditions and they asked whether such conditions are taken sufficiently seriously. I am not sure that in this debate we have quite got to the bottom of why clinicians perhaps do not choose to specialise in or pursue this line of work, but today’s debate is useful in highlighting that.

[Sir Edward Leigh]

Will the Minister take away to her fellow Ministers the point that the psychology of all this is very important and, in particular, read the report from the group chaired by my hon. Friend the Member for Mole Valley (Sir Paul Beresford)? A lot of people, when they poke fun at others because of their appearance —their skin colour or something else—do not realise that they are causing them psychological damage. That is the particularly the case with children. It is an important point that we want to be taken away from the debate.

[Jane Ellison]

I am very happy to give a commitment to take that point away and I will certainly bear it in mind in other discussions that I have.

I am glad that some hon. Members have taken the opportunity offered by the debate to highlight the growing issue of malignant melanoma. It is absolutely right to say that we need to make more people aware of the dangers of skin cancer. I was struck by the point made by my hon. Friend the Member for Romsey and Southampton North about the regional variation and the fact that in her area it is a particular problem.

The Department has funded Cancer Research UK to continue to test approaches to encourage, in particular, men over the age of 50 to visit their GP if they have signs of skin cancer. I have to say that, if anyone can come up with a magic way of making men over 50 approach their GP about anything, that would be very welcome and they would be rewarded by all parts of the NHS.