Implementation: getting started

While developing this guideline, the Guideline Development Group identified 10 recommendations in 6 areas as key priorities for implementation. This section highlights 3 of those areas that could have a significant impact on practice and be challenging to implement. They have been identified with the help of stakeholders and members of the Guideline Development Group, using the criteria outlined in developing NICE guidelines: the manual, section 9.4. See 'Further resources' below for details of where to get help to address these challenges.

Challenge 1 – Using dermoscopy (dematoscopy) to assess pigmented lesions

See recommendation 1.2.1.

Potential benefits of implementation

Dermoscopy performed in secondary care by suitably trained specialists is both more sensitive and more specific in classifying skin lesions than clinical examination with the naked eye alone. It lessens the chance of missing a diagnosis of melanoma and reduces the number of unnecessary surgical procedures to remove benign lesions.

Challenges for implementation

For healthcare professionals in secondary care skin cancer clinics:

  • Using dermoscopy routinely. Dermoscopy is integral to most dermatology services but is thought to be less commonly used in some clinics, for example clinics staffed by plastic and reconstructive surgeons.

For healthcare professionals who assess pigmented lesions:

  • Developing competencies in assessment.

  • Gaining experience in dermoscopy through regular practice.

  • Including formal training in dermoscopy in their continuing professional development and revalidation work.

  • Gaining access to new equipment (in some areas).

For relevant royal colleges and speciality training organisations:

  • Including dermoscopy in speciality training curricula for healthcare professionals who assess pigmented lesions.

Making the changes happen

Commissioners of services could:

  • Include provision of dermoscopy in local service specifications.

Providers of secondary skin cancer clinics could:

  • Arrange for healthcare professionals who assess pigmented lesions to have formal training in dermoscopy. There are a range of academic institutions that deliver national and local courses.

  • Routinely provide experiential training for staff in specialist clinics. This could include competency‑based assessment.

  • Include reference to ongoing experience and competency in the appraisals of healthcare professionals who perform dermoscopy.

The relevant royal colleges, supported by the speciality training organisations, could:

  • Include dermoscopy where relevant in their specialty training curricula, and look at the specialty training curriculum for dermatology from the Joint Royal Colleges of Physicians Training Board as an example.

  • Consider developing work‑based assessments for measuring competency in the use of dermoscopy.

Challenge 2 – Measuring vitamin D levels and advising on supplementation

See recommendations 1.3.1 and 1.3.2.

Potential benefits of implementation

Measuring vitamin D levels at diagnosis allows healthcare professionals to identify people with melanoma whose vitamin D levels are low and who might benefit from supplementation in line with national policies, as well as people with high vitamin D levels who do not need supplementation and in whom supplementation might be harmful. Knowing a person's vitamin D level will also improve the accuracy of the advice given to them about the risks and benefits of sunlight exposure.

Challenges for implementation

For dermatologists (and possibly oncologists) in skin cancer multidisciplinary teams:

  • Measuring vitamin D levels routinely at diagnosis of melanoma.

  • Developing expertise in interpreting vitamin D levels.

  • Providing advice about vitamin D supplementation if needed.

Making the changes happen

Dermatologists (and possibly oncologists) in skin cancer multidisciplinary teams could:

Challenge 3 – Considering sentinel lymph node biopsy and completion lymphadenectomy

See recommendations 1.5.2 and 1.7.1.

Potential benefits of implementation

Considering sentinel lymph node biopsy (SLNB) for people who have stage IB–IIC melanoma with a Breslow thickness of more than 1 mm, and discussing the possible advantages and disadvantages with them, will enable people with these melanomas to make an informed decision about whether or not to have this procedure. Those who choose to have SLNB may benefit from more accurate staging, giving a better indication of outcome (including survival and risk of relapse). SLNB is more sensitive than ultrasound, so lymphatic spread may be diagnosed earlier. In addition, people who have SLNB may be able to participate in clinical trials of new treatments.

Similarly, discussing the possible advantages and disadvantages of completion lymphadenectomy with people who have a positive SLNB will enable them to make an informed decision about whether or not to have this procedure after SLNB. Completion lymphadenectomy can reduce the chance of the melanoma returning and may enable the person to participate in clinical trials of new treatments.

Challenges for implementation

For clinicians in skin cancer multidisciplinary teams:

  • Explaining the value of SLNB as a staging tool to people with melanoma, because there are no clear survival benefits from it.

  • Providing comprehensive information about the possible advantages and disadvantages of having the procedure.

  • Explaining the benefits of proceeding to completion lymphadenectomy to people with a positive SLNB result.

For commissioners:

  • Providing SLNB in services.

Making the changes happen

Clinicians in skin cancer multidisciplinary teams could:

  • Listen to the explanation of the evidence behind the SLNB recommendations on the NICE podcast.

  • Use the option grids that NICE has produced to help discuss the possible risks and benefits of having SLNB and, for people with a positive SLNB, proceeding to completion lymphadenectomy.

Commissioners could:

  • Ensure that service specifications include provision of SLNB. This may not be delivered locally.

  • Visit the NICE local practice collection to see examples of SLNB services.

Further resources

Further resources are available from NICE that may help to support implementation.

NICE produces indicators annually for use in the Quality and Outcomes Framework (QOF) for the UK. The process for this and the NICE menu can be found here.

Uptake data about guideline recommendations and quality standard measures are available on the NICE website.

  • National Institute for Health and Care Excellence (NICE)