FUTURE DERMATOLOGY SERVICES

A POSITION PAPER

INTRODUCTION

1.   This paper sets out the Skin Care Campaign’s (SCC) vision for the future of dermatology services in the UK , identifies the changes that will need to be made if it is to be achieved and proposes means of effecting those changes.

BACKGROUND

1.1   The SCC ‘Future of Dermatology Working Party’ was originally established in the winter of 2002/03 to develop a vision for dermatology services and to develop means achieving it. SCC Forum meetings in January and May 2003 endorsed the original paper and the proposals for implementing it, adopting the May version as representing the SCC’s priorities for 2003/04.

1.2   In the year since then, several things have occurred to move the national dermatology agenda forward, in particular:

•  the establishment in May 2003 of the Department of Health’s Long Term Conditions Care Group Workforce Team Dermatology Group (the CGWT Dermatology Group) has initiated valuable work, building on the outcomes from the Action on Dermatology programme (AOD), beginning the development of new patient pathways (especially for inflammatory skin disease management) and examining ways in which dermatology workforce numbers may best be calculated;

•  a review of the recommendations made in the reports on the seven enquiries conducted by the All Party Parliamentary Group on Skin (APPGS) to date, in order to prioritise them and commit more effort to campaigning for their implementation;

•  considerable progress with the development of dermatology training for health professionals, with:

•  the British Association of Dermatologists (BAD) and the Royal College of General Practitioners (RCGP) working closely together to have dermatology made a more substantial and significant component of GP training; and

•  the development of the British Dermatological Nursing Group (BDNG) /SCC/ University of Southampton dermatology course for primary care nurses.

•  publication in July 2003 of the report on the APPGS enquiry into the impact of skin disease on people’s lives.

1.3   It was therefore agreed at the SCC Forum and Board meetings in January 2004 that would be useful to revise the original paper to reflect these changes and to review its recommendations in the light of them.   

2.   A VISION FOR DERMATOLOGY

  The SCC’s ‘vision’ for dermatology services is:

“The equitable provision of ready access to quality dermatological care and information throughout the UK ” .

3.   STAKEHOLDERS

The SCC sees the following as being ‘stakeholders in dermatology’ – patients, carers and patients parents or partners; support groups representing patients; clinicians (including pharmacists, health visitors, primary and secondary care nurses, general practitioners, general practitioners with a special interest in dermatology (GPwSIs), consultant dermatologists, and other secondary or tertiary care clinicians); health policy developers and decision makers (politicians, Department of Health [DH], NHS Executive, Strategic Health Authorities, Primary Care Trusts [PCTs]); industry; and, indirectly, others including, for example, employers interested in maintaining the health of their workforces.

4.   COMPLEMENTARY AREAS OF WORK

  The SCC notes the work being done by the AOD Programme and the CGWT Dermatology Group, the BAD (especially in respect of workforce numbers and the training of health professionals) and the APPGS (also especially in respect of training).

5.   THE STATUS OF DERMATOLOGY

5.1   Much of the very real progress that has been made, and which has been gathering momentum over the past four years, has resulted directly from the government’s willingness to engage with stakeholders through the AOD Programme and the CGWT Dermatology Group. Changing priorities and re-organisation within the NHS threaten the excellent relationships that have been established between patient organisation, clinicians and the industry on the one hand and the government on the other. Erosion of those relationships would be disastrous for people with skin diseases and damaging to the NHS.

   Action: The SCC will work with relevant health professionals, the DH, the NHS and others to establish permanent and collaborative lines of communication with the DH and the NHS.

   Note: the APPGS has committed to pressing for maintenance of the close and very constructive liaison that has been developed between all stakeholders.

5.2   The SCC feels strongly that dermatology is still accorded too little importance by other health professionals and that there is an urgent need to raise its profile with health policy makers, health service managers and within the medical profession. In particular, the Working Party noted the need to persuade PCTs of the importance of dermatology.

   Note: The APPGS has committed to considering and pressing for a new categorisation for dermatology as an alternative to ‘minor ailments’.

5.3   It was agreed that different audiences may be influenced by different considerations. Whereas the parliament and the public tend to be concerned chiefly with skin cancer and with the quality of life issues associated with skin diseases, the DH, the NHS and health service managers at various levels are generally very much more concerned with the practicalities of waiting times, cost, the burden of inflammatory skin disease within primary care and the subjects that attract payment within the new GP contract.

Action: the SCC will develop and implement sustained and coherent media and lobbying campaigns to raise the profile of dermatology, being careful to match its messages to its audiences. Key targets for these campaigns will be, in order of priority, (a) health policy developers and decision makers, (b) health professionals other than those primarily concerned with dermatology, including especially Primary Care Trusts, and (c) the public.

6.   FIELDS

6.1    Patients’ Needs: The SCC believes that patients’ needs are encapsulated in the ‘vision for dermatology’, para 2 above.

6.2    Service Tiers:

6.2.1   The SCC anticipates that there is likely to be significant change in service tiers over the next ten years. In particular, the growing emphasis placed by the DH on NHS Direct and NHS Direct On-line, the development of nurse and pharmacist prescribing and the introduction of GPwSIs in a range of specialties including dermatology suggest the development of a new model for health service delivery – with greater emphasis on well-supported self-management of long-term conditions (including skin diseases) and, perhaps, direct access to GPwSIs in dermatology, or to ‘office’ or ‘community’ dermatologists. Far more dermatology services would thus be provided in primary care or at the intermediate level (at the interface between primary and secondary care), secondary care services managing rarer, more complex or more difficult conditions and having a substantially increased role in the training and mentoring of primary care health professionals.

6.2.2   The SCC notes the changing economic scene within the NHS – not least the growth of PCT commissioning and the establishment of Foundation Trusts – and will monitor carefully the implications of such issues for people with skin diseases.

6.2.3   The SCC supports strongly the revised patient pathways being developed by the CGWT Dermatology Group, a simple, generic version of which is at Annex ‘A’. In particular, it supports the establishment of clinics for inflammatory skin diseases in primary care, comparable with those already provided for asthma and diabetes.

Note: The APPGS has adopted the establishment of such clinics as one of its aims.

6.2.4   Given the DH and NHS commitment to removing much dermatology into primary care, which the SCC supports, and given that GP practices can only be expected to undertake those tasks they have contracted to undertake and for which they are properly remunerated, we are dismayed that there is no mention of dermatology, either explicit or implicit, in the new GMS Contract.

Action: with the CGWT Dermatology Group, the BAD and the APPGS, the SCC will press for incorporation into the GP contract of appropriate quality measures, the purpose of which should be to measure practices’ commitment to the provision of proper dermatology services.

Note: the APPGS is actively pressing the government to include dermatology quality measures in the contract.

6.2.5   The SCC welcomed publication of the GPwSI framework for dermatology which sets out the core activities and competencies of GPwSIs, and the clinical governance, accountability and monitoring arrangements for GPwSIs.

Action: The SCC will encourage and support the development of sufficient numbers of GPwSIs in dermatology to meet patients’ needs (but see 6.3.7 below.)

Note: The APPGS has committed to pressing the Government to define how GPwSIs will work and to provide an idea of what dermatology services should look like.

6.2.6   The Working Party sees all this as tying in closely with the work initiated by the Action on Dermatology programme and now being progressed by the CGWT Dermatology Group, which, in addition to separating diagnosis from treatment and promoting the removal of much dermatology from secondary to primary care, encourages strongly the development of closer relationships between those service tiers. The SCC applauds this. It recognises that the changes envisaged may be expected to provide readier access to quality dermatology services in both primary and secondary care. It recognises, also, that all tiers within the healthcare system should focus on the things they do best and sees as essential the proper integration of primary and secondary care services.

6.2.7   The SCC believes the Action on Dermatology Good Practice Guide , published in January 2003, still has the potential greatly to improve dermatology services. In particular, it is the foundation upon which much of the work being done by the CGWT Dermatology Group is based. We would wish to see it continue to be used widely.

   Action: The SCC will continue actively to promote and encourage use of the Action on Dermatology Guide.

6.2.8   The SCC notes the inappropriateness of many suspected skin cancer referrals from primary to secondary care, and the extent to which waiting times for inflammatory skin diseases are being extended by the requirement that all suspected skin cancers should be seen by a consultant within two weeks. It notes also that the great majority of inflammatory skin diseases referred to secondary care are, by definition, serious.

The SCC wishes to see the development of fast-track referral for all skin patients with urgent needs, rather than just for those with suspected skin cancer, and of ready access to any health professional who may be able to help with the diagnosis, treatment and management of a skin disease.

Action: the SCC will actively explore means of achieving this with the DH and the NHS.

6.2.9   The SCC recognises that demand tends to expand to overwhelm supply and that demand management is therefore essential to the provision of ready access to quality care for those who need it.

Action: the SCC will actively explore and promote means of managing demands on dermatology services – including, as examples, the promotion of well-supported self-management; expectation management; and development of the role of the pharmacist in the provision of high quality services for people who choose to self-manage their conditions with pharmacist support.

6.2.10   The SCC anticipates that the role of patient support groups will change over time, with greater emphasis being placed on training and supporting health professionals (especially primary care health professionals), on educating patients to enable them to get the most from new healthcare systems and on supporting self-management. Skin patient support groups can add considerable value to the NHS in terms of the provision of information and support for people with skin diseases, support for government initiatives like the Action on Dermatology and Expert Patient Programmes, and the facilitation of patient involvement in dermatology service development.

6.2.11   Skin patient support groups (SPSGs) are keen to work with the DH and the NHS and have much to offer. They will only be able to do this, however, if their role is properly acknowledged and supported by the government. In particular, there is a strong case to be made for exploring the sorts of relationships that could be developed between the SPSGs and the NHS. There is a need also for proper financial support for the SPSGs’ core activities, and for further development of the two-way flow of knowledge and understanding between the DH and skin patient support groups.

Action: the SCC will discuss with the NHS Modernisation Agency and the CGWT Dermatology Group how best SPSGs may add value to the sorts of dermatology service delivery models now under consideration.

Action: the SCC will work with other organisations within the voluntary sector, especially the Long-term Medical Conditions Alliance , pressing for proper government support for patient support groups.

6.3    Healthcare professional recruitment, training and motivation:

6.3.1   The SCC recognises the rapidly increasing workload being placed on secondary care dermatology by the dramatic growth in the incidence of skin cancer. Malignant melanoma is now the commonest cancer in the 15-39 age group and the thirteenth commonest cancer overall. Although official figures suggest that there are currently about 46,000 new cases of skin cancer per annum, it is widely agreed amongst experts that there is massive under-reporting and that the true figure is about 100,000 new cases annually. Current forecasts suggest that there will be 300,000 new cases of skin cancer per annum in ten years time. (Editorial comment: I have asked Cancer Research UK to up-date these figures for us, have not yet heard back from them but will give them a nudge.)

6.3.2   At present, there are 499 filled consultant posts, 77 vacant posts and 190
trainees. The BAD say that skin cancer can occupy as much as forty percent of a consultant dermatologist’s time. If that is so, and if there is not significant investment in training and a commitment fully to fund new posts, secondary care dermatology services will be unable even to deal with skin cancer in ten years time, and will have no resources left for patients with other skin conditions.

6.3.3   The SCC welcomed warmly the government’s agreement to the central funding of 20 new funded NTNs (National Training Numbers) and 20 new unfunded ones for dermatology in England in 2003/04. This is the number the BAD asked for. No new NTNs have been agreed for 2004/05. In time, the task of recommending workforce numbers in dermatology will fall to the CGWT Dermatology Group. The SCC anticipates that the Group will recommend a substantial increase in consultant dermatologist numbers.

Action: the SCC will continue to support strongly the BAD’s arguments for further increases in NTN numbers.

6.3.4   Over 650 non-consultant career grade doctors (NCCGs) work in dermatology in the UK contributing 70,000 clinical sessions to the NHS each year during which they see over a million patients. Fifty eight percent of the sessions are done by 180 doctors working as associate specialists, staff grades, non-GP clinical assistants and hospital practitioners. Of 126 surveyed, 70% are willing to do more sessions. They could do more general and fast track clinics. By working partly in the community, they could reduce referrals to secondary care as well as training primary care staff. Their status, educational opportunities, pay and career progression need improving.

Action: The SCC recognises the very significant contribution NCCGs make to dermatology service provision, their potential to improve them further and the difficulties they often face, the SCC will promote greater use of NCCGs and help seek improvements in their terms and conditions of service.

6.3.5   The SCC notes that, compared with the impermanence of clinical assistant posts, the greater security afforded by the permanence of hospital practitioner ones generates higher morale and greatly enhances dermatology services in both primary and secondary care. The SCC notes also that the remuneration for clinical assistants is inadequate and compares badly with the remuneration received by GPwSIs.

Action: the SCC is prepared to provide active support for any representations the PCDS may make in order to improve clinical assistants’ terms and conditions of service.

Note: The SCC sees it as the role of the CGWT Dermatology Group to seek to assure that pay and terms and conditions of service for all intermediate and secondary care doctors engaged in dermatology are fair and equitable, facilitating recruitment to the specialty, and the retention, of enough high quality people, and will raise all the issues set out above with the Group.

6.3.6   The SCC notes that the training criteria for GPwSIs is set out in the GPwSI dermatology framework, and that the Action on Dermatology team, the BAD, the PCDS, the RCGP, the SCC and others were involved in their development.

6.3.7   The SCC believes strongly that development of the GPwSI role should not absolve non-specialist GPs from being properly trained in dermatology. GPs’ acknowledge freely that they have no training or certification in dermatology and that their knowledge of it is poor. If GPs were appropriately trained in dermatology, that would greatly benefit patients and could significantly reduce NHS costs.

6.3.8   Since the original version of this paper was written in mid-2003, the APPGS, the BAD and the SCC have engaged with Professor Steve Field, Chairman of the RCGP Education Network, who is closely involved with complete revision of the GP curriculum. A dermatology module has been developed and Professor Field has agreed that it should be incorporated in the curriculum as an ‘exemplar’.

Action: In working with the BAD and the RCGP, the SCC will continue to press for the GP curriculum to reflect the proportion of GP time spent on dermatology (around 15-20%). The SCC will also press for the introduction of GP certification in dermatology comparable with the certification for, as examples, child health surveillance and minor surgery.

Action: The SCC will continue to press the government to encourage GPs to pay due attention to dermatology in their continuing professional development.

6.3.9   The SCC notes the barrier presented to the removal of a substantial proportion of dermatology from secondary to primary care by inadequate primary care nurse training in dermatology. Following publication of the first draft of this paper in January 2003, the SCC and the BDNG worked with the University of Southampton to develop an excellent dermatology training package for primary care nurses. The course has been accredited by the University of Southampton and approved by the BDNG. Subsequently, the CGWT Dermatology Group agreed to cover the cost of developing the course materials and piloting the course, beginning in September 2004.

Action: With the CGWT Dermatology Group, the SCC will continue to monitor the development of this course and its roll-out, and to explore other uses for it.

Note : the APPGS has committed to supporting this initiative.

6.3.10   The Working Party noted that the dermatology module of the pharmacists’ CPPE is currently being revised and that it appears to be very comprehensive and robust.

Action: The SCC will continue to explore with the RPSGB ways in which pharmacists might be encouraged to complete the module.

7.   AVAILABILITY OF TREATMENTS

7.1   The SCC believes that because people’s skins differ and different people’s skins react differently to different treatments, the widest possible range of treatments for skin diseases should be available on prescription at appropriate levels within the NHS.

7.2   The SCC believes also that when a patient with a skin disease may be expected to benefit from a treatment licensed for that indication and approved for use within the NHS, that treatment should be made available to the patient.

7.3   Both of these views have been endorsed formally and unreservedly by the British Association of Dermatologists, the Primary Care Dermatology Society and the British Dermatological Nursing Group.

Action: The SCC will continue to oppose any attempt to make treatments for skin diseases non-reimbursable or to limit prescribing choice. Further, it will seek NHS commitment to maintenance of prescribing choice in dermatology and, as part of self-management of inflammatory skin disease, to the facilitation of patient choice.

8.   PRESCRIPTION CHARGES

The SCC believes that having chronic skin diseases recognised for exemption from prescription charges would aid compliance and continuance of treatment. The SCC notes that the LMCA (with others) is developing a campaign for the abolition of prescription charges for treatments for all chronic conditions and that the BMA is supportive of it.

Action: The SCC supports this campaign.

9.   CONCLUSION

The recommendations and actions set out in this paper will need to be publicised and campaigned on continuously by every interested body in every forum possible. We will need to make maximum use of the APPGS, the House of Commons Health Select Committee, interested MPs and Peers and our media connections. It may be necessary to seek funding for a specific communications programme for some of the issues.

Skin Care Campaign

April 2004

This paper is formally reviewed at the Skin Care Campaign Forum Meeting in May/June each year.

Annex A

SIMPLE REVISED DERMATOLOGY PATIENT PATHWAY

Potential Benefits:

Meets patients’ needs, especially in terms of choice and access;

Reduces substantially the burden on primary care.

Requirements:

Quality measures for dermatology in new GP contract;

Funding for inflammatory skin disease clinics in primary care, as for asthma and diabetes;

‘The tools for the job’ – i.e. the widest possible range of treatments

Annex B

SCC FUTURE OF DERMATOLOGY WORKING PARTY