The improved management of chronic or long term
conditions in community based programmes
of care now forms an important element in
government policy. Skin problems form part
of around 15% of all consultations in general
practice in the UK (RCGP, 1995). There are
more referrals by GPs to Dermatologists
than to the rest of General Medicine in
total, and 20% of all referrals to hospital
are for the 3 major inflammatory conditions
(eczema, psoriasis and acne). Despite these
well-documented figures, skin disorders
do not feature in the quality frameworks
for the new GMS contract that now drive
priorities in primary care.
Foremost
among the skin diseases that burden general
practice are atopic eczema, which accounts
for 30% of GP consultations due to skin
disease (Rea et al, 1976), psoriasis and
acne. The diagnosis of these conditions
in their classical form is usually straightforward,
but management is often poor, ill focussed
and unnecessarily expensive. Patients and
carers are often well informed, and highly
motivated, but find difficulty accessing
practical information and informed medical
practitioners to facilitate their self-management.
Eczema
•
The prevalence of atopic eczema has risen
over the last few decades so that it now
affects 15% of infants in the UK (Kay et
al, 1994)
•
The impact of the disease on family life
is greater than that produced by any of
the other chronic disorders including asthma
and diabetes.
•
10% of all referrals to hospital are of
patients with eczema.
•
Management strategies are well documented,
and guidelines of care exist, but patients
and parents require guidance and help with
the practicalities of management.
•
Nurse led clinics and enhanced general practitioner
roles produce a significant impact on the
management of the disorder, improve self-reliance
and reduce the need for hospital referral.
•
Almost all of these affected children will
have concomitant asthma, and may already
be seen by the community based nurse specialists
because of their pulmonary disease: failure
to deal with their cutaneous problems at
the same time is a missed opportunity, but
requires educational input for the nurses,
as well as additional time for consultation.
•
Adequate medical support is also essential,
but will produce improved quality of outcome
as well as reducing hospital referral and
enhancing patient self-management.
•
Both the Dermatology Sub-group of the Long
Term Conditions Care group and the Children’s’
NSF advocate community care for these patients,
but progress is limited by the lack of a
primary care focus.
•
In the smaller adult population with eczema,
dermatitis is the second commonest cause
of absence from work after musculo-skeletal
disorders, and whilst there may be more
factors influencing the disease, the principles
of management are the same.
Psoriasis
•
Psoriasis affects 1.6-2% of the British
population UK (Kidd and Meenan, 1961; Rea
et al, 1976).
•
The condition produces severe social and
psychological consequences and reduces quality
of life significantly (Finlay and Coles,
1995). It is lifelong.
•
In its most severe form it is life threatening,
but for the majority of patients with mild
disease, simple topical therapies work well
provided that the treatments are used appropriately.
•
5% of all referrals to hospital-based Dermatology
will have psoriasis.
•
Misinformation and poor compliance are major
features in poor management of the disease,
and currently 50% of sufferers will require
hospital management over a 5-year period.
•
Nurse led clinics reduce the need
for consultant appointments and improve
patient care.
Acne
•
Acne is the third of the major inflammatory
dermatoses.
•
80% of teenagers suffer at some time, and
by mid twenties, 1% of men and nearly 30%
of women still suffer.
•
Treatment options are well known, guidelines
are in development, and yet 5% of all dermatology
referrals are for patients with acne, and
50% of these will have received sub-optimal
therapy (often none).
•
Nurse-led guideline based care will produce
more effective treatment and more rational
prescribing.
Case
for inclusion of skin disease in the GP
contract
•
Skin disorders represent a chronic burden
to GPs in terms of numbers of patients seen,
time spent with patients, and prescription
of drugs.
•
Despite this, patient management is often
poor, patients are unhappy with their care,
and find difficulty in self-managing.
•
The education of GPs in dermatology is sub-optimal
(APPGS, 2002). There is good reason for
more attention to be paid to training and
assessing of GPs in skin disease. Any programme
of enhanced primary care must deliver appropriate
educational opportunities for doctors and
nurses.
•
Contact with nurses, and improved vertical
integration between primary and secondary
care enhances self care, and the benefit,
is assessable in terms of
•
Hospital referral
•
Use of guidelines
•
Appropriate prescribing
•
We suggest the use of the following quality
statements:
Records - suggested
threshold 90%
SKIN
1. Practices will have a register
of patients with atopic eczema and a register
of patients with psoriasis.
Ongoing
management - suggested threshold
70%
SKIN
2. The percentage of patients
with atopic eczema offered a consultation
with a trained nurse to receive advice,
educational material and a review of treatment.
SKIN
3. The percentage of patients
with psoriasis offered a consultation
with a trained nurse to receive advice,
educational material and a review of treatment.
SKIN
4. Practices will have in use
a protocol, agreed with the local secondary
care provider or appropriate national
body, for the treatment of patients with
acne.
References
All
Party Parliamentary Group on Skin: Report
on the Enquiry into Primary Care Dermatology
Services. London , APPG, 2002.
Eun
HC, Finlay AY. Measurement of atopic dermatitis
disability. Ann Dermatol 1990; 2: 9-12.
Finlay
AY, Coles EC. The effect of severe psoriasis
on the quality of life in 369 patients.
Br J Dermatol 1995; 132: 236-44.
Gawkrodger
DJ. Dermatology: an Illustrated Colour Text,
3 rd ed. Edinburgh , Churchill Livingstone,
2002.
Henseler
T, Christophers E. Psoriasis of early and
late onset: characterization of two types
of psoriasis vulgaris. J Am Acad Dermatol
1985; 13: 450-6.
Herd
RM, Tidman MJ, Prescott RJ, Hunter JAA.
Prevalence of atopic eczema in the community:
the Lothian atopic eczema study. Br J Dermatol
1996; 135: 18-19.
Kay
J, Gawkrodger DJ, Mortimer MJ, Jaron A.
The prevalence of childhood atopic eczema
in a general population. J Am Acad Dermatol
1994; 30: 35-9.
Kidd
CB, Meenan JC. A dermatological survey of
long-stay mental patients. Br J Dermatol
1961; 73: 129-33.
Lewis-Jones
MS, Finlay AY. The children’s dermatology
life quality index (CDLQI): initial validation
and practical use. Clin Exper Dermatol 1995;
20: 38-41.
Rea
JN, Newhouse ML, Halil T. Skin disease in
Lambeth. Br J Prev Soc Med 1976; 30: 107-14.
Royal
College of General Practitioners. Morbidity
Statistics from General Practice: Fourth
National Study 1991-92. London , HMSO, 1995.
Steele
K. Primary dermatological care in general
practice. J Roy Coll Gen Pract 1984; 34:
22-24.
The
All Party Parliamentary Group on Skin
The
All Party Parliamentary Group on Skin (APPGS)
was established in 1994, the culmination
of an SCC campaign to raise awareness of
skin disease in Parliament. Around 400 All
Party Parliamentary Groups exist, representing
a variety of public policy issues.
The
APPGS has a large and active membership
that includes MPs from all political parties,
members of the House of Lords, health professionals,
patient groups and commercial interests.
The
Group’s day-to-day activities are determined
by its Steering Group, which is composed
of non-parliamentary members and is representative
of the associate membership. All activities
are subject to the approval of the Group’s
parliamentary officers led by the Chairman,
the Rt Hon Bruce George MP.
The
APPGS has the following broad objectives:
•
to raise awareness
of skin issues in Parliament
•
to achieve improvements
in the treatment and management of patients
with skin disease
•
to provide an
unbiased means of responding to threats
to dermatology
•
to provide a
forum for partners in skin care – patients,
clinicians, managers, industry and other
skin interested organisations
•
to make recommendations
to Government for improvements to dermatology
services and patient management
The
APPGS holds around five meetings a year
in the House of Commons to inform parliamentarians
about relevant dermatology issues. A variety
of speakers address the Group including
representatives from health professional
organisations, patient groups, political
parties and charities. Meetings are open
to all members and provide an opportunity
to share information and experiences.
The
APPGS also produces written reports, to
which all members have the opportunity to
contribute. Nine reports have been published
to date, addressing a variety of dermatology
issues including the adequacy of service
provision, two on dermatology training for
health professionals, fraudulent practice,
primary care, skin cancer, the elderly,
and the impact of skin disease on people’s
lives. The Group’s reports have been widely
supported by dermatology stakeholders and
have proved useful tools for presenting
evidence to policy makers.
The
APPGS also undertakes ad hoc briefing
activity to highlight new and emerging issues
with its parliamentary members. This includes
liaising with MPs and Peers on parliamentary
questions, early day motions and short debates.
The Group will also raise issues with officials
in Whitehall as and when appropriate.
The
APPGS’s work programme is intended to reflect
key issues in dermatology services and emerges
from consultation with key dermatology stakeholders.
The Group’s priorities have included securing
a dermatology policy lead in the Department
of Health, work to implement the training
report, as well as having dermatology included
in the GP Contract.
The
first part of 2005 saw the APPGS starting
work on its tenth report, to be published
towards the end of year. The report will
address the adequacy and equity of dermatology
service provision, highlighting new developments
in primary care dermatology services and
updating the 1997 report.
Membership
of the All Party Parliamentary Group on
Skin is open to any organisation or individual
with an interest in Skin Disease. If you
would like to become an associate member
of the Group please contact the Secretariat.
All
Party Parliamentary Group on Skin
St James House, 13
Kensington Square, London, W8 5HD
Tel: 020 7368 3100
Fax: 020 7368 3101 Email:
info@portcullispublicaffairs.com
