Experiences of dermatology
services transformation
Julia Schofield, Principal Lecturer
University of Hertfordshire
Consultant Dermatologist, United
Lincolnshire Hospitals NHS Trust
Experiences of dermatology
services transformation
• What did the service look like before the
redesign work?
• What changes were made and how were they
made?
• What the service looks like now
• Where there any barriers and how were they
overcome?
• Examples of models of service from England
How best to answer these
questions?
Setting the scene
1997-2010
The Blair years, the NHS and Dermatology :
period of unprecedented reform
Reform & modernisation: early stages
• Background of long waiting lists and poor
access to services
• NHS Modernisation agency Action on
Dermatology (2000-2003)
• Action on Plastic Surgery (2003-2005)
• Pilot site work and Good Practice Guidance
• Role of GPwSIs and extended role
practitioners
• Lack of good evidence for what worked
Trends in the number of dermatology patients waiting longer than 26 and 13
weeks to be seen using fourth quarter data 1999-2007, England source
www.performance.doh.gov.uk/waitingtimes
30,000
25,000
13 to <26
20,000
>26
15,000
10,000
5,000
0
Q4 99/00
Q4 00/01
Q4 01/02
Q4 02/03
Q4 03/04
Q4 04/05
Q4 05/06
Q4 06/07
So what have we learnt that is
important and where is the
evidence?
The commissioning cycle
Service redesign cycle
The 2009 Health Care Needs Assessment
• The burden of disease:
how much, how
expensive, impact?
• How we manage the
burden: services
available and their
effectiveness
• Recommendations for
models of care based
on the EVIDENCE
http://www.nottingham.ac.uk/scs/documents/documentsdivisions/documentsdermatology/hcna
skinconditionsuk2009.pdf
Structure of the document: chapters
1. Introduction
2. Burden of skin disease
3. NHS reform and its impact
4. Services available and their effectiveness
5. Models of care and organisation of services
6. Specific skin disease areas
7. Recommendations
Lots of references!
Linking the evidence to
service redesign:
ASSESSING NEED
•
•
•
•
Coding systems poor, underestimate problem
Skin disease is very common
Lots of people self care and buy OTC products
24% of the population seek medical advice about a
skin condition each year (12.9 million)
• Commonest reason people present to a GP with a
new problem
Skin disease seen by specialists
• Limited information, good scottish data*
• About 6.1% of people with skin disease are
referred to see a specialist
• 35-48% referrals are skin lesions, more in
coastal areas
• Ever increasing referrals to specialists
• Eczema, acne and psoriasis commonly seen
• Patients still admitted
*Benton, EC, Kerr, OA, Fisher, A, Fraser, SJ, McCormack, SKA,
Tidman, MJ (2008) The changing face of dermatological practice: 25
years' experience. British Journal of Dermatology, 159, 413-8.
Need: summary of key messages
3752 deaths due
to skin disease
Self reported/ self
managed skin disease
50% population
approx 25 million
0.75 million people with skin
disease referred for NHS
specialist care, 1.5%
24% population, 12.9 million
seeking Primary Care
(England and Wales)
Linking the evidence:
SERVICE PROVISION
•
•
•
•
•
We MUST define the level of care and the location
Confusion about terms
Primary care means ‘first point of contact care’
Secondary care means ‘specialist care’
Too much talk of ‘shift’ without understanding the
meaning
Define LEVELS of care: self care, generalist,
specialist, supra-specialist
From Skin conditions in the UK: a Health Care Needs Assessment Schofield et al 2009
Linking the evidence: service provision
Generalist care
• Patients like to be treated by their GP
• GP diagnostic skills for skin lesions are not great
• Standards for GP skin surgery need to be
improved
• Up-skilling of Practice Nurses limited benefit
• Community specialist outreach nursing services
effective for chronic skin disease
Linking the evidence: service provision
Specialist care
• Dermatologists should be diagnosing the skin
lesions: they are good at it
• Dermatologists can prevent hospital admissions
for some conditions
• If GPwSIs are to be used, they need to be
accredited
• Specialist nurse services for prediagnosed
conditions are effective
Services available: who sees what
and where?
Primary care
Skin infections
WHY?
Specialist care
Skin lesions 45-60%
31-59% are for diagnosis – skin lesions even higher
Service provision: the diagnostic bottleneck
Treatment
Surgery
Specialist opinion,
diagnostic service
CORRECT DIAGNOSIS
=
CORRECT MANAGEMENT
Patients with skin disease
requiring diagnosis and
management
Linking the evidence:
DECIDING PRIORITIES
MUST do’s
• NICE guidance includes skin cancer, biologics for
psoriasis, atopic eczema
• DH access targets 31/62 days for cancer
• 18 week patient journey
• Choose and Book
• Care Closer to Home recommendations
Linking the evidence: deciding priorities
Inequity of access need vs demand
• Variable low priority frameworks across
England
• Skin surgery
• Lymphoedema services
• Botulinum toxin services for sweating
• ‘One pot spent well’
• Decisions should be based on the evidence
base
What is need?
Need is ‘the ability to benefit from care’
Williams HC. J Roy Coll Physicians 1997;31:261-2
The use of isotretinoin
to treat acne
The use of the biological
agents to treat psoriasis
Demand and supply
Demand = “that which
is asked for”
Supply = “that which is
provided for”
Williams, HC. J Roy Coll Physicians
1997;31:261-2
Seborrhoeic keratoses –
demand or need?
How to save a billion (part II)
• Up to £700m could be saved if PCTs decommissioned some
procedures:
“relatively ineffective”
Max potential reduction in
procedures (%)
Max potential
savings (£m)
Tonsillectomy
90
45
Back pain injections & infusion
90
24
Grommets
90
21
Knee washouts
90
20
Aesthetic breast surgery
80
18
Varicose veins
80
18
Inguinal, umbilical & femoral hernias
50
50
Minor skin surgery for non
cancerous lesions
25
74
“Potentially cosmetic”
Linking the evidence:
DESIGNING SERVICES
•
•
•
•
•
Emphasis on rapid access to diagnosis
Right place, right person, first time
Range of national guidance about models of care
Integrated care
Local specialist services with links to regional and national
specialist services
• Services for sick patients in hospital
• Day treatment OP phototherapy services
• Patients must be involved in the design of services
Care Closer to Home 2007 Figure 2: Dermatology patient journey (source: modified from Model of Integrated Service Delivery. Skin
Care Campaign 2007)
Patient support groups
The Patient
Drop-in Centre
The facility to refer directly to
secondary care services is essential
2 week wait
cancer
pathway
Pharmacist
Discharge
GP
Referral
management*
Diagnosis and
treatment
GPwSI/PwSI
(where appointed)
Secondary care
* Where referral management
schemes are in place it is essential
that these are led by experienced
specialist clinical triage performed
daily to reduce delays
Tertiary (supra-specialist care)
Diagnosis and
specialist
treatment
Skin lesion models: separate diagnosis and management
18 week skin lesion pathway
Linking the evidence: designing services
• Shifting care to community settings does not
necessarily reduce activity or cost
• There is a link between a reduction in wait
times and increased referral rates
• National standards and review are in place for
skin cancer services
Linking the evidence: designing services
• GPwSI services improve access but do not
reduce cost
• Specialist nurses working with specialist teams
are effective
• Specialty and Associate Specialist doctors are
interested in working in new models of care
Linking the evidence: designing services
• Teledermatology useful for remote areas
• ‘Store and forward’ digital image and referral
useful
• Clinically-led guidelines may be helpful but a
lot of work!
• Referral management services (RMS) evidence
free zones*. ? Role of Tier 2 services/ Clinical
Assessment and Treatment services
Davies, M, Elwyn, G (2006) Referral management centres: promising innovations or
Trojan horses? BMJ, 332, 844-6.
Referral management services
Referral management centres
• Paper/electronic process
• Count referrals
• Assess quality and reduce inappropriate
referrals
• Redirect referrals to appropriate service
• May lack clinical input
Referral management services
DH guidance 2006
• Must not lengthen patient journey
• Must carry clinical support
• Should confer real diagnostic or treatment
benefit
• Not be imposed without agreement
• In England largely financially driven
Experience of a Clinical Assessment and
Treatment Service in Hertfordshire
• Specialist led, GPwSIs, consultant outreach,
specialist nurses
• Specialist triage
• Community settings
• Routine, straightforward dermatology
• Patients happy, good service
• Robust governance and quality
Dermatology Service from September 2007
Referral to CATS service
Other
referrals
Consultant/Associate
Specialist triage
Triage
CHOICE
ROUTINE
ROUTINE
Skin surgery
Needs
specialist
services
Pre-diagnosed
N/L eczema
N/L psoriasis
N/L leg ulcer
CHOICE
GPwSI
Consultant
outreach
Urgent
C
H
O
I
C
E
Wellswood
House
Borehamwood
2 week
wait
Consultant
appointment
OUTCOME
Discharge
or follow up
Impact on secondary care referral rates
400
350
300
250
200
150
100
50
0
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Pre-CATS
CATS period
Apr
May
June
July
Aug
BUT: total referral activity including CATS
referrals increased
600
Pre-CATS
CATS period
TOTAL
500
400
300
200
100
0
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Linking the evidence:
SHAPING THE STRUCTURE
OF THE SUPPLY (!)
• Quality same wherever and whoever provides the
service (OHOCOS 2006)
• Joined up services: integrated models
• Local resources local solutions
• Robust standards of accreditation, DH guidance
• Competency based assessments supervised practice
Linking the evidence:
MANAGING THE DEMAND
• General Practitioner will remain the gatekeeper
• Resources are finite and demand will need to be
managed
• No evidence that strategies to date are effective
• Priority setting may be the key
• Need vs demand increasingly an issue
GP as gatekeeper: education and
training
• Limited undergraduate training
• Postgraduate training not compulsory
• GP curriculum could map better to what is
seen in practice
• Training and education important
• Not a short term solution
The final piece of evidence to think on
30,000
13 to <26
>26
25,000
18% more patients
seen
5.6% more new
patients seen
Fewer people waiting
20,000
15,000
10,000
24% rise in
consultant
numbers
5,000
0
Q4 99/00
Q4 00/01
Q4 01/02
Q4 02/03
Q4 03/04
Q4 04/05
Q4 05/06
Q4 06/07
Implementing the 18 week target
Presented the evidence
• Service redesign cycle
• Needs Assessment
• Burden of skin disease
• Service provision
• Models of care
• Referral management
No magic wand!
THANK YOU
The HCNA is available free at:
http://www.nottingham.ac.uk/scs
/documents/documentsdivisio
ns/documentsdermatology/hcn
askinconditionsuk2009.pdf
Hard copies can be purchased
from the Centre of Evidence
based Dermatology for a
nominal sum from
douglas.grindlay@nottingham.
ac.uk