Dermatology Workforce Service Forecast
Health Workforce New Zealand
November 2014
1
Table of Contents
Executive Summary............................................................................................... 3
Introduction ......................................................................................................... 6
Methodology ........................................................................................................ 7
Dermatology in New Zealand ................................................................................ 6
What is Dermatology? ...........................................................................................6
The burden of disease............................................................................................6
Skin cancer .............................................................................................................6
Health Loss .............................................................................................................7
Data on Hospital Services ......................................................................................7
Data on GP Services ............................................................................................... 7
Comparative ratios of Dermatologists: Population ...............................................8
Academic Dermatology ..........................................................................................8
Current New Zealand Dermatology workforce ................................................... 8
The vision for Dermatology in 2020 ..................................................................... 14
The proposed model of service delivery in 2020 .................................................. 15
Discussion........................................................................................................... 16
Dermatology service in New Zealand ............................................................... 16
Workforce ....................................................................................................... 18
Specific service issues ...................................................................................... 22
Appendix 1: Dermatology Workforce Service Forecast Group .......................... 28
Appendix 2: Examples from literature (New Zealand and overseas) ................. 29
Appendix 3: Vignettes ..................................................................................... 40
Appendix 4: ACC Claims ................................................................................... 45
References ...................................................................................................... 45
2
Executive Summary
From July to November 2013, the Dermatology Workforce Service Forecast group
(the Group) was formed to develop a vision for dermatology services in New Zealand
in 2020 and beyond, describing possible model or models of care that are patientcentred, team based and build in primary care where appropriate.
The Group’s vision for dermatology in New Zealand in 2020 is ‘that patients will
have equitable access to an integrated, consultant-led service that delivers high
quality health care’.
The Forecast was informed by literature reviews, the experience and knowledge of
the Group members, the use of scenarios to illustrate current practice and
information provided by individual district health boards (DHBs) and Health
Workforce New Zealand (HWNZ).
This process highlighted a number of issues, the main ones being highlighted below.
 There is an urgent need to develop a career pathway for public hospital
dermatologists and to increase Senior Medical Officer (SMO) dermatology
posts. There are very few SMO dermatologists working in public hospital
practice, compared to private practice due to a lack of substantive public
positions.
 Access to publicly funded dermatology services in New Zealand is currently
very limited and varies greatly across DHBs and regions.
 The range of dermatology treatments offered varies from region to region.
 There is an urgent need to ensure the continuity and development of centres
of excellence in public hospital dermatology.
 Supportive management structures are required to facilitate public
dermatology.
 Stronger dermatology training and academic capacity is required in New
Zealand to enhance the service in New Zealand.
 There are very few nurses working specifically in dermatology, with limited
or no opportunities for training and further qualifications.
 As services are increasingly being delivered outside of the hospital setting,
there is a need for more education for General Practitioners (GPs), achieved
through better integration with public dermatologists.
 A consistent approach to dermatology is required in New Zealand, with
agreed pathways, standards and guidelines developed and implemented.
This is particularly relevant to the diagnosis and treatment of skin cancer.
 Data on dermatology in New Zealand is hard to access and is not routinely
recorded or centrally collected
In order to address the access issues highlighted, the model proposed by the Group
for 2020, identifies the core services that should be delivered safely and efficiently at
primary care, DHB, regional and national levels. Delivery of services requires
3
appropriately trained staff, working in collaborative teams to provide accurate
diagnosis and treatment plans, which can be delivered in a safe and timely way.
The report notes that support is needed for public Dermatology as a specialty as a
matter of urgency. The report proposes that Health Workforce New Zealand,
business units of the Ministry of Health and district health boards develop a cohesive
plan that provides a sustainable, public sector dermatology service and workforce in
New Zealand for 2020.
Introduction
The Workforce Service Forecasts (forecast) are to provide important input into
HWNZ planning and decision-making around workforce purchasing intentions and
other workforce initiatives.
In July 2013, Dr Darion Rowan was invited to form a Workforce Service Forecast
group, to look at the future needs for dermatology in New Zealand. Group members
were invited who brought skills, experience and knowledge of dermatology, both in
New Zealand and overseas, a dermatology nurse and a local GP. A full list can be
found at Appendix 1.
The aim of the forecast was to develop a vision of the relevant health service and
workforce for 2020 and beyond, and models of care that are patient-centred, team
based and build in primary care where appropriate.
In developing the vision and model the Group needs to take into consideration:
 that the outcomes from this forecast are applicable to the delivery of
dermatology services nationally across New Zealand
 a likely doubling of health service demand but only a 30-40% increase in
funding over the next ten years
 that the population is increasing and ageing
 maintenance of quality in service provision
 a continued need to address inequalities
 increased access to quality services
 the interface with Plastic Surgery, particularly in relation to skin cancer
 a reduction in duplication of services
 the ‘triple aim’ of:
 an improvement in individuals’ experience of their health care and
better individual health outcomes
 an improvement in the health and well-being of communities
 a reduction in the per-capita costs of health care
 that the status quo is only acceptable if there are no superior alternatives,
which is not an option for dermatology.
The process began in July 2013 and was completed by the end of November 2013.
4
Methodology
Three face-to-face meetings of the Group were held, all of them at Greenlane
Clinical Centre, Auckland. A part-time project manager was contracted to assist with
the process. Email was the main form of correspondence and information sharing
between the Group.
At the first meeting of the Group, a background document was tabled, which was a
starting point for information gathering about the current dermatology workforce
and service delivery model being used in New Zealand. The Group then developed
the first iteration of their vision for dermatology and determined the scope of the
project. It was decided to define the core dermatology services and how these
should be provided, to ensure equity of access and then use a range of patient
journeys to describe the current and then the future service delivery model. The
Group identified the information that would be useful to inform the project and the
need to consider overseas work.
The second meeting included reviewing the information that had already been
collected, which included:
 analysis of prescriptions relating to dermatology to demonstrate the burden
of disease
 analysis of the distribution of dermatologists by FTE and DHB and the issues
that this raises
 overview of the documentation provided by Group members, particularly
the literature from overseas.
The Group reviewed and amended the vision, refining the original statement. In
addition, they shared their experiences of working overseas under differing models
of provision. Group members then tabled their ‘patient journeys’ and discussed how
these could be improved in the envisioned future delivery model.
The third meeting involved the Group focussing on the key issues raised, which had
been drafted onto an initial report format.
The Group worked on key findings, relevant data sources and recommendations to
include in the report to HWNZ, which highlight the current situation of very limited
public dermatology provision and the requirements for the envisioned service for
2020.
A three-hour teleconference was held to agree the final version of the report.
5
Dermatology in New Zealand
What is Dermatology?
Dermatology is the study, research and diagnosis of disorders, diseases, cancers,
cosmetic, ageing and physiological conditions of the skin, fat, hair, nails and oral and
genital membranes. It includes the management of these by different investigations
and therapies, including but not limited to dermatohistopathology, topical and
systemic medications, dermatologic surgery, phototherapy, laser therapy, superficial
radiotherapy, photodynamic therapy and other therapies that may become
available.i
The burden of disease
New Zealand currently has 4.3 million citizensii and 61 Registered Dermatologistsiii.
By 2021 the New Zealand population is projected to reach just less than 5 million ii.
Mean age will rise to 37.9 years and 17% will be aged over 65, an increase from 13%
in 2011. By 2026 it is estimated that 1 million New Zealanders will be aged 65 and
over.
An increasingly ageing population increases the chances of developing skin-related
disorders such as dermatitis, bullous dermatoses, skin neoplasms and adverse
cutaneous drug reactionsiv. Decreased immunity and exposure to a range of external
factors, in particular UV light, is likely to lead to an increase in skin cancer. It is
predicted that there will be an increased need for dermatologists to meet these
projected needs.
Skin cancer
New Zealand’s melanoma incidence is higher than that reported in any other nation.
In comparison with Australia, the most recent complete data is from 2009 where the
New Zealand cancer registry reported 2212 new melanomas giving a New Zealand
incidence of 51.2 melanomas per 100,000 people. For 2009, the Australian
government cancer registry published their incidence of 44.8 melanomas per
100,000 people. The United Kingdom melanoma incidence in 2010 was 26.6 per
100,000 people (Cancer research UK statistics). New Zealand’s melanoma rate
continues to be the highest in the world and it is rising.
There were 445 deaths from skin cancer in 2009 of which 326 deaths were from
Melanoma and 119 from non-melanoma skin cancer (for example, merkel cell
carcinoma, squamous cell carcinoma, etc.)v.
The exact rate of non-melanoma skin cancer is unknown, as currently these skin
cancers are not notified. It has been estimated that 67,000 non-melanoma skin
cancers are treated each year in New Zealand making both melanoma and nonmelanoma skin cancers a significant proportion of all cancers (80%).
While the mortality from non-melanoma skin cancer is low, the large and increasing
number causes a significant burden on the health system. The health system cost of
6
all skin cancer in 2006 has been estimated to be $57 million with the additional lost
production cost of $66 millionvi. (Source; The costs of skin cancer: report to the
Cancer Society of New Zealand 2009 by Des O’Dea)
Health Loss
In 2006, health loss from skin conditions found 17 408 Disability Adjusted Life Years
(DALYs) representing 1.8% of the total health loss and 9479 DALYs for eczema and
dermatitis (1% of total). In 2009, there were 95 deaths (58 in 2006) in New Zealand
due to diseases of the skin and subcutaneous conditions.vii
Data on Hospital Services
Data on dermatology in New Zealand is hard to access and is not routinely recorded
or centrally collected. Many patients seek treatment in the private sector and this
information is not centrally held or readily accessed.
Dermatology is predominantly outpatient based and therefore relatively inexpensive
on a per capita basis compared to other hospital specialties. However, dermatology
inpatients are often seriously ill and require prolonged hospital stays with multiple
assessments. Many medical and surgical patients develop dermatological
complications that require the prompt attention of a dermatologist. The need for
inpatient assessments is often not properly factored in to SMO job sizing. Many
DHBs will have difficulty accessing dermatologist care for the seriously ill inpatient.
Where there are inpatient services offered, there are a high number of inpatient
consultations, for example Middlemore Hospital with 973 beds, and 15-20 in-patient
consultations per week.
Data on GP Services
Dermnet, the website of the New Zealand Dermatological Society Incorporated,
notes that in New Zealand, one in six (15%) of all visits to the family doctor (GP)
involves a skin problemviii.
The document ‘Skin Conditions in the UK; A Health Care Needs Assessment’ (2009),
found
 Previous studies on unselected populations suggest that around 23-33% have
a skin problem that can benefit from medical care at any one time and skin
conditions are the most frequent reason for people to consult their general
practitioner with a new problem.
 Surveys suggest that around 54% of the UK population experience a skin
condition in a given twelve-month period. Most (69%) self-care, with around
14% seeking further medical advice, usually from the doctor or nurse in the
community.
 Skin conditions are the most frequent reason for people to consult their
general practitioner with a new problem.ix
Given New Zealand’s high level of skin cancers described above, it is likely that the
figures for New Zealand are higher than those described in the UK.
7
Comparative ratios of Dermatologists: Population
Recommended ratios of dermatologists are based on the numbers of referrals and
may vary for community based and hospital based clinicians1.
Table 1
Country
UK
Canada
Australia
USA
New Zealand
Recommended
1: 62 500x
1: 50 000
1: 50 000
1: 25 000 - 30 000
(see below)
Actual
1: 85 124xi
1: 61 734xii
1: 66 506xiii
1: 31 250xiv
1: 274 146 (public)
There is no researched recommended figure for New Zealand. The Group’s
recommendation is a minimum of 1 FTE: 100 000 of public dermatologists and is a
higher ratio than other countries which reflects the amount of private practice in
New Zealand.
Academic Dermatology
There is currently no academic department, or Professor of Dermatology in New
Zealand.
Current New Zealand Dermatology workforce
Dermatologists
Dermatologists are medical doctors. In New Zealand, after completing six years of
medical school, the trainee dermatologist must complete a general medical training
programme, which usually takes 3 to 4 years. After a rigorous basic physician training
examination, Fellow of the Royal Australian College of Physicians (FRACP), he or she
is then eligible to enter advanced training.
The advanced training in dermatology involves at least a further four years of
intensive study, research and practice in a variety of approved training centres in
New Zealand and overseas. The position is usually that of a registrar or training
fellow who is closely supervised by experienced dermatologists.
As of November 2013, there are five training positions in New Zealand (two each in
Auckland and Waikato DHBs, and one at Counties Manukau DHB). It is expected that
two years of the required four will be spent overseas (usually UK, USA, Australia or
Canada). In total, a dermatologist has a minimum of 13 years of training before
becoming vocationally registered with the Medical Council xv.
A study of the work types of medical doctors in New Zealand carried out by HWNZ in
2009, notes the average hours worked and the average age of practitioners across all
doctors.xvi
1
Comparisons are difficult to make due to differences in health care systems
8
The average age for all doctors was 44 years, with dermatologists having an average
age of 51 years. The average hours worked by all doctors was 43 hours per week,
with dermatologists working an average of 40 hours.
Nine of the practising dermatologists in New Zealand are overseas trained (six in UK,
two in USA and one in Canada). Only one of these studied medicine as an
undergraduate in New Zealand, the remainder immigrated to New Zealand later in
their careers and all are middle aged. This a relatively small proportion compared to
other specialties.
A survey of the dermatological workforce carried out in 2010 by the New Zealand
Dermatological Society Incorporated (NZDSI) was completed by 85% of those invited
to participate. This survey showed that even though 53% of the New Zealand
population lives in 4 urban centres; Auckland, Hamilton, Wellington, Christchurch;
75% of dermatologists live in these cities. Most dermatologists carry out a mix of
private and public work and are often working in a number of settings - 66.3% of
respondents who work in public stating that they worked in two or more public
hospitals sites and 51.1% reporting that they worked in two or more private settings.
Dermatologists were providing between < 1 and 9 half-day (~4hrs) private sessions
per week and between <1 and 8 public hospital sessions per week.
32.1% of respondents stated that they were planning to reduce their hours, retire or
move overseas in the next 5 years, with 20.8% stating that they are planning to
increase their hours.xvii
Requests to all of the DHBs as part of the workforce service forecast demonstrated
the distribution of the dermatology workforce across the country. This showed that
all DHBs were providing some dermatology services, but often this work was
provided by visiting specialists, locums or through private contracts. By looking at
publicly funded dermatology by FTE (Fig 1), the limited provision and therefore
public access to dermatology is clearly shown, with a ratio of 1:274 146 across the
country (based on the current population of 4 496 000 and adding FTE and part time
work together, giving a national FTE of 16.4).
9
Figure 1: Distribution of Dermatologists by DHB (as at Sept 2013)
Data provided from dermatologists and staff at each DHB. Population data from
Ministry of Health http://www.health.govt.New Zealand/new-zealand-healthsystem/my-dhb (Last accessed 19.11.13)
1.2 FTE
0.3 FTE
Ratio 1: 533 000
Ratio 1: 562 970
2.3 FTE
3.1 FTE
Ratio 1: 187 760
Ratio 1: 224 200
2.5 FTE
Ratio 1: 149 000
0.4 FTE
Ratio 1: 537 000
2 clinics per month
Population 103 170
7 days (14 clinics) pa
Population 46 753
1 FTE
Ratio 1: 110 258
1 clinic per month from Mid-Central
Population: 62 210
0.3 FTE (locum)
Ratio 1:820 000
1.2 FTE
Ratio 1: 250 000
12 clinics pa
Population 33 055
6 clinics per month
Ratio 1: 170 200
0.5FTE (on contract)
Ratio 1:72 607
0.4 FTE
Ratio 1:355 000
2.1 FTE + 0.6 FTE (MO)
Ratio 1: 188 837
Sub contracted to private 53 First Specialist
Appointment (FSA) (2012/13)
Population 56 695
78 clinics per annum
Population 154 514
10
Dermatology Nurses
Dermatology nursing in New Zealand does not have a defined definition or scope of
practice. There is currently no specific dermatology training or qualification for
nurses in New Zealand and experience is gained through on the job training and
practice.
There is one practicing Dermatology Nurse Specialist in the Dermatology Clinic at
Christchurch Hospital.
The Nursing Council does not have a training pathway to be called a Nurse Specialist
in Dermatology. Most employers would expect a nurse in that position to have or be
working towards a Master degree or equivalent qualification.xviii Individual DHBs
may have positions for Speciality Clinic nurses, but these are defined by standards
and criteria determined by each DHB.
Specific dermatology nurses work in a range of clinical settings across New Zealand.
(See Figure 2)
An article in the International Journal of Dermatology (2011) ‘argues for the need to
develop a service delivery model in dermatology care that utilizes specialist- nursing
expertise to cascade dermatological knowledge and skill through primary care… The
paper specifically focuses on the development work led by the International Skin
Care Nursing Group (ISNG) to stimulate and develop the capacity of nursing to
respond to these widespread needs through promoting service delivery models that
operate interdependently with dermatologist-led care.’ xix
The New Zealand Dermatology Nurses Society (NSDNZ), a recognised formal
organisation, was discussed at the inaugural dermatology nurses and allied health
professional’s conference in 2006, and the society was incorporated in January 2010.
The NZDNS currently has 54 members and organises conferences and events as well
as supporting and sharing information.
11
Figure 2: Distribution of Dermatology Nurses by DHB (as at Sept 2013)
DHB
Auckland
Canterbury
Counties Manukau
DHB
Northland
Waitemata
Waikato
Lakes
Tairawhiti
Taranaki
Hawkes Bay
Whanganui
MidCentral
Capital and Coast
Hutt
Wairarapa
Nelson Marlborough
West Coast
South Canterbury
Southern
Dedicated dermatology nurse






Dedicated RNs 1.2FTE
Non nursing phototherapy 0.6FTE
Dedicated nurse specialist 1 FTE
General nurse trained to undertake phototherapy 0.4FTE
Dedicated RN 0.5FTE
Dedicated HCA phototherapy 0.6 FTE
Number of Dedicated dermatology nurses
Nil
 North Shore: Dermatology General Outpatient nurse rostered to Clinic
 Waitakere: 0.05FTE Outpatient nurse for dermatology clinic
3.7 FTE
General Outpatient nurse 0.05FTE
General nurse 0.025 FTE
General Outpatient nurse 0.07FTE
General Outpatient RN 0.3FTE
General Outpatient nurse 0.025 FTE
General Outpatient RN 0.15 FTE
General Outpatient nurse 0.375 FTE
General Outpatient nurse 0.75 FTE
Nil
General Outpatient RN 0.1 FTE
General Outpatient enrolled nurse 0.05 FTE
Subcontracted to private provider
General Outpatient RN 0.25 FTE for clinical and 0.4 FTE for phototherapy
Health Care Assistant covers for absence
General Practitioners
In New Zealand, GPs provide most dermatologic services, with one in six (15%) of all
visits to the GP involving a skin problem.xx
Several reviews have been carried out looking at the role of GPs in carrying out
surgical removal of skin lesions, including a scheme in Auckland, involving 21
accredited GPs carrying out 1200 procedures annually. In addition, the Southern
Primary Health Organisations scheme allowed for 350 procedures to be carried out
by GPs in 2011/12 and is looking to fund a similar number of procedures in 2012/13.
A GP can advertise their services as a skin specialist, without any recognised training,
or achievement of dermatology standards equivalent to vocationally registered
dermatologists. This is an anomaly compared to other specialties and can be
confusing for patients to determine where dermatology expertise lies. GPs also do
not have the same requirements of Continuing Professional Development for
dermatoses as dermatologists.
12
Pharmacists
Pharmacists provide advice and over the counter treatments for skin conditions and
are often the first health care professional that patients consult. In addition to this,
hospital pharmacists may be involved in the treatment of inpatients.
13
The vision for Dermatology in 2020
The Group’s vision for dermatology in New Zealand in 2020
‘is that patients will have equitable access to an integrated, consultant-led
dermatology service that delivers high-quality health care’.
The proposed model of service delivery is based on providing the right treatment, by
the right person, at the right time and in the right place.
Given the current numbers of dermatologists, the predicted increase in demand for
services, not only for skin cancer diagnosis and treatment but also for other skin
conditions, it is unrealistic to expect that the current workforce and model will meet
this demand.
Developing consultant-led teams, who work collaboratively to offer diagnosis and
treatment, utilising the skills of other health professionals, including nursing staff
and GPs will be vital to being able to meet demands in a timely way.
An integrated, consultant-led service would be DHB based and centred on an
outpatient service, but with inpatient consults. There would be specialised inpatient
treatment for patients requiring this, for example, very severe eczema, psoriasis or
blistering disorders. Registrars would be part of this service in larger centres.
Dermatology nurses would be an integral part of the team, together with
pharmacists, psychologists and other allied health professionals.
14
The proposed model of service delivery in 2020
Model showing core services provided at each level
*Regional: 5 regions – Northland/Auckland, Mid-Central, Wellington Region, Northern
and Southern South Island
15
National Centre for Dermatology Expertise
In addition to the service model described above, there is a need for a tertiary level
national Centre for Dermatology Expertise in New Zealand. This would provide
opportunities for academic leadership, training, research and education. In addition,
the Centre could provide opportunities for a tertiary referral service for paediatrics
and hard to manage conditions.
Discussion
Based on the personal experiences and research knowledge of the Group, internet
and literature searches were carried out to provide information on current
dermatology workforce and service provision in New Zealand and overseas. These
can be found at Appendix 2.
All the dermatologists on the Group have experience of working in the UK and it was
acknowledged that a significant amount of work has been done there in relation to
dermatology service provision, the development of standards and guidelines and in
nursing training and practice.
This literature was discussed and analysed to help formulate the best model of care
for dermatology in New Zealand in 2020.
In addition, the Group tabled a number of patient journeys that describe current
experience and illustrate issues with service provision and the solutions that the
proposed service model would provide as illustrated in Appendix 3.
Dermatology service in New Zealand
It is clear that currently, public dermatology in New Zealand is very under-resourced
not only in terms of the workforce, but also in the range of services and treatment
options available to the people of New Zealand. The service needs to expand to
address current unmet need, long waiting lists and predicted increased demand, as
well as providing equity of access and service across the country.
It is acknowledged that private dermatology services are available in most centres
and have a role in reducing the pressure on the public system. However, these can
only be accessed by those who are insured or who can afford to pay for the services.
It is also not suited to managing complex conditions.
With numbers of patients with skin cancers already at the highest rate in the world
and increasing, combined with an ageing population and Ministry of Health
outcomes of better, sooner, more convenient health care, the need for accessible,
quality dermatology is only going to increase. There is an increase in medical
16
dermatology and complex cases, for example an increase in organ transplantation
and immunosuppression and the use of biologic agents.
By constructing the pyramid model described above, an efficient, accessible service
will be provided, adequately resourced to deliver quality health care in appropriate
settings.
 High cost treatment options for complex and rare conditions will be provided
at a national level.
 Regional services will provide the next tier of treatment options, reducing
travel for patients and maximising the skills of those in regional centres.
 Consultant-led teams within DHBs will provide a wide range of treatments,
working closely with the PHO/GP tier to provide an integrated service for
patients, while supporting and developing skills.
 Underpinning the model is the proposed Centre of Expertise in Dermatology,
which will provide New Zealand focussed training, research and academic
excellence to enhance the current workforce.
Providing adequately resourced, dermatologist-led, integrated teams in all DHBs will
ensure a solid foundation for the dermatology workforce and service in 2020.
Adequate resourcing will allow dermatologists not only to run outpatient clinics but
also to provide inpatient services as required. In addition, dermatologists will be able
to provide education for trainees, GPs, nurses, pharmacists and other health
professionals to support outreach and teledermatology services if required.
Multidisciplinary teams (linking primary and secondary) provide collegial support,
opportunities for collaborative patient management and treatment plans, education
and training and a holistic health care approach for patients.
Developing a ‘hub and spoke’ approach to delivery, not only in rural areas, but also
in Auckland, is seen as good model for an accessible and effective multi-disciplinary
approach. The Counties Manukau ‘Localities’ programme is seen as a good model for
this.
There is a lack of an academic unit in New Zealand. Unlike most other medical and
surgical specialties, dermatology is lacking the research opportunities and leadership
that this would provide. Currently there is a 2/10th paid position for academic
dermatology research and teaching in Auckland and two honorary posts at Auckland
University. The University of Otago in Christchurch also has 3/10 th paid teaching
positions for senior lecturers.
New Zealand lags behind other countries in the development of standards,
guidelines and pathways for dermatology. The Ministry of Health Tumour Standards
currently being developed, and which include melanoma, are a starting point, but
the high levels of non-melanoma skin cancers are not included in this. There is a
place for developing national standards and guidelines for non-melanoma skin
cancer and other common dermatoses. Existing guidelines, such as those produced
by the British Association of Dermatologists could be a useful starting point.
17
Workforce
Dermatology consultants
As seen from Figure 2 (page 12) nowhere in New Zealand does the ratio of public
dermatologists to population, reach the proposed figure of a minimum of 1 FTE: 100
000. An increase of 30 dermatologists working in the public sector is required to
achieve this target by 2020.
There should be at least three dermatologists in every DHB, who may be part-time.
This would allow adequate cover during times of leave, as well as providing
collegiality, which would ensure better care of patients.
There must be allowance in their contracts for teaching registrars, GPs and nurses,
and other health professionals.
Subspecialties
Establishing national or regional subspecialty tertiary services could enhance the
general quality of dermatological care across the country. Having different
dermatologists or teams head up subspecialty services would support
dermatologists working in isolation and would promote audit and research in
different fields. This would provide pathways for dermatologists to send difficult
patients to, or to have a virtual consultation for advice for example, from a
lymphoma expert, photobiology unit, vulval expert or to send slides to a
dermopathology expert. To establish these tertiary services and have them
adequately resourced, would require the support of all DHBs and leadership at a
national level.
Academic Dermatology
Establishing a dedicated academic unit, the National Centre for Expertise in
Dermatology, would allow for advancements in understanding of skin conditions in
the New Zealand context and would enhance knowledge and understanding, skill
levels and patient outcomes.
As with other specialties, it is important that we undertake high quality research to
investigate New Zealand specific dermatological issues. This ultimately leads to
improved medical care. In addition our dermatology trainees require some training
in research. By 2020 we would hope to have an academic unit in place somewhere in
New Zealand with a Professor or Senior Lecturer to head up the dermatological
research and supervise more junior researchers.
Dermatology Registrars
As of November 2013, there are five training positions over three sites in New
Zealand. There are 14 New Zealand dermatology trainees (one half of whom are
currently overseas finishing their training). There is limited opportunity for public
dermatology positions when they complete their training and return to New
Zealand.
18
There needs to be career pathways into public hospital provision and increased
training placements for dermatology trainees, and at the end of training there must
be hospital positions available for them. As at November 2013, there are no
advertised vacancies in New Zealand for hospital dermatologists, despite the
growing need for more dermatology services in public.
Previously advertised posts have not been filled, as they have been a singlehanded
position of 0.5 FTE. This type of post is not appropriate or attractive for a junior
consultant, where a collegial, supportive team is the ideal, as would be achieved
through adopting the recommendations below.
Because, at present, training for FRACP in Dermatology requires two years to be
spent in an overseas post, HWNZ needs to consider funding this overseas training
and then bond the workforce to come back to New Zealand as specialists – and
needs to ensure that there are posts available.
The development of a New Zealand based Centre of Expertise in Dermatology could
provide more opportunities for New Zealand based training and could reduce the
need for going overseas to one year. Gaining overseas experiences in subspecialisms is seen as very valuable, not only to the consultant themselves, but to
the dermatology service as a whole.
Dermatologists also need to have clear work plans, that are reflected in their
contracts, which are drawn up to allow for outpatient clinics and inpatient and/or
outreach clinics where needed. In addition, to run effective consultant-led teams,
there needs to be time available for their own professional development, providing
collegial support for other dermatologists (particularly those working in isolation)
and teaching opportunities for GPS, nurses and other health professionals.
Dermatology nursing
It is recognised that nurses can play a vital role in the delivery of dermatology and
should be a part of all consultant-led teams. Dermatology nursing roles can include
providing education and health promotion advice, organising clinics and
multidisciplinary teams and observing inpatients. Providing better education for
specialist nurses, including training to perform minor procedures such as skin
biopsies and diathermy, would also help to improve accessibility and reduce waiting
times.
Dermatology trained nurses should be employed at all dermatology clinics and in
wards in hospitals where dermatology patients are treated. These nurses could act
as nurse educators for generalist nurses. Ideally dermatology inpatients should be
nursed in a dermatology ward. If this is not possible, then nurses with dermatology
training or at least with assistance from dermatology nurse specialists, should care
for inpatients.
Skilled dermatology nurses also administer phototherapy, perform skin biopsies,
provide a range of treatments for day stay patients, observe inpatients and support
19
patients and their families. Nurse-led clinics for education such as paediatric eczema
management or monitoring of systemic medications are also supported. In addition,
nurses must be supported by administration staff (see below) to enable them to
concentrate on nursing.
There is currently no defined role, standards, definition or qualifications available to
nurses who would like to further their career in dermatology in New Zealand. Figure
2 shows that only three DHBs currently have dedicated Dermatology nursing staff.
Following the lead of the Dermatology Nurse Education Australia, professional
courses could be developed through interaction with the Nursing Council of New
Zealand and academic institutions.
Providing a career pathway in dermatology nursing would benefit the whole model,
supporting and being trained as part of consultant-led teams and gaining relevant
qualifications, responsibilities and skills would help to ensure that each member of
the team could perform the tasks that only they are able to perform, thus
maximising the resource available. Including dermatology nurses in GP practices is
also seen as adding huge value to the service.
In addition, ensuring that the undergraduate-nursing programme for all nurses has a
significant dermatology component is essential.
General Practitioners
From the information provided above, it is clear that GPs are seeing, treating and
managing a high proportion of the community with skin conditions. Referral
pathways to dermatology services are not always clear and, due to the limited
provision currently available, are sometimes insufficient to provide timely access to
secondary care. Improved communication with specialists (dermatologists and
plastic surgeons) would ensure timely outpatient management of skin neoplasms.
Other countries, such as the UK, are supporting the development of GPs with a
Special Interest in Dermatology. In the New Zealand context, however, this was not
seen as the best way forward. Rather than having a few GPs with a higher skill level,
it was felt as more useful if all GPs had an increased level of training in dermatology
and in particular, in the management of skin cancer. By linking GPs into consultantled DHB based teams and by consultants working with GPs in community-based
clinics, GPs can have better access to more dermatology clinical time. Improving GPs
competency and knowledge of dermatological conditions and treatments, should
result in reduced referrals. In addition, it will improve the quality of consultations
and advice given to patients.
There is also a need for the development of guidelines and standards for GPs for the
management of skin disorders and skin lesions, for example the UK NICE guidelines
for psoriasis and childhood eczema, or New Zealand specific guidelines could be
prepared. Referral pathways, both for inpatients and outpatients need to be clearly
defined, which could be developed at a national level or by individual consultant led
teams and involving GPs.
20
GPs would also benefit from the Centre of Expertise in Dermatology, which could link
with the College of GPs to enhance postgraduate training in dermatology and
develop continuing professional development modules as required. Providing a GP
biopsy service funded by the DHBs would reduce delays in diagnosis of skin lesions
and dermatoses.
Other surgical specialities including: Plastic Surgery, General Surgery, Head and
Neck surgery and Ophthalmology
While dermatologists and dermatological surgeons play a major role in the diagnosis
and management of skin cancer the surgical specialities have an important role
particularly in the advanced stages of the disease. Currently each DHB has a different
pathway for skin cancer. In some centres, cases are seen first by plastic surgeons in
secondary care but in other DHBs dermatologists are the initial service for patients
referred by GPs.
Dermatologists usually excise most lesions but will if necessary refer to plastic
surgeons for complicated cases requiring skill and expertise beyond their scope.
Examples include:
 Plastic surgery for complex reconstruction and large flap repairs.
 General surgery for advanced melanoma and sentinel node biopsy
 Ophthalmology for reconstruction of surgical defects around the eye.
There needs to be closer relationships between dermatologists and surgical
colleagues and clear referral pathways and guidelines for the more complex cases.
This can be achieved with regular multidisciplinary clinics, (including plastic surgeons
and general surgeons), for discussion of diagnosis, and treatment options in these
complex cases with the primary goal of deciding the best outcome for the patient
diagnosed with a skin cancer.
Psychological services
Many dermatology patients have psychological distress because of their skin
disorders, whether this is a congenital lesion or an acquired lesion or dermatosis.
Other patients have skin diseases that are the direct result of stress or indicate a
serious underlying psychiatric disorder. Currently there is no direct access to these
services within DHBs.
Having psychological support available to the dermatology team would provide the
patients with a holistic treatment plan that leads to better outcomes.
Pharmacists
Pharmacists are the first port of call for many common skin conditions. In order to
ensure quality health care, the information provided by pharmacists about
treatment regimes and prescribed medicines needs to be informed and accurate.
Pharmacists should be knowledgeable about when to refer and to whom and these
pathways need to be kept current.
21
Providing pharmacists with continuing professional development in dermatology to
increase knowledge was supported and could be part of the consultant-led
education programme.
The new role of Clinical Pharmacist Prescriber was not seen as appropriate for
dermatology due to the complexity of diagnosis of skin conditions.
Administration
Providing a good level of administrative support for the consultant-led teams,
including dermatology nurses, will again increase the amount of time available to the
health professionals for seeing patients and providing the support and education
identified above. Administrative and clerical staff need to be an integral part of the
dermatology team.
Specific service issues
Skin Cancer
As stated above, New Zealand has the highest level of skin cancer in the world. The
low level of public dermatology and the increasing numbers of patients presenting
with this condition is not sustainable.
The Group supports the development of multi-disciplinary teams for skin cancer in
every DHB, led by a Dermatologist, as recommended in the UK NICE guidelinesxxi.
Dermatologists are expert diagnosticians of skin lesions, due to their training and
wide experience in all aspects of dermatology including benign, premalignant and
malignant skin lesions. Appropriate treatment depends on accurate diagnosis. A
dermatologist led team would result in a reduction of unnecessary excisions and
more appropriate treatment of lesions. Dermatologists are experienced in a wide
variety of treatment options including medical (topical and systemic), surgical and
other modalities such as cryotherapy and photodynamic therapy.
Multidisciplinary teams should include representatives from plastic surgery,
radiation oncology, nursing, General Practice, pathology and general surgery. Teams
would be involved in running clinics, reviewing cases, discussing morbidity and
developing management plans. Where Mohs surgery is being considered, the case
should be discussed in such a multidisciplinary clinic.
National standards of care of patients with suspected skin cancer should be
developed de novo or from other sources which already exist, along with clear
referral pathways. Standards should also be developed for Mohs surgery.
The Group supports adopting the practice currently used in the UK involving all of
those involved in managing skin cancer, including GPs, dermatologists, plastic and
general surgeons whether in public or private practice. They are required to be part
of a multidisciplinary team, as well as on a register of approved practitioners and are
22
subject to regular review and audit. This will ensure appropriate treatment and
outcomes and appropriate standards are maintained.
Correct diagnosis of skin lesions is paramount and can often be made clinically.
Biopsy or excision should be performed in cases where there is a definite neoplasm
or diagnosis is not certain. GPs require access to more training in the management of
skin cancer, funded by DHBs as currently some GPs pay up front for training.
The dermatology component of all medical training needs to be increased. There
also needs to be more time for teaching by dermatologists in the basic
undergraduate medical course. Currently some medical students in New Zealand
have no dermatology training at all, while others receive several half days, which is
totally inadequate.
At PHO level, community teams should be available to provide on-going care and
rehabilitation when required.
Paediatric Dermatology
There is currently not enough funding for paediatric dermatology in New Zealand.
Access to this service is patchy and is often not available. There is a large unmet
need.
Nursing involvement in paediatric services, to provide education to patients and
their caregivers, has been shown to have very positive results.
Having paediatric dermatology based at all DHBs, in dedicated paediatric facilities,
along with outreach clinics as required, will ensure equitable access and quality
health care is provided.
Teledermatology
For GPs working in remote areas of New Zealand or as part of the hub and spoke
approach, the use of teledermatology could be expanded. Uses could be as a triage
tool for skin lesions, as an alternative to a face-to-face consultation or as a
combination of these. Live teledermatology clinics allow access to the patient near
home, but are difficult to set up and implement. ‘Store and forward’ is a more
practical method of getting an opinion from a dermatologist, but it’s limitations must
be recognised.
A recent New Zealand seminar showed that there was excellent concordance
between face-to-face and teledermatology diagnosis for lesions, while a UK case
study showed that teledermatology was effective at reducing unnecessary
secondary appointments, reduced time to be seen by a specialist and delivered
financial savings.
Further research and development, and national guidelines are needed in New
Zealand, to maximise the use of this potentially effective, cost-saving tool.
23
Contact Dermatitis and occupational dermatology
There is currently an unmet need for this service in every DHB in New Zealand.
Contact dermatitis accounts for 4-7% of all dermatological conditions. Work related
dermatitis can result in patients having time off work, the development of chronic
disability and in some cases, the inability to work.
Appropriate specialist care and investigation is necessary to distinguish between
occupational and non-occupational contact dermatitis, and constitutional eczema,
since the management of these conditions is very different. xxii
Patients with persistent eczema or dermatitis should be investigated by patch
testing, at least to an extended standard series of allergens. Specialist dermatologists
working in DHBs should have had training in the investigation and management of
contact dermatitis. This service should be provided at either secondary DHB level
locally and/or at tertiary regional level in a subspecialty clinic for contact dermatitis
and occupational dermatitis. DHBs would hold a series of common allergens with
the more specialty allergens held regionally. A regional bank of patch testing
chemicals would allow chemicals to be sent to different regions as required. This
could be cost effective as the price of patch testing chemicals is high, especially as
they have a short shelf life.
At primary care GP clinics and occupational doctors’ and nurses’ clinics, there is a
need for an awareness of contact and occupational dermatitis and referral to
dermatology specialists. Funding of referrals for consultations, investigations
(including patch testing) and reporting, needs to be available and this could include
Accident Compensation Corporation (ACC) funding.
Statistics from ACC (Appendix 4) show a decline in the numbers of contact
dermatitis claims. It was noted, by the Group, that ACC are reluctant to compensate
for the investigation and treatment of occupational dermatitis, despite the fact that
much dermatitis seen at a primary and secondary level may be occupational in
origin. This situation needs to be changed and would reduce the cost to DHBs.
Phototherapy
Phototherapy is recognised as a safe and effective treatment for moderate to severe
psoriasis. New biologic treatments are being produced but they are very costly and
can have unwanted side effects.
It is recommended that as a minimum all DHBs should provide nbUVB and some
DHBs may wish to provide hand and foot or total body PUVA therapy. These should
be available in evenings and weekends to fit with patient’s needs, as multiple visits
are required for effective treatment. Childcare provision should also be provided to
enable regular treatments. Skilled nurses or technicians can provide phototherapy.
This treatment could be one of a suite of treatments offered in day stay units for
dermatology that should be provided for the consultant-led teams.
24
Research overseas has found that providing home UVB phototherapy units for
people living too far from a base clinic can be equally successful. Pre-programmed
home units can be safe and effective, both clinically and for quality of life and could
be loaned by DHBs.
Medical photography
Access to high quality medical photography, including in studio medical photography
in all DHBs is necessary. While digital technology is advancing, it is still important to
have studio quality pictures. There is also a need for all DHBs to use software that
enables photos to be attached to patient records, which can be later reviewed in
sequence.
Day stay units
The Group recommends that day stay units be an integral component of DHB
dermatology services. These units offer intensive topical therapies to outpatients as
well as the provision of effective topical treatments that cannot be safely selfadministered. Intensive topical treatments provided by day stay units are recognised
to reduce the requirement for expensive systemic medications, therefore offering
treatment alternatives with a significantly safer side effect profile. Day stay units are
usually staffed by dermatology nurses, who provide education as well as medical and
psychological support for dermatology patients. In addition they lead to a reduction
in expensive inpatient care.
25
Recommendations
To achieve the vision for dermatology in New Zealand in 2020
‘that patients will have equitable access to an integrated, consultant-led
dermatology service that delivers high-quality health care’, the Group proposes the
following recommendations:
1. Every DHB has a dermatologist-led team providing a core of
dermatology services.
a. All DHBs to have a minimum of 1 full time equivalent (FTE) public
dermatologist per 100 000 population.
b. Dermatology teams to include nurses, a psychologist, GPs, a
dermatopathologist and other allied health professionals.
c. Multidisciplinary clinics held for difficult cases (both dermatoses and
skin cancer) in all DHBs or at least at a regional level.
d. Teams to integrate primary and secondary care, using technology
where appropriate.
e. Patch testing, UV phototherapy, Mohs surgery and expert
dermatopathology to be available in all DHBs.
f. Administration/clerical staff to be provided in all dermatology
departments.
g. Dermatologists to have paid time for their education (continuing
professional development) and for providing training to others.
2. Comprehensive dermatology training provided in New Zealand.
a. Greater proportion (3 out of 4 years) of specialist dermatology
training provided in New Zealand with public consultant posts
available at completion of training.
b. Increase training posts for registrars to 15, to achieve required
number of SMOs to fulfil proposed ratio.
c. Increase number of sites for registrar training from 6 to 10 to include
Wellington and Waitemata, with additional posts in Auckland and
Waikato.
d. Use bursaries to fund overseas posts, which are required for
dermatology trainees to complete their specialist training.
e. Recognition of the importance of having appropriately trained and
accredited dermatopathologists within each DHB.
f. Accessible and meaningful accreditation of training for GPs to better
manage dermatoses and skin lesions including neoplasms.
g. Expanded, defined roles and career pathways for dermatology nurses
with positions available in all DHBs.
h. Development of a postgraduate course leading to a Nurse Specialist in
Dermatology qualification.
i. An increased emphasis on dermatology for Pharmacists during
training and opportunities for continuing professional development
26
3. Dermatology services are accessible equitably across New
Zealand.
a. All DHBs to run a comprehensive dermatology service.
b. Where appropriate, a hub and spoke service should be run from
DHBs, to provide services where there are currently difficulties in
access.
c. Improved access to paediatric dermatology services.
d. Equitable access to publicly funded phototherapy.
e. Better availability of, and defined pathways for patch testing and
biologic clinics.
f. National guidelines, pathways and protocols for the management of
common dermatoses are developed and incorporated into relevant
training and professional development programmes.
g. Establishment of teledermatology clinics or services where necessary.
4. Dermatology expertise is enhanced.
a. Establishing a Centre for Dermatology Expertise, led by one or more
professors/senior lecturers in dermatology.
b. Establishing a network of national or regional subspecialty tertiary
services.
5. The key role of dermatologists is recognised in the management
of skin cancer.
a. Building multidisciplinary skin cancer teams led by dermatologists.
b. Developing national standards for the treatment of all skin
cancers including non-melanoma skin cancer.
c. Increasing the speed of access to high quality services.
d. Expanding the current curriculum for all health professionals to
include agreed pathways, standards and guidelines.
6. Better information gathering and data collection.
a. Workforce data is centrally collected and updated and includes
private practice.
b. Data on incidence of non-melanoma skin cancers should be collected
regularly and routinely.
c. Information on inpatient and outpatients is collected to improve the
management of services.
d. Audits of skin conditions and neoplasms seen and the number of
outpatient and inpatient visits, to aid future planning.
27
Appendix 1: Dermatology Workforce Service Forecast Group
Darion Rowan (Dermatologist, Counties Manukau DHB, Chair)
Steven Lamb (Dermatologist, Auckland DHB)
Deborah Greig (Dermatologist, Auckland DHB)
Martin Keefe (Dermatologist, Nelson & Christchurch)
Weng Chyn Chan (Dermatologist, Middlemore Hospital)
Wee-ling Koo (GP, Cornwall Medical Centre, Auckland)
Karen Agnew (Dermatologist, Auckland DHB)
Ann Giles (Dermatology Staff Nurse, Greenlane Clinical Centre, Auckland)
Barbara Graves (Project Manager)
28
Appendix 2 Examples from literature (New Zealand and overseas)
Workforce
Dermatology (General)
Several studies in the UK have identified issues similar to those currently being seen
in New Zealand.
In 2007, the Dermatology Workforce Groupxxiii noted that too many patients are
attending hospital-based services and that any future model of care should
concentrate on service delivery governed by three broad statements:
 Secondary Care Teams should do the things that only they can do,
 care should be delivered in the right place, by individuals with the right skills
and at the right time; and
 policies should facilitate patient self-management.
It was also noted that service models should be patient oriented and that correct
diagnosis is the starting point for quality care. It was identified that primary care
should take responsibility for straightforward management of long-term skin
diseases and facilitate patient self-management.
The educational role of secondary care should be acknowledged and developed and
appropriate educational modules should be developed, to ensure knowledge and
expertise of those in primary care.
Multi-disciplinary teams to deliver Dermatology care were identified as central.
In 2008, the Workforce Review Team reported on ‘Workforce Planning for
Dermatology in the National Health Service’ xxiv(NHS, UK).
Key points included the need for networked specialist teams to provide care delivery
in hospital and community settings.
The report also noted the aging Dermatology workforce and that little work on
researching and planning for the Dermatology service has been carried out. Changes
to delivery, including the increasing requirements for care in the community and
changing GP practice, have led to the service being fragmented.
The British Association of Dermatologists (BAD) carried out an audit of Dermatology
service provision, with the focus on the care of those with Psoriasis in 2008xxv. This
audit was designed to examine staffing and facilities at Dermatology Departments in
the UK. Again, the findings reflect the current situation in New Zealand.
The Royal College of Physicians revised fifth edition of ‘Consultant physicians
working with patients’, recommends one Whole Time Equivalent (=FTE)
Dermatologist per 62 500 population and that no consultant should work in
isolation. Clinical networks should be developed to provide support. Dermatology
nurses should be available in all units to support inpatients and outpatients with skin
diseases. Clinical psychology should be more widely available. Increased resources
would be required to provide for advanced drug therapies such as biologics.
29
Resources should be invested to collect outpatient data to improve management of
dermatology services.
In 2011, Primary Care Commissioning UK published a report on ‘Quality Standards
for Dermatology’xxvi. This report brings together best practice and existing guidance
and aims to meet the needs of commissioners of services in the NHS. Eight standards
are identified and are based on overarching principles:
 that the full range of dermatology services should be accessible at all levels of
care and should be developed using stakeholders
 consistent, high quality care meets independent quality standards (such as
NICE standards)
 people with skin conditions should have their care managed at the
appropriate level, acknowledging that this may change over time
 all dermatology services should be supported by a range of services
addressing the wider need of patients, including psychological, social worker
and occupational therapists as needed.
The 2009 ‘Health Care Needs Assessment of Skin Conditions in the UK’ xxviiprovides
information on the burden of disease, quality of life data and direct economic costs.
The range of available services is discussed along with the evidence of effectiveness
of services. The Needs Assessment makes several recommendations including:
 the provision of high quality information and the role of patient organisations
 patient self care and self management supported by increased training of
community pharmacists to enhance treatment and provide knowledge of
when to refer
 advanced training for pharmacists
 increased dermatology training in the diagnosis and management of common
skin conditions
 all pre-qualification nurses receive a programme that includes information
about common skin conditions with relevant post-qualification training to
support dermatology nursing in a variety of settings
 changes to consultant Dermatologist training to reflect population needs
 development of the role of Specialty and Associate Specialist doctors in
teaching of primary health care professionals
 development of quality of life tools to measure effectiveness of interventions
alongside clinical outcomes measures
 accreditation of dermatology units.
Early in 2013, the specialised services national definition of Specialised Dermatology
Specialistsxxviii was commissioned. Specialised services are provided in the UK to
serve populations of more than one million people and the definitions help with
service reviews, planning and commissioning. This definition outlines the roles,
workload, service delivery models and standards required to deliver high quality
dermatology and again, emphasises the need for the correct diagnosis, adequate
training and staff, multidisciplinary teams, services provided in the right place and at
the right time, the need for standards and audits and the need for good
communication across professional boundaries.
30
Consultant Dermatologists
As has been found in New Zealand, the UK has concerns over the future
Dermatology workforce. The Royal College of Physicians Census on Dermatology –
2010xxix found that for the first time, female dermatologists outnumbered males, a
trend likely to continue. It also found that dermatology has twice the proportion of
consultants working less-than-whole-time (35.3%) than the mean value for all
medical specialties. It was also noted that although vacancies still exist, numbers of
consultant Dermatologists are rising and that Dermatologists work 50% over their
contracted time for academic work. The lack of cohesive planning for the workforce
was also highlighted.
The revised 5th edition of ‘Consultant physicians working with patients’ in 2013xxx
notes that Dermatology care is carried out most efficiently in the UK using a hospitalbased team led by a consultant dermatologist, with Staff grade and Associate
Specialist (SAS) doctors, GPs and nurses in secondary and integrated intermediate
care. Multi-disciplinary teams in skin cancer clinics involve dermatologists, surgeons,
histopathologists, oncologists, radiotherapists, nurses, and psychiatrists and
psychologists. Combined clinics between dermatologists and hospital specialists exist
for complex problems, e.g. involving rheumatology, plastic surgery, HIV, genital/oral
diseases, psychiatry, paediatrics, genetics, stomas, eyes, vascular surgery and allergy.
Dermatology Nursing
The definition and scope of Dermatology nursing is not consistent, or even evident,
in many countries. Through contact with the Dermatology Nursing Education
Australia and the British Dermatological Nursing Group, it was found that both
organisations are currently working on this.
The UK has recently developed general competencies for nurses working in
Dermatologyxxxi and is currently working on developing standards. They also carried
out a workforce survey, which identified three key issues.
 The need for dedicated dermatology departments allowing patients
to
access specialist care from a multidisciplinary team. This includes
dermatology-trained nurses with appropriate skills for treatments and
management of patients with dermatological conditions.
 A nationally recognised post-registration dermatology qualification in
managing patients with skin disease to enable nurses to work within a
nationally recognised competency framework at a level appropriate to their
area of work.
 Patients to have access to clinical psychologists with the knowledge and
expertise of managing patients living with skin disease. To have easy access
to refer patients from both medical and nursing professionals will help to
support patients and give them skills to manage their skin disease from a
psychological perspective.
31
The Dermatology Nurses Association (USA) has a defined ‘Scope of practice’ and
‘Standards of Clinical Practice’. The scope of practice uses the framework of core,
dimensions, boundaries and intersections to inform practitioners, educators,
researchers and administrators as well as other health professionals and the public.
The Standards of Clinical Practice are to provide definitive direction for the provision
of care and professional role activities of dermatology nurses, through assessment,
measurable outcomes and nursing interventions customized to meet the needs of
the individual.
Several UK reports highlight the importance of nursing in dermatology care delivery
and the currently unmet potential of nurses to provide education to patients and
other health professionals, to take on increased roles, to administer therapeutic
regimes and to coordinate care. A solution to the lack of dermatologists worldwide
was seen as providing effective delivery by nurses as part of multidisciplinary teams,
community outreach and management and self-management of skin conditionsxxxii.
Another report highlighted the integral role that nurse-led care provides to
dermatological services and noted that nurses are currently providing treatment in a
broad range of settings. Where nurses were involved, patients reported faster access
to treatment, reduced referrals to GPs and increased knowledge of their condition.
Again, the lack of educational opportunities for nurses was cited.xxxiii
A questionnaire-based study of ‘The expanding role of nurses in surgery and
prescribing in British Departments of dermatology’ xxxivfound an anticipated increase
in nurse-run clinics and a wide variation in nurses prescribing and administering
treatments. Obstacles to extending nursing roles were seen as opposition from
administration or nursing hierarchies, funding and uncertainties from the nurse
themselves. Dermatologists supported the development of increased roles, as long
as they were provided with adequate training protocols and staff support.
Advanced nursing roles, where nurses take on a range of procedures more
commonly provided by other health professionals are outlined in several studies.
The article ‘Biological Nurse Specialist: goodwill to good practice’xxxv notes that with
additional training, the specialist nurse may take responsibility for a number of tasks
in the patient pathway including screening, treatment administration, patient
education, prescription coordination, patient monitoring and data collection. The
report also notes that nurses trained to deliver increasingly widely used biologic
therapies are of great benefit to patients and central to the operation of multidisciplinary teams. However it is also noted that they need to have in-depth nursing
knowledge built on a foundation of biologic therapy and disease activity.
Two American papersxxxvi,xxxvii which considered the role of nurse practitioners in the
assessment and referral of skin cancers, again highlighted a lack of measurement of
barriers. A lack of time was cited as the most common barrier. Recognition and
referral of skin lesions was inconsistent, but improved over time. There are few skin
cancer training programmes available for Advanced Practice Nurses, but these need
to be put in place to increase the skills needed and to enhance the role that nurses
can take on in the assessment and management of skin cancers.
32
General Practice
In 2011, the Department of Health in the UK revised the NICE (National Institute for
Health and Care Excellence) ‘Guidance and Competencies for the provision of
services using GPs with Special Interests (GPwSIs): Dermatology and skin surgery’.
xxxviiiThis framework was developed by a multi-disciplinary team including specialists,
GPs and patients. It is designed to help dermatology GPwSIs understand and develop
the extended knowledge and skills they require to provide services beyond the scope
of their generalist roles. The Royal College of General Practitioners has developed
accreditation based on this framework.
The key points of these guidelines are that the training and development of GPwSIs
will require the on-going support from Dermatology specialists. Improving diagnostic
skills is essential, but the core activities of the GPwSis will depend on the resources
and skills of the GP. The service would be required to be supported by suitable
trained dermatology nursing, necessary facilities and equipment, links with
dermatology and histopathology departments, administrative support and good
record keeping, including photographs.
This guidance should be read in conjunction with:
‘Implementing care closer to home: Convenient quality care for patients Part 3: The
accreditation of GPs and Pharmacists with Special Interests Supporting Q&A (2007)
and providing care for people with skin conditions: guidance and resources for
commissioners’ (NHS Primary Care Commissioning 2008)
In New Zealand, several regions are working on developing GPs with a special
interest in skin lesions and/or developing skin lesion pathways.
The skin lesion GP service in Otago has been running for approximately four years,
and has seven trained GP practitioners. The service receives referrals from primary
care, mostly for suspected skin cancers, and is contracted by Southern DHB to
perform 350 procedures each year. Under this service, patients can still be referred
to secondary care clinicians when required; however, because of referrer knowledge
of the service, and the level of expertise and experience GPwSIs have developed, 99
percent of referrals are managed by the trained GPs. The service was reviewed in
2012.xxxix The benefits of the scheme are:






Reduced waiting times for treatment: the average waiting time from referral
to treatment for minor surgery was 12.3 days in 2010/11.
Increased capacity, quality and range of services delivered in primary care
and reduction of unnecessary referrals to secondary care.
A quality, timely service provided at no cost to patients close to their home.
Improved integration and communication between primary and secondary.
A valuable opportunity for GPs to develop new clinical competencies and
undertake a greater variety of clinical activities.
Reduced waiting times for patients and reduced administration for the
33
service, and a higher conversion ratio from referral to surgery with referrals
from the GP skin lesion service.
Key learnings are noted as:
 Before developing services that are appropriate for specific community
needs, DHBs considering establishing such GP services should undertake a
comprehensive assessment of current patient flows, capacity, demand and
community health need.
 Establishing quality services requires the synchronisation of technical,
administrative and clinical expertise in both primary and secondary care.
Delivering services in the right place at the right time by the right people to
the right patient will result in improved quality of care for patients, improved
staff satisfaction and a more cost-effective and efficient service.
 Clinical prioritisation based on patient need and ability to benefit relative to
other patients referred, is a fundamental requirement of all publicly funded
elective services. DHBs need to develop access criteria linked to available
capacity, which ensure services are provided to patients with the greatest
need.
 In order to maintain clinical competencies and sustainable service delivery,
GPs need to work with a minimum number of 50 referrals per year and
preferably 100.
In Christchurch the Canterbury Initiative have been running a programme for the last
few years in which GPs are trained in skin surgery techniques by the plastic
surgeons. Once accredited, they receive a subsidy to excise skin cancers from public
patients who would not otherwise be able to afford treatment in primary
care. Accredited GPs can take referrals from colleagues. The programme is carefully
audited to make sure that most of the lesions excised are indeed skin cancers and
that excisions are done satisfactorily. The scheme has proved popular and effective.
A recent report released in the UK notes that, in the UK, ‘GPs with a special interest
(GPwSI) in dermatology can provide effective intermediate care for individuals with
chronic mild/moderate inflammatory diseases, skin infections, sun damage and
certain skin cancers as part of an integrated consultant dermatologist-led team.
There is no good evidence that these services reduce secondary care referrals or
save money; they may ‘de-skill’ GP colleagues. There are detailed Department of
Health safety, governance and training guidelines for the accreditation of GPwSIs,
which some primary care trusts (PCTs) ignore, risking patient safety’.xl
Pharmacists
In many countries, including New Zealand, pharmacists can undertake continuing
professional education on a range of subjects related to Dermatology.
In 2013, in New Zealand, the Medicines (Designated Pharmacist Prescriber)
Regulations 2013 was introduced in July 2013. This enabled the introduction of a
scope of practice for pharmacist prescribers.
34
Scope of Practice
Under the Health Practitioners Competence Assurance Act 2003 the Pharmacy
Council (the Council) must publish a description of the contents of the profession in
terms of one or more scopes of practice. The Council has developed the competence
and registration requirements for the Pharmacist Prescriber scope of practice. In this
scope suitably qualified and trained pharmacists who are already working in a
collaborative health team environment will be able to prescribe medicines.
Dermatology is not currently listing as an area of practice.
Dermatology service
One of the Group was involved in the establishment of community dermatology
(Intermediary care) in the UK. This was part of the ‘Care closer to home’ initiative.
The proposal included primary care, specialists and nurse specialists.
This was intended to lead to a cheaper service, bringing consultants closer to GPs
and with an educational component, providing a hot line to the consultant. The
service involved consultants, GPWSis and specialist nurses.
This was seen to be cheaper, and more accessible patient care, having the service
clinic based and with a limited criteria for treatment. It was good for the GPs as they
were working closely with the consultants and were gaining training at the same
time.
The consultants felt it was good to work more closely with the GPs. In this instance,
the specialist-nursing role, as first point of contact with the service, didn’t really
work, as the nurse did not know all the dermatological conditions. The role of
specialist nurse worked well when given specific tasks such as skin biopsies and
providing patient education, rather than in a general clinical role.
Paediatric Dermatology
In 2012, The British Association of Dermatologists and British Society for Paediatric
Dermatology produced the ‘Working Party report on minimum standards for
Paediatric Services’xli. The aim of this report was to provide a consensus statement
for the provision of paediatric dermatology.
Again, multidisciplinary teams were recommended, based in appropriate childfriendly facilities with high levels of information and choice for parents. In addition,
basing the service on the needs of the child, rather than the child fitting in with the
existing services was highlighted. Detailed information provided includes
descriptions of services, pathways, referral management, staffing requirements and
training, facilities, education, procedures, administration, prescribing and
governance.
Two New Zealand studies looked at children with specific dermatological
conditionsxlii A longitudinal study of the prevalence of childhood eczema showed
35
that it remains a significant problem, particularly for young Māori and Pacific New
Zealanders in whom less recognition of eczema and poorer access to effective,
sustained eczema management may be contributing factors. A study of serious skin
conditions in the Tairawhiti region found that serious skin infections are an
increasing problem for all New Zealand children, but incidence rates in the Tairawhiti
region are consistently greater than average national trends, with significantly larger
ethnic disparities.
Teledermatology
In the UK, ‘Quality Standards for Teledermatology’ xliiihave been produced. This
document compares teledermatology to face-to-face consultations. Three levels of
teledermatology are described – as a triage tool, as ‘full teledermatology’ where it is
offered as an alternative to a face-to-face consultation and intermediate
teledermatology – which combines both of these approaches.
A case study in the UK in 2012xliv described a service that used teledermatology to
avoid unnecessary referrals and improve the quality of care for patients usually seen
in primary care settings. The study showed that the service was effective in
preventing avoidable attendances at secondary care, delivered financial savings,
reduced the time for patients to receive specialist opinion and was popular among
GPs. The British Teledermatology Society describes teledermatology in the UK,
shares best practice and provides educational opportunities and information on
setting up services.
In New Zealand, a Clinical Research Seminar with the title ‘Improving access and
grading evaluations using in-depth teledermatology: image it trial’ found that:
 there was excellent concordance between face-to-face and teledermatology
diagnosis for all lesions with only a 6-7% significant difference
 of all lesions referred, there was potential for >80% of all lesions to be
managed by the General Practitioner
 the results of this study showed that teledermatology can be used as a triage
tool to improve healthcare access and delivery.
Contact Dermatitis and Patch Testing
In 2009, the British Association of Dermatologists produced an update to the
‘Guidelines for the management of Contact Dermatitis.’ xlv The recommendations in
these guidelines are:
1. Patients with persistent eczematous eruptions should be patch tested.
2. A suggested annual workload for a patch test clinic serving an urban population
of 70 000, is 100 patients patch tested
3. Patients should be patch tested to at least an extended standard series of
allergens.
4. An individual who has had training in the investigation of contact dermatitis
prescribes appropriate patch tests and performs day 2 and day 4 readings in
patients undergoing diagnostic patch testing
Minimum standards include; a lead dermatologist for the unit, who attends regular
training, best practice guidelines being followed, electronic gathering of information
with audits and up to date reference material.
36
Skin Cancer
A report to
The Cancer Society of New Zealand in 2009 “The Costs
of Skin Cancer to
New Zealand’ notes that
 Skin cancer is by far the most common cancer affecting New Zealanders.
 There were 18,610 new cancer registrations in 2005.
 Of these 2,017 were ‘Malignant melanoma of skin’; 10.8 percent of all cancer
registrations.
 Non-melanoma skin cancers are not registered. If, however, an estimated
67,000 new non-melanoma skin cancers per year are added, new skin cancer
cases each year total about 69,000; and all new cancers about 86,000.
 Skin cancers account for just over 80 percent of all new cancers each year.
Skin cancers fall into two types, Melanoma and Non Melanoma Skin Cancer (NMSC).
In New Zealand, The Ministry of Health are about to launch Melanoma Tumour
Standards as part of a wider tumour standards initiative, designed to:
• ensure patients receive the same standard of care regardless of the DHB area
or region they live in
• enable the development of efficient and sustainable best practice
management of specific tumour types
• promote a nationally coordinated and consistent approach to service
provision for the tumour type.
Several regions of New Zealand are working to develop skin lesion pathways
(Hawke’s Bay) and the Wellington Sub-region has an established Melanoma
Multidisciplinary Team based at Hutt Hospital, with an established protocol for
management of melanoma.
In 2006, the NICE guidance ‘Improving Outcomes for People with Skin Tumours
including Melanoma ‘(UK)xlvi on skin cancer services, outlines how healthcare
services for people with skin tumours should be organised. The key
recommendations include:
 Cancer networks should establish two levels of multidisciplinary teams to
care for patients.  Patients with a precancerous lesion should either be treated by their GP or
referred.  Patients who need specialist diagnosis should be referred to a doctor trained
to diagnose skin cancer.  Skin cancer teams should work to agreed protocols.
 Protocols should cover the management of care for people in high-risk or
special groups.  Follow-up care should be agreed.  All patients and carers should have access to high quality information.  Information should be collected.  More research should be done.
37
These guidelines were reviewed in 2010 when NICE published a partial update of this
guidance. Recommendations and text relating to the management of low-risk basal
cell carcinoma (BCCs) in the community have been removed from the 2006 guidance
and replaced by 'Improving outcomes for people with skin tumours including
melanoma (update): the management of low-risk basal cell carcinomas in the
community'.
An analysis of the potential economic impact of the guidelines was also produced in
2006, to illustrate the costs to service commissioners of providing the recommended
services as per the guidelines.
The ‘Clinical Practice Guidelines for the Management of Melanoma in Australia and
New Zealand’ xlviiproduced by the Cancer Council Australia, Australian Cancer
Network and the Ministry of Health, New Zealand in 2008 recommends that:
 prevention is important
 appropriate interventions are required
 early detection and accurate diagnosis, by trained health professionals is vital
 awareness of cultural differences is important
 access to histopathology is imperative
 psychosocial support is provided
 population based screening is not supported
 communication is very important
 high risk patients should be identified
 multidisciplinary teams are appropriate
Home Phototherapy
Two articles in the British Medical Journal support the delivery of home-based
phototherapy as a treatment option. An editorial in the British Medical Journal
(BMJ)xlviii ‘Home UVB phototherapy for psoriasis’ refers to a pragmatic study that
compares home UVB with outpatient UVB as part of normal clinical practice. The
study highlights an important gap in the provision of treatment for patients with
psoriasis. With new potent, but costly, biological treatments now widely available for
moderate to severe psoriasis, it is timely to reassess conventional treatments such as
UVB. It would be inappropriate for patients to receive these new and expensive
treatments when the infrastructure to deliver well established cheaper treatments,
such as UVB, is lacking.
Dermatologists should reflect on the shortcomings of current phototherapy services,
where many patients are excluded because they live too far from their local unit. The
case for home provision of UVB phototherapy for psoriasis is most persuasive in
sparsely populated areas. Experience in Germany, the US, the Netherlands, and
Scotland confirms that it would be feasible and practical to implement home based
UVB phototherapy.
The study referred to in the editorial, Home versus outpatient ultraviolet B
phototherapy for mild to severe psoriasis: pragmatic multicentre randomised
38
controlled non-inferiority trial (PLUTO study)xlix, found that Ultraviolet B
phototherapy administered at home is equally safe and equally effective, both
clinically and for quality of life, as ultraviolet B phototherapy administered in an
outpatient setting. Furthermore, ultraviolet B phototherapy at home resulted in a
lower burden of treatment and led to greater patient satisfaction.
In the USA, the National Psoriasis Foundationl note that home phototherapy is an
economical and convenient choice for many people. Like phototherapy in a clinic, it
requires a consistent treatment schedule. Individuals are treated initially at a
medical facility and then begin using a light unit at home.
39
Appendix 3: Vignettes
Current patient experience
Phototherapy
1. 35 yr old male with psoriasis.
Phototherapy treatment
recommended. Workplace not
flexible and early time slots
already taken. Delayed
treatment, condition worse and
systemic treatment offered
instead.
2. 45yr old woman in Blenheim,
nearest phototherapy service
Nelson, therefore 3x per week
not feasible. Condition
deteriorates and patient
approved for expensive biologic
treatment instead.
3. 25yr old single mother with 3
children unable to attend 3x per
week due to lack of transport and
childcare. Continues to use
inadequate topical treatment.
Issues identified
Patient experience under
proposed model
Phototherapy needs to be
Increasing phototherapy
accessible at convenient times. 3x provision – provision at all
per week for maximum benefit.
DHBs.
Benefits
Needs to be accessible, provide
childcare, parking and fast turn
around time to minimise time
from work or childcare.
Extended hours for providing
phototherapy treatment to
allow treatment early and late.
Phototherapy is a safe treatment but
currently requires medical specialist
to be available.
Provision of childcare facilities.
Could be part of day stay unit and
combined with other treatments.
Limited service provision across
S.Island at Dunedin, Christchurch
and Nelson.
Relatively cheap and successful
treatment not accessible to all
patients therefore increasing
alternative drug use and reducing
outcomes for patients.
More trained nurses to provide
the service.
In remote areas, provision of
portable lamps for the duration
of treatment.
Patients can access treatment at
times to suit their lives and maximise
treatment programmes.
Nurses/technicians trained to deliver
phototherapy, therefore freeing up
Dermatologists to provide other
services.
Costs involved would be offset by
reduced use of conventional systemic
drugs and biologic agents (drug costs,
side-effects, repeated visits to health
professionals).
Home phototherapy can increase
delivery for patients in remote areas.
40
Current patient experience
Issues identified
2. Elderly patient (96yrs) with skin
cancer.
Referred 4 times over a year.
Communication problems led to
patient declining surgery as
thought treatment was as
inpatient.
Delays in getting first
appointment.
Could not afford to have surgery
done privately.
Funding of GPs not adequate to
deliver excision of lesions.
GPs unsure of referral pathways
to Dermatology or Plastic Surgery
for skin lesions.
Is Dermatology providing surgical
expertise as well as diagnosis and
management?
3. Skin Cancer cases
a) High risk skin cancer patient –
65 yrs – with history of ischaemic
cardiac disease. 3 previous BCC
excisions. Lesion on cheek.
Requires careful assessment on
the correct management and
Lack of communication to allow
patient to make informed choice.
Lack of clear referral pathway.
Options for inpatient treatment
while patient in hospital with
another condition not explored.
Delays caused by inaccessibility
Currently faster response time if
GP refers to Plastic Surgery
(Counties Manukau) rather than
Dermatology in Auckland.
Need to have a Dermatologist
review the lesion – limited access
due to low numbers in public
sector.
Lack of standards for treatment –
Melanoma Guidelines due out
Patient experience under
proposed model
More Dermatology FTE to
improve access to clinics.
Benefits
Provision of virtual clinics
(teledermatology) and outreach
clinics to improve access.
Patient able to make informed
decisions based on detailed discussion
of options.
Integrated approach to respond
to GP referral based on what is
best for the patient.
Access to services increased through
use of technology and outreach
clinics.
Better communication between
multidisciplinary teams.
Publicly funded Dermatology
provision matches community needs.
Multidisciplinary team,
including Dermatologist, in
every DHB for skin cancer with
national standards applied.
Community teams to provide
on-going care and rehabilitation
when required, supported by
Patients are seen early and have
multidisciplinary approach to
treatment.
Patient seen and treated in a timely
way.
GPs better trained and involved at
team level.
41
Current patient experience
Issues identified
Patient experience under
proposed model
PHOs.
Hospital based skin cancer
clinics held with
multidisciplinary team
diagnosing and developing
management plan.
Benefits
reconstruction.
b) 35yr old with history of
melanoma. Mother died of
melanoma at 55. Presenting with
irregular mole.
Requires Dermatological
assessment and excision and ongoing surveillance and skin care
education.
c) 85yr old man with rapidly
enlarging lesion on leg. Needs
help with daily living in rest
home. Has range of comorbidities. Requires
consideration of pre-morbid state
and available treatment options.
Increased risks of skin breakdown
and poor healing.
shortly but not for NMSC.
Lack of training for GPs both
during pre-registration training
and on-going professional
development.
Record all tumours and
outcomes.
Patients have access to range of
options to ensure best outcomes.
Hold morbidity meetings.
Lack of community based follow
up post surgery.
Provide more training for GPs –
include 3 month session as
dermatology registrar in
training.
Multidisciplinary teams provide
collegial support, training and
educational opportunities.
4. Paediatric patient
7yr old with extensive psoriasis.
Topical treatment not successful
Being teased and afraid of going
swimming. 6 month wait for
specialist appointment at
Insufficient funding for paediatric
Dermatology leading to long
waiting times.
Faster referral time to see
specialist in correct clinic (ie
Paediatric).
Nurses able to spend longer with
patients explaining how to use
treatments for maximum benefit.
Right treatment provided by GP
but inadequate and incorrect
Better information provided by
nurses at clinics.
Longer appointment times lead to
more informed patients.
Lack of multidisciplinary teams.
Lack of audit and review of cases,
treatment and outcomes.
Standards of care are provided and
audited across New Zealand.
Records of all cases are available for
review and audit, including
photographs.
More time for teaching for
Dermatologists
42
Current patient experience
Issues identified
paediatric service. Ended up at
adult clinic where found that
condition had deteriorated and
spread. Advice from GP led to
insufficient topical treatment and
no diagnosis of secondary
infection.
Change of medication and
appropriate advice led to
significant improvement in
psoriasis and also in quality of
life.
5. Patch testing
Young female hairdresser with
hand dermatitis. Lots of time off
work due to severe eczema.
advice on how to use it.
Length of consultation time with
GP very short compared to time
with Dermatologist.
Dermatologist recommended
comprehensive patch testing but
access to this is limited. Costs of
this could be covered by ACC.
Patient experience under
proposed model
Benefits
Longer time spent with health
professionals as administrative
tasks are carried out by other
staff.
Better education for GPs and nurses
and clear referral pathways lead to
better provision of services.
Very rare to have nursing input at
GP practice to provide education.
Increased training for pharmacists will
enhance the management of a range
of skin conditions.
Education of patients/caregivers
vital to successful management of
conditions.
Limited access to patch testing in
New Zealand.
Patch testing is resource
intensive.
Guidelines for patch testing exist
in other countries, e.g. UK, but
not currently in NEW ZEALAND.
Lack of data recorded on
incidence and outcomes and no
audits carried out.
Patch testing available in timely
way for identification of
allergens and appropriate
treatment and plan developed.
Patient can be diagnosed accurately
and continue in employment.
Reduced time off work.
Data on patch testing will be available
for audit and review, leading to better
understanding.
Better informed to make
decisions.
Bank of allergens can be centrally held
and distributed to regions as required.
Standards of care maintained through
Dermatologist led service, regular
training and review processes.
43
Current patient experience
Issues identified
Patient experience under
proposed model
Benefits
Access to Contact Dermatology
and Occupational Dermatology
very limited in New Zealand.
44
Appendix 4: ACC Claims
Contact Dermatitis and Other Skin Related Condition ACC Claims (20092013)li
Table 1: Summary of contact dermatitis claims lodged
between 2009 – 2013 financial years.
These figures include all conditions listed in the table below. The cost includes
one or more services per distinct claim.
Number of
Financi distinct
Cost Ex
al Year claims
GST
2009
305 $46,087
2010
205 $20,885
2011
129 $14,852
2012
110 $15,525
2013
94
$8,911
Table 2: Top 8 contact dermatitis diagnoses lodged
between 2009 – 2013 financial years.
Read Code Description
Irritant contact dermatitis
Contact dermatitis and other
eczemas
Irritant contact dermatitis due
to other chemical products
Contact dermatitis NOS
Contagious pustular
dermatitis
Allergic contact dermatitis
Allergic contact dermatitis
due to other chemical
products
Other*
200 201 201 201 201
9
0
1
2
3
128
50
26
17
6
55
71
39
24
32
19
13
19
9
7
19
11
16
16
9
29
26
14
7
<4
5
12
6
5
<4
5
30
9
26
9
20
6
18
9
14
*Other includes all other dermatitis related descriptors
where the value is too low to report separately
45
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