Experiences of dermatology services transformation

Julia Schofield, Principal Lecturer University of Hertfordshire

Consultant Dermatologist, United Lincolnshire Hospitals NHS Trust

Experiences of dermatology services transformation

• What did the service look like before the redesign work?

• What changes were made and how were they made?

• What the service looks like now• Where there any barriers and how were they

overcome?• Examples of models of service from England

How best to answer these questions?

Setting the scene1997-2010

The Blair years, the NHS and Dermatology : period of unprecedented reform

Reform & modernisation: early stages

• Background of long waiting lists and poor access to services

• NHS Modernisation agency Action on Dermatology (2000-2003)

• Action on Plastic Surgery (2003-2005)• Pilot site work and Good Practice Guidance• Role of GPwSIs and extended role practitioners• Lack of good evidence for what worked

Trends in the number of dermatology patients waiting longer than 26 and 13 weeks to be seen using fourth quarter data 1999-2007, England source www.performance.doh.gov.uk/waitingtimes

So what have we learnt that is important and where is the

evidence?

The commissioning cycle

Service redesign cycle

The 2009 Health Care Needs Assessment

• The burden of disease: how much, how expensive, impact?

• How we manage the burden: services available and their effectiveness

• Recommendations for models of care based on the EVIDENCE

http://www.nottingham.ac.uk/scs/documents/documentsdivisions/documentsdermatology/hcnaskinconditionsuk2009.pdf

Structure of the document: chapters

1. Introduction2. Burden of skin disease3. NHS reform and its impact4. Services available and their effectiveness5. Models of care and organisation of services6. Specific skin disease areas7. RecommendationsLots of references!

Linking the evidence to service redesign: ASSESSING NEED

• Coding systems poor, underestimate problem• Skin disease is very common• Lots of people self care and buy OTC products• 24% of the population seek medical advice about a

skin condition each year (12.9 million)• Commonest reason people present to a GP with a

new problem

Skin disease seen by specialists• Limited information, good scottish data*• About 6.1% of people with skin disease are referred to

see a specialist• 35-48% referrals are skin lesions, more in coastal areas• Ever increasing referrals to specialists• Eczema, acne and psoriasis commonly seen• Patients still admitted

*Benton, EC, Kerr, OA, Fisher, A, Fraser, SJ, McCormack, SKA, Tidman, MJ (2008) The changing face of dermatological practice: 25

years' experience. British Journal of Dermatology, 159, 413-8. 

Self reported/ self managed skin disease

0.75 million people with skin disease referred for NHS

specialist care, 1.5%

50% population approx 25 million

24% population, 12.9 million seeking Primary Care (England and Wales)

Need: summary of key messages

3752 deaths due to skin disease

Linking the evidence: SERVICE PROVISION

• We MUST define the level of care and the location• Confusion about terms• Primary care means ‘first point of contact care’• Secondary care means ‘specialist care’• Too much talk of ‘shift’ without understanding the

meaning

Define LEVELS of care: self care, generalist, specialist, supra-specialist

From Skin conditions in the UK: a Health Care Needs Assessment Schofield et al 2009

Linking the evidence: service provision

Generalist care• Patients like to be treated by their GP• GP diagnostic skills for skin lesions are not great• Standards for GP skin surgery need to be

improved• Up-skilling of Practice Nurses limited benefit• Community specialist outreach nursing services

effective for chronic skin disease

Linking the evidence: service provision

Specialist care• Dermatologists should be diagnosing the skin

lesions: they are good at it• Dermatologists can prevent hospital admissions

for some conditions• If GPwSIs are to be used, they need to be

accredited• Specialist nurse services for prediagnosed

conditions are effective

Services available: who sees what and where?

Primary careSkin infections

Specialist careSkin lesions 45-60%

WHY?

31-59% are for diagnosis – skin lesions even higher

Service provision: the diagnostic bottleneck

Patients with skin disease requiring diagnosis and

management

Specialist opinion, diagnostic service

Treatment

Surgery

CORRECT DIAGNOSIS=

CORRECT MANAGEMENT

Linking the evidence: DECIDING PRIORITIES

MUST do’s• NICE guidance includes skin cancer, biologics for

psoriasis, atopic eczema• DH access targets 31/62 days for cancer• 18 week patient journey• Choose and Book• Care Closer to Home recommendations

Linking the evidence: deciding priorities

Inequity of access need vs demand• Variable low priority frameworks across

England• Skin surgery• Lymphoedema services• Botulinum toxin services for sweating • ‘One pot spent well’• Decisions should be based on the evidence base

What is need?Need is ‘the ability to benefit from care’Williams HC. J Roy Coll Physicians 1997;31:261-2

The use of the biological agents to treat psoriasis

The use of isotretinoin to treat acne

Demand and supply

Demand = “that which is asked for”

Supply = “that which is provided for”

Williams, HC. J Roy Coll Physicians 1997;31:261-2

Seborrhoeic keratoses – demand or need?

How to save a billion (part II)• Up to £700m could be saved if PCTs decommissioned some

procedures:

“relatively ineffective” Max potential reduction in procedures (%)

Max potential savings (£m)

Tonsillectomy 90 45

Back pain injections & infusion 90 24

Grommets 90 21

Knee washouts 90 20

“Potentially cosmetic”

Aesthetic breast surgery 80 18

Varicose veins 80 18

Inguinal, umbilical & femoral hernias 50 50

Minor skin surgery for non cancerous lesions

25 74

Linking the evidence: DESIGNING SERVICES

• Emphasis on rapid access to diagnosis• Right place, right person, first time• Range of national guidance about models of care• Integrated care• Local specialist services with links to regional and national

specialist services• Services for sick patients in hospital• Day treatment OP phototherapy services• Patients must be involved in the design of services

The PatientPatient support groups

Care Closer to Home 2007 Figure 2: Dermatology patient journey (source: modified from Model of Integrated Service Delivery. Skin Care Campaign 2007)

GP

GPwSI/PwSI (where appointed)

Secondary care

Tertiary (supra-specialist care)

Drop-in CentrePharmacist

Referral management*

Diagnosis and treatment

Diagnosis and specialist treatment

Discharge

2 week wait cancer

pathway

* Where referral management schemes are in place it is essential that these are led by experienced specialist clinical triage performed daily to reduce delays

The facility to refer directly to secondary care services is essential

Skin lesion models: separate diagnosis and management

18 week skin lesion pathway

Linking the evidence: designing services

• Shifting care to community settings does not necessarily reduce activity or cost

• There is a link between a reduction in wait times and increased referral rates

• National standards and review are in place for skin cancer services

Linking the evidence: designing services

• GPwSI services improve access but do not reduce cost

• Specialist nurses working with specialist teams are effective

• Specialty and Associate Specialist doctors are interested in working in new models of care

Linking the evidence: designing services

• Teledermatology useful for remote areas• ‘Store and forward’ digital image and referral

useful• Clinically-led guidelines may be helpful but a

lot of work!• Referral management services (RMS) evidence

free zones*. ? Role of Tier 2 services/ Clinical Assessment and Treatment services

Davies, M, Elwyn, G (2006) Referral management centres: promising innovations or Trojan horses? BMJ, 332, 844-6.

Referral management services

Referral management centres• Paper/electronic process• Count referrals• Assess quality and reduce inappropriate

referrals• Redirect referrals to appropriate service• May lack clinical input

Referral management services

DH guidance 2006• Must not lengthen patient journey• Must carry clinical support• Should confer real diagnostic or treatment

benefit• Not be imposed without agreement• In England largely financially driven

Experience of a Clinical Assessment and Treatment Service in Hertfordshire

• Specialist led, GPwSIs, consultant outreach, specialist nurses

• Specialist triage• Community settings• Routine, straightforward dermatology• Patients happy, good service• Robust governance and quality

Urgent

ROUTINE

Pre-diagnosedN/L eczema

N/L psoriasis

N/L leg ulcer

GPwSI

Consultant outreach

Consultant appointment

ROUTINE

Needs specialist services

OUTCOME

Discharge or follow up

2 week wait

Consultant/Associate Specialist triage

Dermatology Service from September 2007

                                                         

Referral to CATS service Other referrals

Triage CHOICE

CHOICE

CHOICE

Wellswood House

Borehamwood

Skin surgery

Impact on secondary care referral rates

0

50

100

150

200

250

300

350

400

Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug

Pre-CATS CATS period

BUT: total referral activity including CATS referrals increased

0

100

200

300

400

500

600

Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug

Pre-CATS CATS period TOTAL

Linking the evidence: SHAPING THE STRUCTURE OF THE SUPPLY (!)

• Quality same wherever and whoever provides the service (OHOCOS 2006)

• Joined up services: integrated models• Local resources local solutions• Robust standards of accreditation, DH guidance• Competency based assessments supervised practice

Linking the evidence: MANAGING THE DEMAND

• General Practitioner will remain the gatekeeper• Resources are finite and demand will need to be

managed• No evidence that strategies to date are effective• Priority setting may be the key• Need vs demand increasingly an issue

GP as gatekeeper: education and training• Limited undergraduate training• Postgraduate training not compulsory• GP curriculum could map better to what is

seen in practice• Training and education important• Not a short term solution

18% more patients seen5.6% more new patients seenFewer people waiting

24% rise in consultant numbers

The final piece of evidence to think on

Implementing the 18 week target

Presented the evidence• Service redesign cycle• Needs Assessment• Burden of skin disease• Service provision• Models of care• Referral management

No magic wand!

THANK YOU

The HCNA is available free at:http://www.nottingham.ac.uk/scs/documents/documentsdivisions/documentsdermatology/hcnaskinconditionsuk2009.pdf

Hard copies can be purchased from the Centre of Evidence based Dermatology for a nominal sum from douglas.grindlay@nottingham.ac.uk