1. Skin conditions a Health Care Needs Assessment: key messages
Julia Schofield
Special Lecturer University of Nottingham
Principal Lecturer University of Hertfordshire
Consultant Dermatologist, Lincoln

2. What I am going to talk about?
What is need?
What is a Health Care Needs Assessment?
Some background to the new document
What does the updated Dermatology Needs Assessment for the UK tell us?
Recommendations for the future

3. What is need? Need is ‘the ability to benefit from care’
Williams HC. J Roy Coll Physicians 1997;31:261-2
The use of isotretinoin to treat acne
The use of the biological agents to treat psoriasis

4. Seborrhoeic keratoses – demand or need?
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?

5. What is a health care needs assessment (HCNA)?
1. The burden of disease
Prevalence and incidence
Impact on quality of life
Economic burden
2. Managing the burden The services available The effectiveness of those services
3. Recommendations for models of care and delivery of services to manage the need

6. Some background to the project
1997
Dermatology: Health Care Needs Assessment
Hywel Williams
Radcliffe Medical Press (one of 38 chapters still available on the HCNA website)
2007
Needed revision

7. Some background to the project
BAD sabbatical fellowship April 2007
Additional funding PCDS, Psoriasis Association, CEBD
March to July 2008
Peer review process
Published by CEBD October 2009

8. The team Professor Hywel Williams Strategic lead for the project
Author of original Dermatology Health Care Needs Assessment
Dr Douglas Grindlay
Information Specialist, NHS Evidence – skin disorders (based at CEBD)
Information searching, referencing, editing
Dr Julia Schofield
Lead researcher and lead author

9. Structure of the document: chapters
Introduction
Burden of skin disease
NHS reform and its impact
Services available and their effectiveness
Models of care and organisation of services
Specific skin disease areas
Recommendations
Lots of references!

10. What does the document tell us?

11. The HCNA: key messages 1. The burden of disease
Prevalence and incidence
Impact on quality of life
Economic burden
2. Managing the burden
The services available
The effectiveness of those services
The cost-effectiveness of those services
3. Recommendations for models of care and delivery of services
How to manage the need
Supply and type of services

12. Prevalence and incidence
Examined skin disease
Self reported skin disease
People with skin disease seeking generalist medical care
People with skin disease seeking specialist medical care 12

13. Examined skin disease in the UK
Nothing new since the Lambeth study in 1976*
2180 adults studied
55% population had any form of skin disease
22.5% had skin disease worthy of medical care
Tumours and naevi commonest but 90% considered trivial
Prevalence of eczema 9% but 2/3 moderate or severe
Authors concluded:
Skin conditions that may benefit from medical care are extremely common
Most sufferers do not seek medical help
*Rea et al Skin disease in Lambeth: a community study of prevalence and use of medical care. Brit J Prev Soc Med 1976;30:107-14

14. Self reported skin disease
Proprietary Association of Great Britain (PAGB)
Nationwide (UK) study of minor ailments and how people manage them
1987, 1997 and 2005
A picture of health 2005 PAGB/Reader's Digest Report*
*ww.pagb.co.uk/pagb/primarysections/marketinformation/otcconsumeresearch.htm

15. Self reported skin disease: PAGB study
1500 people questioned all over the UK
Minor ailments in the last 12 months
Questions related to a limited number of conditions
818/1500 (54%) reported a skin condition
The 1500 questioned reported 1524 episodes of skin disease
135 mothers reported eczema in 30% of their children

16. Self reported skin disease PAGB study: management

17. PAGB study of self reported skin disease: limitations
Diagnostic information limited, symptom based
Limited range of conditions included in study
Respondents not asked about warts, verucca, psoriasis, dandruff, hair loss, headlice, boils, cradle cap and nappy rash.
No lumps and bumps, skin lesions
Under-estimates skin conditions

18. Skin disease seen in Primary Care
Primary care data from RCGP Research and surveillance Unit weekly returns service (WRS)
Data from 47 practices in England and Wales representing about 400,000 people
Data captured on all patient encounters
Incidence, prevalence and consultation rate data

19. Data capture and coding issues
ICD 9 and 10
Disorders of the Skin and Subcutaneous Tissues
Does NOT include:
All skin tumours, benign and malignant
Many common skin infections including viral warts
Seriously underestimates the amount of skin disease

20. Skin disease in Primary Care: messages
24% of the population seek medical advice about a skin condition each year (12.9 million)
This is the commonest reason for people to consult their GP with a new problem
Consultation rate is 2 per episode
Average GP: 630 consultations per year for skin conditions
Under-estimate due to coding issues

21. Skin disease seen in Primary Care
Condition
Prevalence
Episode incidence
Consultation rate
Skin infections
785
656
1131
Eczema
413
274
557
Acne
164
125
251
Psoriasis 69 33
109
Urticaria 53 40 70
Prevalence, episode incidence and consultation rates for selected skin conditions per 10,000 population Source: RCGP WRS

22. Key messages Skin infections commonest reason for consultations
20% of children under 12 months are diagnosed with eczema
Psoriasis not very common cause of GP consultations

23. Skin disease seen by specialists
Limited information other than numbers
About 6.1% of people with skin disease are referred to see a specialist
35-48% referrals are skin lesions
Eczema, acne and psoriasis commonly seen
Patients still admitted

24. Specialists casemix: by % of new patient activity
Skin lesions

25. Services available: who sees what and where?
WHY?
Specialist care Skin lesions 45-60%
Primary care Skin infections
31-59% are for diagnosis – skin lesions even higher

26. Epidemiology: summary of key messages
0.75 million people with skin disease referred for NHS specialist care, 1.5%
3752 deaths due to skin disease
24% population, 12.9 million seeking Primary Care (England and Wales)
Self reported/ self managed skin disease
50% population approx 25 million

27. The cost of skin disease in the UK
Direct and indirect costs
Over the counter (OTC) sales
Prescribing costs for skin disease
Costs to the NHS of delivering services for patients with skin disease
The cost of disability due to skin disease

28. Coughs colds and sore throats
Skin disease
Pain relief

29. Primary Care prescribing costs 2007
BNF Chapter 13
35 million items, £239 million, net ingredient cost £6.77
2.85% total budget, no real change for many years
Excludes hospital prescribing and oral antibiotics
Dovobet: £21 million, NIC £54.95

30. Economic burden: disability living allowance claims by age

31. Burden of skin disease: impact on quality of life
1990 Psoriasis > impact on QoL than hypertension and angina
1999 Psoriasis same impact as angina or cancer
2000 High DLQI scores significant in primary care patients with skin disease
2003 Willingness to Pay for cure higher in acne, atopic eczema and psoriasis than angina hypertension and asthma.

32. Impact on quality of life: new data
Psycho-social morbidity
Skin-Brain axis
Impact on the rest of the family: ‘greater patient’
Impact on life choices
(co-morbidities)

33. The HCNA: key messages 1. The burden of disease
Prevalence and incidence
Impact on quality of life
Economic burden
2. Managing the burden
The services available
The effectiveness of those services
The cost-effectiveness of those services
3. Recommendations for models of care and delivery of services
How to manage the need
Supply and type of services

34. Services available and their effectiveness
Self care, expert patient programme
Internet: e-health
Primary (generalist) care
Referral management
Specialist services
Supra-specialist services

35. Services available and their effectiveness
Self care, expert patient programme
Internet: e-health
Primary (generalist) care
Referral management
Specialist services
Supra-specialist services

36. Services available and their effectiveness: self care
Patient groups important but vulnerable
Some evidence for social network groups
No Expert Patient Group Evidence
High sales OTC skin treatment products but limited teaching and training of pharmacists
No formal evaluation of pharmacists

37. Patient information: important points
The digital divide: 70% of over 65s have never used the internet
NHS Direct: 4% of all calls skin rashes
Written information variable quality (Picker Institute 2006)
Patients not involved, clinicians still write the material
Health on the Net Foundation code of accreditation, none of common dermatology sites accredited

38. Services available and their effectiveness: Primary Care
Limited evidence
Evidence that teaching and training inadequate (APPGS and others)
Little formal evaluation
Some evidence that skin lesion diagnostic skills not great
Not a lot of evidence that up-skilling practice nurses helps

39. Services available and their effectiveness: Primary Care
MISTiC study 2008
Hospital vs GP skin surgery
Some concerns about quality of GP surgery
Malignancies missed
Hospital more cost-effective
Patients preferred GP skin surgery

40. Services available and their effectiveness: GPwSI services
GPwSI services are effective
Patients like the GPwSI services
Not particularly cost-effective
Overall may increase costs
May not be the most cost effective way of increasing overall capacity of specialist services (Roland 2005)

41. Effectiveness of specialist services
Little evaluation of effectiveness of ‘doctor’ services
Nurse services are better evaluated
Few specialist services measure clinical outcomes

42. Evidence for effectiveness of specialist services
Good diagnosticians
Supports role of Inpatient treatment
Manage skin cancer effectively
Specialist nurses are effective
Role in managing cellulitis

43. Models of care and organisation of services
Consensus documents about models
Referral management ‘evidence free zone’
Shift : specialists in community settings and joint working improves access to care and maintains quality, no reduction in OP activity
Digital imaging: useful but not implemented

44. Education and training
Not enough training for Primary Care health care professionals
What there is: not needs based, curriculum does not match casemix
Remains optional, undergraduate and postgraduate nursing and medicine

45. The HCNA: key messages 1. The burden of disease
Prevalence and incidence
Impact on quality of life
Economic burden
2. Managing the burden
The services available
The effectiveness of those services
The cost-effectiveness of those services
3. Recommendations for models of care and delivery of services
How to manage the need
Supply and type of services

46. 10 key recommendations
Improve self care: better information, community pharmacy training
Improve undergraduate nursing and medical training
Needs based educational programmes
Referrals should be triaged by experts in integrated teams
More pyramidal service needed

47. All patients with skin conditions
The link between the amount and complexity of skin disease and current levels of training and knowledge
Highly trained supra-specialists
Large numbers of patients managed by clinicians with limited knowledge and training
Knowledge and skill of clinicians: small number of highly trained specialists treating few patients
Increasing complexity of skin disease: fewer patients
Increasing amount of training
All patients with skin conditions
Large numbers of cases of straightforward, less complex skin disease

48. All patients with skin conditions All patients with skin conditions
Optimising the link between the amount and complexity of skin disease and levels of training and knowledge
Specialists and supra-specialists diagnosing and managing more complex skin problems
Appropriate levels of education and training based on ‘need’ as determined by the type and amount of disease seen and its complexity
Increasing complexity of skin disease: fewer patients
Increasing amount of training
All patients with skin conditions
All patients with skin conditions
Large numbers of cases of straightforward, less complex skin disease

49. 10 key recommendations
6. Population based teams of health care professionals 7. Accreditation process needed 8. Dermatologists: diagnosis, management of complex skin problems 9. Cancer service led by dermatologists 10. Patient Reported Outcome Measures needed

50. Thank you Acknowledgements British Association of Dermatology
Psoriasis Association
Primary Care Dermatology Society
Professor Hywel Williams & Douglas Grindlay