Presentation on theme: "Experiences of dermatology services transformation Julia Schofield, Principal Lecturer University of Hertfordshire Consultant Dermatologist, United Lincolnshire."— Presentation transcript:
Experiences of dermatology services transformation Julia Schofield, Principal Lecturer University of Hertfordshire Consultant Dermatologist, United Lincolnshire Hospitals NHS Trust
Experiences of dermatology services transformation What did the service look like before the redesign work? What changes were made and how were they made? What the service looks like now Where there any barriers and how were they overcome? Examples of models of service from England
How best to answer these questions?
Setting the scene 1997-2010 The Blair years, the NHS and Dermatology : period of unprecedented reform
Reform & modernisation: early stages Background of long waiting lists and poor access to services NHS Modernisation agency Action on Dermatology (2000-2003) Action on Plastic Surgery (2003-2005) Pilot site work and Good Practice Guidance Role of GPwSIs and extended role practitioners Lack of good evidence for what worked
Trends in the number of dermatology patients waiting longer than 26 and 13 weeks to be seen using fourth quarter data 1999-2007, England source www.performance.doh.gov.uk/waitingtimes 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/hcna skinconditionsuk2009.pdf
Structure of the document: chapters 1.Introduction 2.Burden of skin disease 3.NHS reform and its impact 4.Services available and their effectiveness 5.Models of care and organisation of services 6.Specific skin disease areas 7.Recommendations Lots of references!
Linking the evidence to service redesign: ASSESSING NEED Coding systems poor, underestimate problem Skin disease is very common Lots of people self care and buy OTC products 24% of the population seek medical advice about a skin condition each year (12.9 million) Commonest reason people present to a GP with a new problem
Skin disease seen by specialists Limited information, good scottish data* About 6.1% of people with skin disease are referred to see a specialist 35-48% referrals are skin lesions, more in coastal areas Ever increasing referrals to specialists Eczema, acne and psoriasis commonly seen Patients still admitted *Benton, EC, Kerr, OA, Fisher, A, Fraser, SJ, McCormack, SKA, Tidman, MJ (2008) The changing face of dermatological practice: 25 years' experience. British Journal of Dermatology, 159, 413-8.
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 care Skin infections Specialist care Skin 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) Tonsillectomy9045 Back pain injections & infusion9024 Grommets9021 Knee washouts9020 “Potentially cosmetic” Aesthetic breast surgery8018 Varicose veins8018 Inguinal, umbilical & femoral hernias50 Minor skin surgery for non cancerous lesions 2574
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 Centre Pharmacist 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-diagnosed N/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 CHOICECHOICE Wellswood House Borehamwood Skin surgery
Impact on secondary care referral rates
BUT: total referral activity including CATS referrals increased
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 seen 5.6% more new patients seen Fewer 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/documentsdivisio ns/documentsdermatology/hcn askinconditionsuk2009.pdf Hard copies can be purchased from the Centre of Evidence based Dermatology for a nominal sum from douglas.grindlay@nottingham. ac.uk douglas.grindlay@nottingham. ac.uk