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

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

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

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?

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

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

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

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

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!

What does the document tell us?

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

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

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

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

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

Self reported skin disease PAGB study: management

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

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 http://www.rcgp.org.uk/clinical_and_research/rsc.aspx

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

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

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 2006. Source: RCGP WRS

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

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

Specialists casemix: by % of new patient activity Skin lesions

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

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

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

Coughs colds and sore throats Skin disease Pain relief

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

Economic burden: disability living allowance claims by age

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.

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)

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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