Independent King's Fund report finds major failings in NHS services for people with skin diseases
Date: Apr 2015
A report by the King’s Fund* into a major NHS specialty - dermatology - has identified staff shortages, poor training, inconsistent quality in diagnosis and treatment and large variations in access to specialist care, affecting millions of patients across the UK each year.
Dermatology represents an important part of NHS provision. Each year, approximately 24 per cent of the population will visit their GP with a skin complaint, making skin conditions the most frequent reason for people to consult their doctor with a new problem.
The independent report by the King’s Fund, commissioned by the British Association of Dermatologists and released today, reveals a number of worrying challenges facing dermatology services and identifies opportunities for improvement, which may also be applied to other health specialties. The report looked at a range of issues, including workforce (staffing), training, use of temporary or locum staff, technology and the role of pharmacy, making a number of observations and recommendations.
The authors Nigel Edwards and Candace Imison summarise: “Dermatology represents an important part of NHS provision. There are approximately 13 million GP consultations for skin conditions a year and 716,830 new referrals and yet this important area is poorly understood and has received comparatively little attention. Commissioning has often been poor. Inadequate planning has left gaps in the workforce. The 40,000 GPs managing this workload have received little training in dermatology and there are only 650 consultants to advise them and provide the more specialist care.
These include the following two key recommended objectives:
- To urgently improve quality of dermatology knowledge in primary care.
The report outlines: “GP dermatology teaching averages approximately only six days and most GP training schemes have no dermatology attachment…. Dermatology undergraduate training averages a couple of weeks at most, is variable in terms of quality as well as syllabus, and it is not compulsory.” As well as improved education and training and targeted continuing professional development, other solutions might include the development of experts in larger GP practices, and the use of peer review and decision-support.
- To improve commissioning
The report states: “Our work exposed major concerns about the current quality of commissioning for dermatology services and the lack of specialist knowledge among commissioners… Commissioning should not be driven by short-term tactical decisions designed to minimise the price paid rather than to improve value for patients; there is a danger of service fragmentation and of models of care that make false economies … or in the worst case threaten the quality of care. We saw a number of examples of this.”
The British Association of Dermatologists (BAD) asked The King’s Fund to explore the current challenges facing dermatology services and identify opportunities for the future. The King’s Fund engaged a wide range of stakeholders from within and outside dermatology to help address this question. This engagement activity included a survey, stakeholder interviews with patients and with clinicians from both primary and secondary care, interviews with the independent sector and commissioners, visits to specialist dermatology services, and stakeholder workshops.
"There are opportunities to improve these services but also an increasingly urgent need to respond to: growing demand and expectations; rising costs of new treatments; inconsistent quality in diagnosis and treatment (particularly within primary care); large variations in access to specialist care; issues with patient experience; and shortages, and an uneven distribution, of senior medical and nursing staff. There is a challenge for primary care where there are some of the greatest opportunities for improving the quality of care for people with skin conditions. This report looks at these issues and the options for addressing them.
"Dermatology is a useful case study that can shed light on thinking for other outpatient-based services and how these can develop new delivery models that make better use of limited specialist skills."
Dr David Eedy, President of the British Association of Dermatologists said: “This independent report confirms our suspicions about many of the problems currently facing dermatology, while suggesting some interesting solutions. Workforce and GP education are already top of our agenda, yet seem to be ignored by the powers that be. Given that as much as 20 to 25 per cent of GP workload involves skin disease, the added pressure on GPs will not be alleviated by cutting further Consultant Dermatologists who help them with some of their most numerous, time consuming clinical problems. And yet the shortfall in Consultant numbers is not being addressed by creating further trainee posts in dermatology, which would seem like a logical step. Furthermore, it is widely acknowledged that there is a lack of knowledge about skin disease in general practice as a result of poor undergraduate and postgraduate teaching which leaves most GPs lacking the skills to manage dermatology and results in more patients being referred to Consultants. This is not the fault of the GPs but of the education they are offered.”
The report will be disseminated to a range of stakeholders to whom it is relevant, including medical professionals, commissioners and skin disease charities and patient groups.
Key facts about skin disease from the British Association of Dermatologists:
- Dermatology comprises a vast proportion of the total UK health burden. Dermatologists manage over 2,000 diseases of the skin, hair and nails in adults and children.
- Each year 54% of the population is affected by skin disease, and 23 to 33% of the population at any one time has a disease that would benefit from medical care.
- Approximately 13,000 melanomas and around 500,000* non-melanoma skin cancers are diagnosed a year. The number of just one type of skin cancer, basal cell carcinoma, equals all other cancers combined, and increased by 133% between 1980 and 2000. Melanoma incidence increased by 50% over just 13 years. *Actually the true figure is not known because the government does not collect the numbers!
- Approximately 4,000 deaths occur in the UK annually due to skin disease, most often from malignant melanoma.
- Skin diseases represent 34% of disease in children, with atopic eczema affecting 20% of infants.
- Skin cancer is the most common cancer and the second most common cancer causing death in young adults.
- Hand eczema is one of the most common reasons for disablement benefit in the UK.
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