This Dermatology Blog will keep track of all the activity undertaken by the Dermatology Specialty Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wishes to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
Guest blog by John McFadden, GP and Managing Partner Inverness Primary Care LLP
Inverness Primary Care LLP is a GP federation consisting of the 12 general practices in Inverness. We have a contract with NHS Highland to provide more dermatology within practices in order to reduce the number of referrals to dermatology and the number of skin lesion excisions performed in hospital below an agreed number. The LLP works collaboratively with another 25 practices in NHS Highland to provide this service covering a population of approximately 123,000 patients.
To help achieve our objectives, initially we triaged referrals and ran a small community clinic at which an Associate Specialist in Dermatology both saw patients and educated GPs. However as practices took on more dermatology we were able to stop this.
The way we achieved the required outcomes was;
1. To report to practices the referral rates so they could see if they needed to change, by how much and how other practices were performing.
2. We performed an analysis of referrals to dermatology which led to education focussed on the dermatological conditions which we though could be treated within general practice.
3. We encouraged practices to scrutinise their referrals before they are made and to develop within practices individual GPs who have an interest in dermatology to act as a resource for their colleagues.
This project meets the first key principle of the Scottish Access Collaborative in that patients now have to travel less. The other five principles are not really relevant to this project as it reduces referrals before use has to be made of the other five principles.
Sharp eyes will see initially we made a greater reduction in referrals than the 30% we were required to achieve. This is because we had designed a system that we thought could reduce referrals ultimately by somewhere between 50-60% but the funding was not available for this degree of reduction. Secondly, some of you will have noticed that we are unfortunately now breaching our referral target. We think this is because interest in the project waned partly because of other pressures on General Practice and partly because of difficulty engaging with NHS Highland management. With a new Dermatology Service Manager in Highland, ongoing Consultant support for the projects and efforts by the LLP the project is being reinvigorated and as you’ll see referral rates are falling again.
The follwoing images are also available as PDFs in the dermatology document repository
National Dermatology Improvement Nurse
Guest Blog by Dianne Ross for Scottish Access Collaborative
The posts of National Dermatology Improvement Nurse are both for a fixed term of three years. One is hosted in NHS Greater Glasgow and Clyde and the other in NHS Tayside but both have responsibility for developing services across both Scotland and the CAWT regions of Ireland.
The Modern Outpatient Programme is designed to support the delivery of high-quality, effective, and sustainable dermatology services across Scotland ensuring care is delivered in as responsive and person-centred a manner as possible, and, critically, as close to home as possible
A revamp of the way dermatology care is delivered is imperative if increasing demand on services and patient expectation is to be met. One way of doing so would be the advancement of the role of the nurse in line with current health policy. There are over 300 nurses employed to provide dermatology services in secondary care across Scotland. This development of nursing roles will require assurances that nurses are competent and capable of carrying out such a role and that they are sustainable for the future.
The Scottish Government Modern Outpatient programme and CAWT (Cooperation and Working Together) which is based in Northern Ireland and bordering counties in Republic of Ireland have similar priorities for dermatology services and have united in the goal of developing a standardised national training programme for dermatology nurses, primarily in secondary care.
Currently dermatology nurse education is organised locally, study days are limited and academic education does not go beyond degree level. A programme of education on four levels is proposed. The first level would be mandatory for Health Care Support Workers, and the second would be mandatory for all trained nurses. The third level would be optional for those nurses wishing to progress to specialist nurse roles and the fourth for those in advanced roles. This education would include a mix of e-learning, competency based, study days, virtual education sessions, speciality specific courses and academic education.
Over the first year in post the nurses have carried out a scoping exercise involving every health board in Scotland. This has allowed them to map the existing service provision and identify current training opportunities, specialist academic courses and local internal training programmes. This scoping work has helped to identify current education resources, future service developments, gaps in current training provision, future training need and barriers and facilitators to education.
In January 2019, the Digital Health and Care Institute (DHI) began work with the NHS Scotland Dermatology Specialty on improving pathways for patients and staff. Under the umbrella project The Scottish Access Collaborative, the specialty group and the DHI team will work together to unpick current dermatology services and make recommendations for service innovations based on the findings and insights gathered over the coming months.
The aim of the Scottish Access Collaborative is to sustainably improve waiting times for patients waiting for non-emergency procedures. The program is guided by its six founding principles which foreground patient experience, clinical benefit, and transparent services. The six principles can be seen here.
The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. It is part funded by Scottish Government. DHI support innovation between academia, the public and third sectors and businesses in the area of health and care.
The DHI was commissioned by Scottish Government to design workshops for the Scottish Access Collaborative clinical specialty-led programme. These workshops involve a range of clinical staff from primary and secondary care, health managers, patients and third sector organizations undertaking a cycle of design-led workshops.
In this first workshop, the aim was to map out the common symptoms and conditions dermatology deal with currently as part of their non-acute out-patient service, and prioritize what issues the group want to focus on in the next two workshops.
To begin with the conversation centered on the general state of dermatology services. There are currently long waiting times across all health boards due to overall under-capacity of the service to meet current demand. There was discussion around the impact of staffing shortages in some areas and the impact on capacity resulting from this. Long waiting times impact GPs as some patients return for multiple appointments while they are waiting to be seen in secondary. There is variation in waiting times between boards yet the reasons are not well understood and there is an opportunity to fully explore this.
The group recognised that dermatological complaints are a significant part of the primary care workload and that the majority of patients are managed in primary care. Concern was raised that any loss of GP capability and capacity can and will have a major impact on secondary care referrals/demand with a resultant impact on dermatology waiting times. Diverting some roles from GPs to other professionals may be the impact of the new GP contract; the increasing role of ANPs was raised as one area with an adverse impact on dermatology demand. One area for further exploration would be enhanced training for ANPs to mitigate the effect of capability and capacity loss.
Although there was a recent update of referral guidance formulated by both primary and secondary care, it is not being universally adopted with some areas using local guidance. It was also suggested that visibility and accessibility of these guidelines were limiting use. There is a lack of sharing of best IT practice across boards.
Vetting of referrals in secondary care should be a crucial part of dermatology work, there are examples of this being done well across Scotland but it varies. It requires investment of clinical time but it can give you ‘big wins’ in terms of getting patients the correct care quickly. One major issue is the varied IT systems in place across the boards.
Common Symptoms: Why focus in this?
Through a discussion around common symptoms and opportunities for improvements, the group focused in on a number of areas for focus for the next two workshops. To help prioritize the aims for the next two workshops, it was useful to reflect on each common symptom and ask ‘why’ this would be a good area to focus on.
- Skin lesions (pigmented and non-pigmented): this is a significantly large volume of referrals into dermatology. Pigmented lesions cover brown marks that patients and GPs worry might be cancer. There are several potential diagnoses and the majority of pigmented lesions referred are benign, but cause a high level of anxiety for patients. There are some simple educational things that could be done for GPs to increase accuracy of referral which will significantly help with triage. To date, education has focussed on recognizing skin cancer rather than recognizing benign legions and it was suggested that focusing on malignant lesions may not be the best way of managing demand. A change in demographic (older population) is leading to an increase in lesion referrals. There is geographical variation in referrals, i.e. some boards use photos, some do not, some referrals come from AHPs rather than GPs, but ANPs do not have the right training to make a diagnosis and so they tend to refer more (risk management). Enhancing capability for minor surgery in primary care was suggested as a way of reducing referrals to dermatology appointments. However, current guidelines state potential melanoma skin cancers should be managed in dermatology. Building capacity to do this in primary care is also expensive and needs to comply with strict standards which can be a barrier to services. There are established referral guidelines for GPs but they are not universally applied and many GPs do not know they exist. There is an opportunity to invest in high quality information resources, especially for patients to help support self-help.
- Rash: inflammatory skin diseases are a large percentage of dermatology work the other large part being lesions. It can be a resource intensive chronic condition. Triage of patients relies on the GPs description and consultants decide level of urgency based on this resulting in variation of referrals. As with lesions, who and how referrals for skin disease are done varies nationally, some ANPs can some can’t, some are done then vetted by a GP some are not vetted by a GP. GPs deal with a lot of skin conditions in primary care, any decrease in their capacity will have a significant impact on secondary care referrals
- Leg ulcers: this is a fairly common symptom for dermatology and an increase in ageing population and lifestyle conditions like obesity will only drive the number of cases up. Traditionally, most leg ulcers had been seen in primary care but currently the capacity, in terms of resource and infrastructure, is not there. There is regional variation in terms of the approach to dealing with this symptom. It is a labour-intensive investigation and management process. There is some crossover with dermatology and an opportunity to look at this symptom in the context of the two services. Inpatients who develop leg ulcers are sent to dermatology for treatment (compression bandaging), treating these patients takes away capacity from outpatients. For some this is a sizable volume of work and resource. Secondary services have developed ‘organically’ based on special interests in specific clinics. When departments change, i.e. staff change, the service design cannot deal with the demand. GP practice has an increased responsibility for chronic care management for conditions like diabetes, so the management of leg ulcers is less of a priority. Socio-economic factors are impacting on the amount of leg ulcers with knock on effect on primary and secondary care.
- Monitoring of systemic medications: while not a symptom, the monitoring of drug treatments is an area for focus for dermatology. There is currently huge variation in how this is managed, many patients are monitored in secondary care. For stable patients, monitoring does not necessarily require a secondary care consultant led clinic. However, a point of discussion was the clinical responsibility for results and ease of primary/secondary care communication. Getting agreement and acceptance on protocols is an issue. Improving the pathway for monitoring with a focus on community capacity can reduce the number of miles’ patients must travel for follow ups, and free up capacity in secondary care.
- Acne: most patients with acne need to start treatment from the moment they visit the GP. However, not all explore the available options before attending secondary care. The provision of isotretinoin for acne (a retinoid medication which is teratogenic and requires monitoring during the treatment course) is another significant part of the secondary care workload. Discussion explored the possibility of other protocols for monitoring involving primary care. There is an opportunity to develop alternative ways of dealing with acne that require fewer visits to secondary care
The next steps for dermatology will be to dig deeper into the issues and opportunities for the identified prioritised areas and highlight any recommendations for service improvements in line with the Access Collaborative principles. This will take place over two further design workshops facilitated by the DHI team. While the Access Collaborative aims to develop new ways of working for NHS services, there is also recognition that there are national work programs already underway as well as existing innovations in individual boards and hospitals. Over the coming months the DHI team will also work with the dermatology group to promote relevant national initiatives and share examples of best practice through this blog.
If you would like to know more about this work or would like to attend the next workshops, please contact the DHI project team via email at firstname.lastname@example.org
Guest blog by Dr. Rita Rigg, General Practitioner
The estimated prevalence of leg ulcers in the population is 0.1 to 0.3% in UK with a risk of developing a leg ulcer in ones lifetime estimated to be 1%.
60-80 % of leg ulcers have a venous component. Venous leg ulcers are the most severe manifestation of venous disease caused by venous hypertension. Mixed arterial - venous causes affect up to 26% of patients. 9% occur in cases of rheumatoid arthritis. 5% have diabetes.
The cost of treating an ulcer is over £1600 / year. The total annual cost in Lothian for dressings is £3.72 million (ISD).
The mainstay of treatment is compression bandaging where ABPI is more than 0.6.
Management advised is to offer early referral to vascular specialists for ulcers that have not healed within two weeks of treatment or that recur. (ÉVRA trial Semin vascular surg 2015:28:54-60)
Duplex USS can confirm diagnosis.
Early endovenous ablation of superficial venous reflux promotes healing of venous leg ulcers. Surgery can be performed for arterial revascularisation as indicated.
Best medical therapy for arterial cause should be given. Refer early to vascular surgeons. If not either venous or arterial cause found refer dermatology (optimal skin care, patch testing, malignancy), plastic surgery (grafting), rheumatologist (Vasculitis), diabetologist (association), haematogist (anaemia, polycythemia)
Amongst the risk factors are high BMI and sedentary lifestyle. Providing dietary and phsyiotherapy services in the community will reduce risk factors.
Service requirements to provide optimum, cost-effective, evidence based timely care:-
- Facilities and resources to provide timely vascular specialist investigation and intervention
- Resources in primary care to provide weight management programmes and physiotherapy services
In February 2019, the Scottish Access Collaborative Dermatology specialty reconvened for their second design led workshop. The ultimate aim of the collaborative is to collectively enhance clinical pathways for staff and patients so patients who need primary and secondary care are identified, diagnosed, and treated appropriately and efficiently. This will involve mapping current service designs, identifying current issues, responding with ideas for new innovations, and also identifying and replicating best practice where possible. In the first Dermatology workshop, some common symptoms were proposed and some common issues identified resulting in a number of specific symptom profiles. This second workshop reviewed the proposed symptoms, enhancing the existing symptom profiles by adding more issues, developing some focussed challenges in the form of ‘how might we’ statements, and proposing some initial ideas for improvements. The reason for developing how might we statements is to combine and prioritise some of the main issues for Dermatology into individual manageable tasks that form the basis of new ideas and innovations that the group will propose and detail in the next phase.
What follows are short summaries of the enhanced key symptom profiles for Dermatology as well as a summary of a general discussion, the how might we statements that developed as part of the group discussion and some initial ideas of how to improve current services.
Symptom 1: Rash
Huge range of possible diagnosis with some diagnostic uncertainty. There is some variability in practice when referred. The range of expertise with rash in primary care varies. There can be periods of waiting where there is no contact with the patient.
Issues: The issues around rash can occur in primary care, for example knowing when to refer a patient. In secondary care, there are a shortage of consultants. Issues can arise following referrals, for example during waiting times between primary and secondary care. Throughout the pathway there is a patient expectation quite often his is to do with the language used, for example a ‘referral’ raises the expectation for some that they will be seeing a specialist.
Flagged issues include an inconsistency of referrals leading to varying severity of condition being referred. The difficulty in triage if no photo is included or the description is poor. It was identified that some patients could have had treatment in primary care. During waiting times a patient can become anxious, rashes can improve or worsen with no advice or contact during this time.
For who: This is an issue for GPs, patients, nurses, administrative staff, medical team, managers. There is an issue for technology specialists looking at referral systems fit for purpose. For primary care, if treatment pathways need developed then time and resources will be required.
How might we…:
- Make referral guidelines support which is available to GPs
- Support the diagnosis and treatment of psoriasis eczema, lesions, and acne in primary care?
- Decide on the balance between what is done in primary care and secondary care?
- Manage patient expectations?
- Find and communicate another term for triage and vetting that is about finding the best pathway?
- Get a fuller history with the referral?
Ideas: For the how might we….get a fuller history with the referral?
On referral, potentially via a phone call on triage / pre-assessment, collect information on patient history, medication past and present, surgical history, condition specific information and compliance with medication.
The patient can collate information. The GP can provide as clear referral information as possible, a fuller history with photos. ANPs could, have the ability to phone / contact patient to get more information.
Impact: The impact of this change could be time saved in consultation, improves the quality of consultation, improves the pathway for patients, and reduce the number of consultations. This benefits consultants and patients. The effect would be a reduction in waiting times and the number of patients in secondary care receiving treatment they could have received in primary care.
Rather than triage of referrals would be re-assessment would be a more efficient streaming pathway.
An ‘ask for a specialist opinion’ option instead of the usual triage / vetting.
Symptom 2: venous ulcers
Summary: There can be a delay in diagnosis of ulcers. Inappropriate treatments can be administered for too long. There is perhaps a lack of early assessment by the appropriately trained staff.
Issues: There is a direct cost implication with treating leg ulcers that exacerbates over time if the condition is not dealt with. There are currently not enough staff who are appropriately trained in dealing with this symptom. More could be done in terms of prevention. Ulcers can be linked to public health issues like smoking and public health messaging around the link between smoking and this condition could be improved. Dealing with ulcers effectively can be effective in reducing morbidity, helping patients return to work earlier, and improving quality of life.
For who: The issues impact mainly on patients in terms of their discomfort, the impact on their general health and the time it takes to treat the ulcer. For secondary care, more time would be freed up if better care could be delivered earlier. For GPs, there would also be a saving in their time if ulcers were treated earlier.
How might we…:
- Prevent more leg ulcers?
- Improve early diagnosis and treatment of ulcers?
- Improve public health messaging about ulcers?
- Improve uptake of education to nurses to recognise and assess ulcers?
Ideas: For the how might we…improve early diagnosis and treatment of leg ulcers?
A community service with secondary support, potentially a leg ulcer liaison nurse. The community service would provide early assessment, treatment, and monitor patients for an initial 12-week period. If there were no sign of improvement after the initial period, then the community team could refer non-healing ulcers. There is a question as to whether the referral would be to dermatology or a vascular referral, both specialities deal with ulcers.
The challenges to this idea would the time for training, the investment costs for equipment for example the purchase of Dopplers, and the impact of other community based activity.
Impact: The impact of such a change could be fewer venous leg ulcers with a reduction in costs. An improvement in job satisfaction in ulcer care nurses. Improved outcomes for patients, fewer dermatology referrals and in patient stays.
Symptom 3: lesions & changing moles
Summary: There is a difficulty in diagnosing. The GP training currently is poor and there is a difficulty getting GPs to access it. There are long waiting times in some areas and there is variation in access GPs with a special interest. Some clinicians are using photo triage, but this can be time consuming for GPs. There is a lack of good patient information Minor surgery is very expensive to set up and maintain.
Issues: The current situation leads to unnecessary referrals. Many lesions can be managed in primary care but are not. There is a lack of good quality technology options for sending pictures and a lack of minor surgery facilities in the community. Few GPs are trained in dermatology and patients are poorly informed.
For who: The issues mainly affect patients, consultants and nurses.
How might we:
- Give better patient information?
- Improve access to minor surgery in the community?
- Improve local access to dermatology specialist advice for patients to reduce travel for patients?
- Enhance better trust and working relationships between primary and secondary care across all boards?
- Improve GP access to training?
- Improve diagnostic accuracy / appropriate referrals from primary?
- Improve technology in primary care?
- Improve support for GPs with special interest?
Ideas: For how might we…improve GP training / support GPs with special interest.
Special interest clinics perhaps within clusters, with more training of GPs with special interests. Enhancing / more minor surgery in the community. Special interest clinics can upskill a primary workforce and take on a transfer of resources into primary from secondary care.
Impact: This new idea would potentially increase patient satisfaction while reducing the cost to secondary care. There will in this scenario be an increase in workload for GPs and additional minor surgery nurse support required. The change should reduce referral rates from primary to secondary and see an increase in patient satisfaction.
Barriers: Funding will be key for training in terms of time away from practice, also costs for equipment. There would be a cost to GPs along with the additional time and workload. Secondary care would also lose some of its funding. Not a barrier as such, but the scope for technology disruption in dermatology referral practice could affect the need for / content of GP training.
Taster weeks for GPs
The next step in a third workshop will be to return to the how might we statements, develop more detailed ideas to address the challenges, and develop some associated action plans. All the agreed actions will be documented as recommendation in the Dermatology report to be published via this site.
The Scottish Government, Scottish Enterprise and NHS Scotland are running a Small Business Research Initiative (SBRI) competition designed to identify innovative new ways to improve dermatology services.
The competition is divided into two phases. In phase one, which lasted 6 month, 5 companies developed proof of concept ideas. At the end of this, 2 companies were selected for phase 2, which will last for 18 month. During phase 2, the companies will develop and demonstrate their prototypes in a variety of health boards in Scotland.
The two shortlisted companies are Storm ID and GP Commissioning Solutions (GPC). Storm is developing an asynchronous virtual clinic model that allows patients to log into a website and upload photos and answer questionnaires that can be then reviewed by the consultant. This includes the ability to request more information from the patient. The consultant can then decide on the appropriate outcome, in much the same way as a traditional appointment.
GPC are developing a set of software applications that uses machine learning to help GPs to carry out more accurate diagnosis and treatment of skin conditions, assisted differential diagnosis and context sensitive education materials. They are also developing a patient planner application to assist patients with reminders, help and advice and adherence to their treatment plan. This will include integration with Amazon’s “Alexa”.
The links below are to a recent Health and Social Care Innovation Network meeting where both companies presented their work to date. Please see “HSCN19 - Murrayfield - 230119 – Dermatology” for links to the slides and the video of the presentation.