It is estimated that 1 in 2 people in the UK each year, will suffer from some type of skin disease or condition. Skin cancer has the highest number of cases of any cancer in the UK. 20 per cent of children and 10 per cent of adults will suffer from eczema. There is a clear demand for services to meet this need, but for a health service that is currently facing unprecedented challenges both economic and structural, it is vitally important to find out how that need can best be met; in primary, secondary and tertiary settings.

At the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th) a number of presentations are being made which seek to address these questions.
At primary level General practitioners (GPs) are under considerable pressure to ensure that all referrals to specialist dermatology services are necessary. Commissioners of services are keen to manage demand for these services in order to get best value for money in a cash-limited National Health Service, a study in Hertfordshire sought to understand dermatology referrals and, using this information, identify ways to reduce referrals from an individual GP practice. The study, which took place over a six month period revealed that where referrals were made for long term skin conditions they tended to be highly appropriate, but those for skin lesions were less so, also that the average for a practice could be strongly skewed by a single high volume referrer. The study revealed that skin cancer referrals made up about two thirds of the total number, but that the accuracy and appropriateness of the referrals was low.1
Julia Schofield, one of the authors of the study says “This study demonstrates the challenges for GPs in trying to reduce dermatology referrals. Most GPs see 42 patients per day, and with that level of activity, reducing referral rates from 2–3 per month is likely to be difficult, particularly across the breadth of dermatology conditions. However, we did see that in some cases a single GP might be referring far more than colleagues and that targeting education to high referrers within a practice is important, also some referrals might be reduced by improving GP skin lesion diagnostic skills and perhaps using digital images with referrals.”

A number of presentations were made on the need for local acute dermatology services, including on-call services.

A study by a team in Manchester looked at the usage of ‘urgency clinics’ (a three times a week clinic into which patients can be booked following urgent referral) and compared them with usage of general dermatology clinics.2 As anticipated the largest groups of patients in both clinics came from the two local PCTs, however the urgency clinics also saw a higher than proportionate number from 6 more distant PCTs which the team suspect to reflect the lack of acute dermatology clinic appointments in those areas, putting pressure onto central services and extending journey times for patients.

Sarah Felton, one of the authors of the study says ‘It is clear that when commissioning dermatology services within a community it is important to assess the need for acute dermatology services in order to be able to deal appropriately with urgent referrals as close to home as possible”.

Another study, this time in Leeds, focussed specifically on the on-call service.3 The hospital provides a 24 hour, seven days per week non-resident on-call service and not only provides a service to patients but also allows dermatology trainees the opportunity of gaining sufficient experience in emergency dermatological presentations to become competent in managing acute serious skin disease. Looking at the number and type of cases referred to the service over a two month period the data showed a significant demand for an out-of-hours service.

Sangeetha Shanmugam, one of the authors of the study says “Over 15 per cent of the cases we referred out of hours, and at least half required assessment on the day of referral, our data shows that there is a real need for this service providing essential specialist care for patients with a variety of serious skin diseases.”

Many people suffering with a chronic skin condition may not need urgent care, but do require specialist referral. A team in Dewsbury looked at whether specialist multi-professional clinics were necessary for patients with complex skin problems.4 The aim of the clinic was to provide a multi-professional review of patients with complex and rare skin conditions, especially where the diagnosis was in doubt or there were problems with management. Facing criticism that this one hour a month clinic was a ‘luxury’ the team sought to analyse it’s exact benefits. The most important benefit was shown to be that 95% of the patients seen could be offered a new diagnosis or treatment and that improved patient care would also have beneficial cost-implications.

Manu Shah, the author of the study says “A regular specialist multi-professional clinical meeting is a good use of clinician time and produces great benefits to patient care. In the economic climate, dermatologists must strive to maintain quality care for their patients, despite pressures from medical and non-medical managers.”
-Ends-

Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. The challenge of demand management and dermatology referrals: the general practitioner’s view
M.A. Syed, J.K. Schofield* and A. Kanji, Chequers Surgery, Prestwood, Great Missenden and *University of Hertfordshire, Hatfield, U.K.
The aim of this study was to look at dermatology referrals and, using this information, identify ways to reduce referrals from an individual GP practice. All referrals from a practice population of 12,800 with eight GPs (six whole-time equivalents) were counted and reviewed during a 6-month period. The referrals were categorized into skin lesions and other skin conditions. Information was obtained about the GP and hospital diagnosis and based on this, an attempt was made to assess whether the referral was appropriate. For four of the six months, detailed information was obtained about the number of referrals from the individual GPs. Over the six-month period there were 117 referrals to the dermatology service, an average of about 19 per month. This represented a relatively high referral rate compared with other local practices (top third). The average referral rate among the eight doctors over the six-month period was 2.38 per month. More detailed analysis of the individual GPs’ referral activity, following adjustment to allow for their clinical commitment, showed the average monthly rate of referrals for seven of the eight GPs to be between 1.25 and 2.75. The eighth GP had a referral rate of 9.4 per month. With respect to the type of referrals, 74 (63 per cent) were skin lesions and of these 45 were for suspected skin cancer. Pick-up rates were as follows: 4/10 suspected squamous cell carcinomas, 7/26 suspected basal cell carcinomas and 0/9 malignant melanomas. Appropriateness of referrals was highest in the long-term skin conditions (approaching 100 per cent). This study demonstrates the challenges for GPs in trying to reduce dermatology referrals. Most GPs see 42 patients per day, and in the context of this level of activity, reducing referral rates from 2-3 per month is likely to be difficult, particularly across the breadth of dermatology conditions. Some referrals might be reduced by improving GP skin lesion diagnostic skills and offering a digital image with referral service. Targeting education to high referrers within a practice is also important.

2. Regional approach to dealing with demand for acute dermatology services
S. Felton, J. Newsham and J. Williams, Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester, U.K.
Significant demand is placed on acute dermatology services across the country. Within the region of the study, on-call Registrars cover a large catchment area. In addition to urgent out-of-hours review where required, on-call Registrars have access to Registrar-led ‘Urgency clinics’ three times a week, into which they may book patients following urgent referral. The objective of the study was to examine the pressure on the Urgency clinics at the local hospital, in terms of patient population distribution. The postcode of each new patient attending an Urgency clinic appointment over the 3-month period, July–October 2011 (n = 132) was recorded and then mapped according to their local Primary Care Trust (PCT). Data were compared with the PCTs of newly referred patients attending general dermatology clinics at the same hospital over the same time period (n = 2412). Results demonstrated significantly different population distributions between patients attending Urgency clinics and those in the general clinics (P < 0.0001): in the general clinics, patients from the two local PCT areas formed the largest patient subgroups (41% and 24%, respectively). While the commonest sources of referral to the Urgency clinics were the same two PCTs, the proportions of patients from these areas were lower than would be predicted from the general clinic population data, at 22% and 23%, respectively. In contrast, a greater than anticipated number of patients from six more distant PCTs was seen in the Urgency clinics. The relative lack of patients in Urgency clinics from those PCTs in the immediate vicinity of the study hospital may be a result of patients attending Accident & Emergency and Walk-in centres where they are seen on the same day as an ‘emergency’, rather than waiting for an urgent appointment. However, it is more likely that capacity meets demand locally. The data demonstrate that patients from distant PCTs are over-represented in the Urgency clinics, so placing extra pressure on the study hospital’s services. The team suspect that this is a reflection of the relative lack of acute dermatology clinic appointments in patients’ local areas, so forcing them to travel further afield for urgent problems. This pressure is likely to increase if PCTs commission services from alternative providers without also commissioning ‘acute’ care services. Such pressures could destabilize services. Given the increasing pressure on dermatology services at a national level, the data also emphasizes the overall need for commissioning of acute dermatology services, particularly where local provision for urgent review is limited.

3. Demand for dermatology on-call service: an audit in a large teaching hospital
S. Shanmugam and V. Goulden, Leeds General Infirmary, Leeds, U.K.
The 2010 Dermatology curriculum requires trainees to have sufficient experience of emergency dermatological presentations to become competent in managing acute serious skin disease, both assessing severity accurately by telephone and making decisions to come in from home to see patients urgently. This requires a regular out-of-hours on-call commitment for trainees but the future of on-call in dermatology is uncertain. For the last few years and particularly in the present financial climate, the cost of on-call is under close scrutiny in many trusts. The department at Leeds General Infirmary currently provides 24 h, 7 days per week nonresident on-call service. The team carried out an audit to assess the demand and clinical cases referred to the service. Data were collected prospectively over a period of 2 months between 1 November and 31 December 2011. The total number of referrals for the period was 228. The age range of patients varied from 8 weeks to 90 years. Of 228 patients, 188 (82.5%) were referred within normal working hours, 18 (7.9%) out-of-hours on weekdays and 22 (9.6%) at weekends. Nearly half of the referrals were from hospital wards (109), 67 from general practitioners, 39 from the Accident & Emergency department and 13 from other specialty clinics. One hundred and fourteen (50%) patients required assessment on the day of the referral. Among the patients seen by the on-call registrars, 46 (20.2%) were assessed between 17:00 and 09:00 h. Twenty-one patients needed biopsy and 45 patients required subsequent follow-up. A wide variety of conditions was seen including Stevens–Johnson syndrome, pustular psoriasis, eczema herpeticum, acute graft-versus-host disease, immunobullous disease, drug rashes, viral rashes, cellulitis as well as Sweet syndrome, pyoderma gangrenosum, lichen planus, psoriasis, eczema, pityriasis lichenoides, leg ulcers and tinea infections. In summary, the data show a significant demand for an out-of-hours dermatology service with 17.5 per cent of patients referred outside of normal working hours. The study also demonstrated that the service provides essential specialist care for patients with a wide variety of serious skin disease as well as invaluable experience for trainees.

4. Are specialist clinics for patients with complex skin problems necessary?
M. Shah, Dewsbury & District Hospital, Dewsbury, U.K.
Dewsbury & District Hospital started a specialist clinic in 2010, made up of four consultant dermatologists, one with a special interest in paediatrics and genetics. The aim was to provide a multiprofessional review of patients with complex and rare skin conditions especially where the diagnosis was in doubt or there were problems in management. The clinic time is 1 h per month and was described by a (nondermatological) clinical manager as a ‘luxury’. The clinic was audited to assess any benefits or drawbacks. Twenty patients were seen over five clinics (15 min each). Twenty per cent were children (mean age 4.25 years). Six patients had been under follow-up for 10 years or more (mean duration of follow-up for the entire group 54.2 months). In 12 patients (60%) the clinical diagnosis was certain prior to the clinic but there were problems in management. In the other eight patients the diagnosis was uncertain but a new diagnosis was offered from the clinic in six. New treatment suggestions were offered from the clinic in 16 patients (80%) and further investigations were suggested in 11 (55%). Reviewing patients with complex and difficult problems is essential. Benefits of this clinic include receiving a higher tariff per patient and valuable learning experience for clinicians which can be used as part of medical education. However, the most important aspect was being able to offer a new diagnosis or treatment in 19 of 20 patients (95%). This improved patient care should also have cost-improvement implications. A regular specialist multiprofessional clinical meeting is a good use of clinician time and produces great benefits to patient care. In the current economic climate, dermatologists must strive to maintain quality care for their patients, despite pressures from medical and nonmedical managers.

Salford Royal NHS Foundation Trust is an integrated provider of hospital, community and primary care services, including the University Teaching Hospital. The Trust employs 6,000 staff and provides local services to the City of Salford and specialist services to Greater Manchester and beyond. The Trust also offers specialist care to people from all over the UK who need expert help with brain, neuroscience, kidney, bone, intestine or skin conditions. The Trust has an excellent track record; having the highest consistent rating for service quality coupled with one of the highest sets of patient and staff satisfaction scores. www.srft.nhs.uk / @salfordroyalnhs