Good Practice Guide
Action On Dermatology
Modernisation Agency
Produced by Action On Dermatology
January 2003
For additional copies
call 08701 555 455
Quoting Ref: MA/SIT/AO/002
© Crown Copyright 2003
Action On Dermatology Good Practice Guide
i
Contents
Action On Dermatology
Good Practice Guide
Foreword by the Rt Hon John Hutton MP
iii
Introduction
iv
Executive summary
v
How to use this guide
vi
Chapter 1 Dermatology: the Cinderella service?
1
What’s the problem?
2
Why are we waiting?
2
Who does what?
3
Where next?
4
Chapter 2 Meeting the challenge: services
5
Specialist clinics
7
General practice
8
Facilities
8
Effective management
10
Chapter 3 Meeting the challenge: service providers
11
Community pharmacists
12
Family doctor services
12
GPs with a special interest
12
Hospital services
16
Nurse-led services
18
Linking the parts together
22
Guidelines on treatment: guidelines on referral
25
Chapter 4 Making changes
27
Where are you now?
28
Where do you want to be?
30
Measuring progress
34
Chapter 5 Recommendations
35
Recommendations for local action
36
Recommendations for national action
40
Action On Dermatology Good Practice Guide
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Contents
Appendix 1 Pilot site summaries
Devon
42
Eastern Wakefield
43
South Manchester
45
West Herts
47
St Mary’s
49
Basildon & Thurrock
51
Birmingham
53
North Staffs
55
Southampton
57
Medway
59
Addenbrooke’s
60
South Derbyshire
62
Oldham
63
East Kent
65
West Middlesex
66
Appendix 2 Contact details
ii
41
67
Steering board
68
Charities and patient groups
70
Professional bodies
71
Action On Dermatology Good Practice Guide
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Foreword
Foreword
by the Right Honourable John Hutton MP, Minister of State for Health
The NHS is currently undergoing its largest period of sustained investment and modernisation
since its creation in 1948. I firmly believe that this period of change will result in the delivery
of a modern, patient focused health service fit for the 21st century. My vision is for a health
service where patients are seen promptly; in the right place; by the right clinician with the
right skills.
As part of this, teamwork and collaboration are vital to the regeneration of the NHS. Real
improvement will only come about if all parties involved in delivering care, work together to
provide a better service to the patient. The Action On programmes typify this spirit of
partnership and I am delighted to be asked to endorse this Good Practice Guide.
I am particularly pleased to see that professional and patient bodies within the dermatology
community have also endorsed the Action On Dermatology Good Practice Guide. There are
many examples in the guide of doctors, GPs, nurses and patients being involved in projects
leading to improved performance.
The guide contains examples of good practice from around the country. It also sets out how
Trusts and individuals can help in achieving the Government’s plans to provide faster and
more convenient access to care. It is a valuable document and I commend it to you.
the Rt Hon John Hutton MP
Minister of State for Health
Action On Dermatology Good Practice Guide
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iv
Introduction
Introduction
The Action On Dermatology programme was designed to improve access and quality of care for
patients with skin disease. It was also intended to raise the profile of a service that healthcare
providers and commissioners often overlook.
The programme has, without doubt, raised the profile of dermatology. The establishment of the
Action On Dermatology steering board has improved communication between the Department
of Health and the dermatology healthcare community. In addition, the steering board has heard
about good practice and patient-centred models of care from around the country. The work of
the 15 pilot sites, upon which much of this document is based, has yielded some encouraging
results that have built on pre-existing areas of good practice, extended them and allowed their
dissemination. We believe that the Action On Dermatology Good Practice Guide, in sharing the
lessons learned from this work - the successes and the failures - represents a significant
contribution towards achieving the programme’s aims.
This document is intended to serve not as a gold standard but as a resource for those working
to develop local solutions to local problems. We hope that the information it contains can be
widely shared, explored and evaluated both within and beyond the dermatology community.
Alan Marsden
President - British Association of Dermatologists
Dawn Preston
Chair - British Dermatological Nursing Group 2000/02
Stephen Kownacki
Chairman - Primary Care Dermatology Society
Peter Lapsley
Chief Executive - The Skin Care Campaign
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Action On Dermatology Good Practice Guide
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Executive Summary
Executive Summary
Action On Dermatology was set up in September 2000, together with Action On ENT and Action
On Orthopaedics. Since then, the 15 Action On Dermatology pilot sites have been working to
improve access and enhance quality by looking at innovative ways of working.
Team working is a significant feature of Action On Dermatology, with clinicians and management
working together to improve the service given to patients. This good practice guide represents
the distillation of the accumulated experience, knowledge and expertise gained as a result.
In the first chapter of the guide, dermatology is described as the Cinderella service, due to the
relatively low priority it is given by many acute trusts and primary care trusts (PCTs). This is set
against the harrowing impact that skin disease can have on sufferers’ lives, whilst also looking at
waiting times and the way the service is structured.
An optimised dermatology service is described, drawing on the experience of the Action On
Dermatology steering board as well as that of the pilot sites.
This model suggests the
development of a structure of specialist clinics as well as a comprehensive nurse-led service.
Interaction with general practices is also covered, as is the provision of suitable and appropriate
outpatient facilities.
Case studies from pilot sites are highlighted throughout the report, ranging from the
accreditation of GPs with a special interest to a joint project between a trust and the Skin Care
Campaign.
They vary in style and content as they represent the voices of the pilot sites
themselves. The roles of all healthcare professionals, from pharmacists to consultants, are
discussed and where appropriate illustrated by a pilot site case study.
The final chapters look at the processes involved in making changes, again drawing heavily on
the pilot sites’ experience.
The need for benchmarking in order to measure progress is
discussed, along with the tools necessary to do so.
Finally the appendices give summaries of the pilot site projects as well as details of the steering
board membership and other useful contacts.
Action On Dermatology Good Practice Guide
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How to use this guide
How to use this guide
The guide consists of two parts:
1. This booklet, summarising the current challenges faced by dermatology services in England,
the good practice which is being used to address them, and the work of the
Action On Dermatology pilot sites in testing and developing it. It is intended as a resource for
those who wish to review the way in which they are providing care for their patients, and as a
guide for those responsible for planning and commissioning services at all levels.
2. A CD-ROM resource pack, containing useful information and documentation developed by
the pilot sites and others during the programme.
Of particular interest will be the
benchmarking information, containing a wealth of detail, in an easy to use format, covering
success measures in dermatology and how individual trusts are performing.
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Action On Dermatology Good Practice Guide
Chapter One
1
Chapter One
Dermatology: the Cinderella service?
1
1
Chapter One - Dermatology: the Cinderella service?
Dermatology: the Cinderella service?
What’s the problem?
Skin disease affects between one quarter and one third of the population at any one time. It
accounts for up to a fifth of all GP consultations, and in 2001/02 generated over 600,000 GP
referrals to secondary care. Yet dermatology has traditionally been given a relatively low priority
within the health service.
In part, no doubt, this is a reaction to the fact that although skin disease can kill, mortality rates
are generally low. Services are largely outpatient based and do not occupy a high profile in many
acute trusts or amongst service commissioners. However, the effect that skin disease can have
on people’s lives can be harrowing, as graphically illustrated by patients quoted in this guide.
The relative invisibility of dermatology begins at
medical school, where despite the amount of
skin disease seen in general practice, GPs
Acne has
ruined my life for the past seven
receive an average of no more than six days
years and I don’t really have what I
training in dermatology during the whole of
call a life to speak of, more just
their time as undergraduate and postgraduate
medical students.
an existence.
It is possible to become a
principal in general practice without having undertaken any
training in dermatology at all. At the other end of the spectrum, a recent survey of dermatology
consultants revealed that:
1.
Only two in five departments had an identified budget for the specialty
2.
Less than half had regular meetings with service commissioners
3.
Three out of four did not have an agreed long-term plan for the provision of
dermatology service
Little wonder then that dermatology has been described by some as healthcare’s
“Cinderella service”.
Why are we waiting?
Skin disease accounts for some 60,000 hospital inpatient episodes a year, but it is mostly
managed within the community on an outpatient basis. In 2001/02 there were over 600,000
dermatology referrals from GPs to secondary care services and in excess of two million
outpatient appointments. Despite their relatively low profile then, dermatology departments
are amongst the busiest in most hospitals. So it is perhaps not surprising that in March 2002
dermatology referrals accounted for nearly 8% of patients waiting over 13 weeks for a first
outpatient appointment.
Demand for dermatology services has risen steadily over the last decade and continues to rise.
This, combined with varying levels of service provision across the country has led to long waiting
2
Action On Dermatology Good Practice Guide
Chapter One - Dermatology: the Cinderella service?
1
times for patients needing a specialist opinion. The proportion of patients waiting over 13
weeks for their first consultant outpatient appointment rose
from 23% in 1995/96 to nearly 30 % in 2000/01.
Efforts
to
reduce
waiting
times
The pain and
sadness has certainly changed
my life, the thought of coping with this
until the day I die is not one I relish.
Every day things like turning on a tap or
taking a top off a bottle of milk are a
painful experience.
have
traditionally involved short term measures,
such as introducing temporary additional
clinics, rather than a longer term review
of patients’ needs and the structure of
dermatology services.
The development of new technologies, in
particular
more
sophisticated
light
treatment
(phototherapy) and the use of laser surgery, has led to a greater need for suitable treatment
facilities. Light treatment and day treatment require frequent visits over an extended period and
need to be easily accessible to patients at times that are convenient to them. This can prevent
the need for hospital admission. Equally, phototherapy equipment and facilities for bathingbased treatments are bulky and require significant space. Getting the right balance between
patients’ needs and the practicalities of service provision remains one of the major challenges
facing healthcare professionals in dermatology.
Who does what?
Skin disease diagnosis can be a complex issue. This, combined with the lack of training in
dermatology in medical and nursing undergraduate courses, and in vocational schemes for GPs,
contributes to a high secondary care referral rate. Many of the patients referred will need the
expertise, facilities and treatment facilities that are only available
in secondary care. But a significant proportion will not.
They will be referred to secondary care simply
because there is nowhere else for them to go.
Consultant time remains a bottleneck in most
dermatology services. In April 2002 there were 96
vacancies amongst existing consultant posts with
I am a single parent
and my daughter needs 24 hour
care. I never get a whole night’s
sleep, if it wasn’t for the support of
my family helping me I honestly
don’t think I could cope.
a
further 25 being filled by locum appointments, leaving some
parts of the country with very limited access to any specialist service. Evidence suggests that
these posts are becoming harder to fill. This is despite dermatology being an extremely popular
specialty amongst medical graduates and dermatology specialist registrar posts attracting large
numbers of applicants. Trainees prefer consultant appointments in larger departments offering
better peer group support and better facilities for the development of specialist interests.
There has been a steady increase in the provision of care by GPs with a special interest in
dermatology (GPwSIs), but this has been hindered by lack of money and facilities, as well as a
dearth of training and ongoing specialist support. The issues surrounding GPwSIs are discussed
Action On Dermatology Good Practice Guide
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1
Chapter One - Dermatology: the Cinderella service?
in more detail in Chapter 3, together with case
If I could sell my soul
studies from the pilot sites. But the crucial
to the devil in exchange for
point to come from them is relatively
one thing it wouldn’t be wealth, or
straightforward: consultants should only do
power over people, but simply to
that which only consultants can do.
be free of psoriasis.
Where next?
The NHS Plan set out some challenging targets. Of particular relevance to dermatology are the
commitments to:
1.
Reduce the maximum wait for outpatient appointments to three months by the end of 2005
2.
Reduce the number of patients waiting more than 13 weeks and implement a maximum
waiting time of 21 weeks by March 2003
But targets are only part of the story. The NHS Plan made clear that services should be focused
on the needs of the patient. This has been at the heart of the projects implemented by the
Action On pilot sites. Maintaining that focus whilst at the
same
time
questioning
established
It is difficult to put into
brought real benefits for the
words exactly how I feel about psoriasis.
Action On pilot sites and the
I am angry, upset and frustrated. I don’t feel
patients they serve.
The
feminine, I can’t bear to look in the mirror at
chapters that follow sum up
my body and my self-confidence has
the lessons learned by those pilot
plummeted. You feel an outcast.
doctrines of service provision has
sites as well as providing details of the
methodology they used.
4
Action On Dermatology Good Practice Guide
Chapter Two
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Chapter Two
Meeting the challenge: services
5
2
Chapter Two - Meeting the challenge: services
2 Meeting the challenge - services
Dermatology services must meet the needs of large numbers of patients, a significant proportion
of whom will have long lasting conditions needing different sorts of care at different times.
Services need to match these needs by being accessible, convenient and flexible. The paragraphs
below outline the components of a comprehensive dermatology service, and the contributions
that various of the key elements can make to providing it. They represent the experience drawn
from those working in the pilot sites and from those working elsewhere within dermatology, and
the conclusions reached by the Action On Dermatology steering board.
Services need to provide –
1.
Easy access to the right level of service to meet patients’ changing needs
throughout their lives (see box 1 below)
2.
Rapid access to diagnostic services
3.
A high quality of clinical care
4.
Treatment appropriate to the patient’s condition
5.
Informed choice for all patients, and the flexibility to meet their needs
Box 1 - designing services around the patient’s changing needs
Expert patient initiative
Community Pharmacist
Patient Support Groups
PRIMARY CARE
Nurses
GP
GPwSI
John, a bank clerk aged 25
has mild psoriasis, which
he looks after himself
•
•
(BAD Patient
information gateway)
John’s is now 45 and
unfortunately his psoriasis has
become worse. He has moderate
psoriasis, which he would like
treating. He is now manager of
the local bank and cannot take
time out of his daily work to
attend the hospital for treatment
SECONDARY CARE: Local DGH offering
•
Information Internet
Consultant led services with second line treatments
and specialist nursing support.
Dermatology treatment unit offering phototherapy,
day treatment for patients,
Local to their home at times to suit their needs and
enable them to continue to work normally.18-24
treatments needed so must be close to home.
REGIONAL CENTRE
•
•
•
•
•
6
Regional/national specialists
In patient beds and supporting staff
(medical and nursing)
Access to sophisticated, complex treatments,
that may be very expensive
Possibility of involvement in trials of new treatments
Refer back to local DGH when acute
episode resolved
Unfortunately John’s psoriasis has stopped
responding to all the usual sorts of treatments at
the local DGH and is not responding to
straightforward treatment. The local consultant
has suggested that he may need to be admitted
to hospital for intensive treatment with drug
treatment that is reserved for very severe cases.
Action On Dermatology Good Practice Guide
Chapter Two - Meeting the challenge: services
2
To do this effectively they require integration of service provision across primary, community and
secondary services to maximise the use of skills within all staff groups. A description of the
model of care developed in West Hertfordshire and a letter to GPs describing new care pathways
are included in the resource pack. There needs to be provision of appropriate levels of staff,
equipment and facilities at all levels, supported by flexible and effective administrative systems.
Services need to be consultant led, with a work pattern that supports an emphasis on good
clinical practice and a structure of clinics that allows appropriate time to be devoted to each
patient’s needs. Adequate time for consultants and other healthcare professionals must also be
available for:
1.
Clinical audit, clinical governance, teaching, training and
management responsibilities
2.
The support of continuing medical education (CME) and professional development
3.
The development of specialist interests
4.
Research, development and clinical trials in some centres
Specialist clinics
A structure of specialist clinics needs to be developed, tailored to meet local population needs.
These should cover areas such as paediatrics, photodermatology, vulval conditions, psoriasis,
eczema, acne, cancer/pigmented lesions and often the interface with other medical and surgical
specialties: for example, leg ulcers and connective tissue disease.
An integral part of the service will be a comprehensive nurse specialist service, fully integrated
across the inpatient, outpatient and community settings. This should offer nurse-led treatment
clinics for patients suffering from common skin diseases such as eczema, psoriasis and leg
ulcers. The clinics should work to agreed protocols, which should include prescribing by
nurses. In addition the nurse specialist service should offer:
1.
Dermatology outpatient treatment including day treatment and phototherapy
2.
Patch testing for allergic contact dermatitis
3.
Minor surgery
4.
A link to primary care and community care nursing services, including provision of a
help line service
5.
Provision of teaching/training support for primary, community and acute nursing
staff in the care and treatment of patients with skin disease.
6.
An access and advice service for long term patients, through a help line
7.
Education for patients and carers concerning common skin diseases.
8.
Assistance to the wider health education of the population concerning skin disease
The service will need access to designated ward space for specialist inpatient care of
patients suffering primarily from skin disease.
Action On Dermatology Good Practice Guide
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2
Chapter Two - Meeting the challenge: services
General practice
A good interaction with general practice is crucial, enabling GPS who wish to do so to develop
as GPwSIs. This development should be founded on supervised clinical work within specialist
clinics (as a clinical assistant/hospital practitioner for example) and should include access to the
local CME programme as well as engagement in local specialist dermatology clinical audit
systems. The interaction with general practice should also provide:
1.
Accessible and up to date guidance on treatment of skin diseases in primary care
2.
Mutually agreed protocols regarding conditions that should or should not be
referred to specialist services (skin tags would be an example of the latter)
3.
A telephone advice service for GPs.
4.
A fast track mechanism for urgent referrals, including potential skin cancers.
5.
GP direct booking to appropriate services or clinics.
6.
The development of teledermatology systems to support referral and advice
mechanisms where appropriate.
Facilities
There must be a focus for education and training of local healthcare professionals (especially
nurses and GPs) through, for example, regular postgraduate meetings and training courses.
An appropriate range of outpatient consulting and treatment facilities should be provided that
enable prompt and easy access by patients. Including, for example, extended opening hours for
dermatology treatment, and the provision of ‘outpost’ clinics in community settings where
necessary. These facilities should also:
8
1.
Be co-located with inpatient facilities so as to maximise use of nursing and
consultant skills
2.
Be capable of accommodating the range and level of activity taking place, whilst
giving patients the space and privacy necessary for their treatment
3.
Include facilities for phototherapy, day treatment, bathing, contact allergy patch
testing, and surgical procedures. Equipment for cryotherapy and electrotherapy
(cautery and diathermy) must be available.
4.
Enable effective use of staff time: for example by providing two exam rooms per
consulting room
5.
Offer facilities and audiovisual aids for teaching
6.
Have access to good photographic services
Action On Dermatology Good Practice Guide
Chapter Two - Meeting the challenge: services
2
Box 2 gives a first hand account of how Action On Dermatology capital was used to update
facilities in South Manchester.
Where possible the treatment of suspected pigmented lesions/skin cancer referrals will be
undertaken through “One Stop” clinics
Box 2 New dermatology centre at South Manchester
Like many other dermatology services in the country, patients at South Manchester
were seen in an assortment of different outpatient clinics in different locations. After
receiving an Action On Dermatology capital allocation we thought all our problems
would be solved. In fact many of them were just beginning!
Our original thoughts of where this new facility would sit had to be changed and
everything looked bleak for a while. “Out of the ashes” we identified a building next
to the main hospital, which had been empty for months and in a pretty dilapidated
state. Undaunted, we set about using the money to refurbish it.
After an amazing transformation we now have a wonderful dedicated dermatology
centre where our redesigned service of consultants, GPwSIs, specialist nurses and
dermatology nurses work together. This is a truly integrated joint venture between
the acute and primary care trusts, which is improving the access of patients to
dermatological care.
Action On Dermatology Good Practice Guide
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2
Chapter Two - Meeting the challenge: services
Effective management
Effective management of specialist services is essential and needs to include:
1.
Dedicated management support
2.
The use of partial booking systems, and regular validation of waiting lists
3.
The use of ‘common’ or ‘pooled’ lists for referrals for common conditions
4.
Maximum flexibility in appointments systems: for example through the use of
partial or full booking systems for first outpatient appointments and self booking of
patients for treatment appointments
5.
Dedicated clinic administrative staff
6.
Adequate office, departmental library and seminar facilities
7.
Computer and word processing facilities
8.
Patient administration system (PAS) with the capacity to provide service ‘‘tailored’’
to dermatology services
9.
Information systems that provide information about activity, waiting times
and casemix
10.
An identified budget for dermatology services within a trust’s overall budget, and
powers to determine changes to the use of resources within the budget.
Sometimes it gets really
bad on my arms, legs and face and
especially around my eyes. This is when
I get depressed and uncomfortable
about going out and sometimes get
picked on at school.
10
Action On Dermatology Good Practice Guide
Chapter Three
3
Chapter Three
Meeting the challenge: service providers
11
3
Chapter Three - Meeting the challenge: service providers
Meeting the challenge – service providers
The way in which services are provided will depend upon many different factors, including the
geography of the area, the facilities available and the availability of staff with the appropriate
experience and qualifications. The paragraphs below outline some of the key elements of skin
care service providers and the contribution that they can make to the whole.
Community pharmacists
Pharmacists are often the first point of contact between people with skin disease and the health
services. They may be asked for advice on self-treatment, and will often provide advice to
patients on the best use of treatments prescribed by a doctor. The development of pharmacist
prescribing is under discussion within the profession.
Supplementary prescribing by a
pharmacist after initial diagnosis by a doctor might enable adjustment and amendment of initial
prescriptions in the light of patient response. Such a system would be of particular benefit to
patients with long-term conditions.
Development of this approach would require close liaison between pharmacists and doctors to
ensure that patients who need to see a doctor will be referred appropriately. Participating
pharmacists would require appropriate initial training and ongoing support, as well as suitable
premises and facilities.
Family doctor services
Currently only one in five GP training schemes offer a dermatology element in their training
programmes.
This, combined with a reduction in undergraduate teaching of dermatology
makes it inevitable that many doctors will enter general practice with limited knowledge and
understanding of common skin diseases. Changing this position will require a combination of
national and local debate on the part of doctors, medical schools, service planners and service
commissioners.
Skills and capacity within primary care can be enhanced through the provision of educational
events, see and treat clinics, and the use of clinical assistant posts to develop GP special interests.
The provision of accessible advice and support systems using telephone and computer links will
help those GPs wishing to provide a broader range of services to do so. Larger group practices
can be encouraged to develop in-house dermatology expertise by offering training opportunities
for interested partners and for nursing staff.
GPs with a special interest
Some GPs will have a special interest in skin disease and will wish to provide a broader range of
services to their own patients, and possibly to patients from other doctors or practices. Services
provided by such “GPs with a special interest” (GPwSIs) have been developed in many specialties
in recent years. Primary Care Trusts (PCTs) can play a significant role in encouraging and
supporting the use of GPwSIs.
12
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Chapter Three - Meeting the challenge: service providers
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The Primary Care Dermatology Society (PCDS) now has over 400 GP members who have a
particular interest in providing care for skin diseases in primary care.
Box 3 Guidelines for accreditation of GPwSIs
One of the first issues tackled by Birmingham’s whole health system dermatology group,
the Birmingham Skin Services Group (BSSG) (see box 23) was the development of local
guidelines for the accreditation of GPwSIs.
It was clear from the outset that the development of a primary care dermatology service
should be approached from a whole health system perspective – not least because hospitalbased consultants would have a vital role in ongoing professional development,
supervision and clinical governance. It was also clear that there would be significant
advantages to developing a consistent approach across the health system. Guidelines for
accreditation seemed a logical place to start and these were developed by a
multidisciplinary team with representation from both primary and secondary care and
subsequently endorsed by the BSSG. A copy of the guidelines and a sample application
form are included in the resource pack.
The Department of Health has recently published information on the establishment of such
services, and the British Association of Dermatologists (BAD) has also set out its views on this
service model in dermatology. Copies of the Department of Health/Royal College of General
Practitioners guidance: Implementing a scheme for General Practitioners with Special Interests,
April 2002 and the BAD’s position statement GPs with a Special Interest in Dermatology,
September 2002, are included in the resource pack. Where PCTs have decided to take forward
the GPwSI model, locally agreed supplementary guidance for GPs who might be interested in
such a role has proved useful (see box 3, above). A number of GP led service models have been
used by Action On Dermatology pilot sites (see box 4, page 14). A variety of material has been
developed by the pilot sites to support GPwSI services. A selection is included in the resource
pack, including samples of appointment cards, clinical audit forms, patient leaflets, accreditation
criteria and requirements for CME.
Every time someone
looks at me I’m paranoid they’re
staring at my face and thinking
cruel things about my
personal hygiene
Action On Dermatology Good Practice Guide
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Chapter Three - Meeting the challenge: service providers
Box 4 Different models for GPwSI services (see box 15 for a diagram of the models)
Addenbrooke’s NHS Trust
Referrals from the co-operating PCTs come in to the acute trust but are immediately
forwarded to the two GPwSIs. The GPwSIs select the referrals that they wish to take,
focusing on patients who are unlikely to require follow-up. This approach ensures that
they see a casemix that they feel comfortable with and allows the GPwSIs to keep their
waiting time down to two to four weeks.
Ongoing professional development is provided by working alongside the consultant once
per month and regular participation in audit and clinical governance. The GPwSI is also
expected to attend relevant dermatology courses eg surgery updates and will undergo
annual appraisal and assessment.
West Hertfordshire Hospitals Trust
The GPwSI, supported by a specialist dermatology nurse from the trust, sees routine
referrals selected by the hospital consultants from an agreed list of conditions. The GPwSI
also undertakes one general clinic per week in the hospital outpatient department, plus a
minor surgery session, and attends departmental training and clinical governance sessions.
Referrals are currently triaged and the clinic administered from secondary care. It is hoped
that the service will be taken over by the PCT and the GPwSI will see GP to GP referrals for
the same casemix but still supported by the secondary care specialist nurse, thereby
ensuring ready access to secondary care services. A description of the electronic referral
process is included in the resource pack.
Southampton University Hospital Trust
Currently in training, the GPwSIs work alongside a nominated consultant in a hospital
setting, seeing patients triaged by a consultant dermatologist.
In the autumn, once the first tranche of GPwSIs are fully accredited, they will be located in
a community setting seeing patients referred directly by GPs. For continuing professional
development they will spend one session per month working alongside a consultant
mentor to ensure ongoing accreditation and training. A significant part of the GPwSI role
will be providing education for other GPs. Further information about the accreditation and
training programme are included in the resource pack.
Eastern Wakefield PCT
GPs may refer to either the GPwSI service or the hospital according to referral guidelines.
All referral letters to secondary care are triaged and suitable patients are passed straight to
the primary care service. Patients seen by the five GPwSIs who need to be referred on to
the hospital go via the rapid access clinic to avoid a further wait. Some patients initially
seen in secondary care are referred on to the GPwSI service for follow-up or minor surgery.
A checklist of the requirements for ongoing development and re-accreditation is included
in the resource pack.
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Experience within the pilot sites and elsewhere shows that GP led services need support from
and access to strong specialist services if they are to develop effectively. The workload in
teaching and training, and providing ongoing professional development and support for
GPwSIs, can be a significant one for consultant staff and needs to be recognised in assessing their
overall workload.
GPwSI led services will also require access to an appropriate range of support. Specialist nursing
support in GPwSI clinics can be a very effective way of linking the service to local specialist
services (see box 5, below). Other services will include access to minor surgery, pathology and
light treatment services, as well as the ability to refer patients to appropriate nurse-led treatment
clinics. Box 6 (page 16) gives an example of GPwSIs performing minor surgery in Oldham.
Box 5 Joint working in Cambridge
Insufficient capacity to meet the demand for dermatology outpatient appointments
previously saw long waiting times (14 months for a routine appointment in 2000) brought
down only by sporadic waiting list initiatives. The last such initiative was in March 2001
where most patients waiting over 26 weeks were seen by holding extra clinics in the
evenings. The impact was short-lived and the numbers of patients waiting over 26 weeks
immediately began to climb in the early months of 2001/02.
The dermatology department agreed to assist two key primary care organisations in the
training, accreditation and ongoing support for two GPwSIs.
Both GPwSIs started
community-based clinics early in 2001/02, siphoning referrals from those made to the trust
(see box 4 and 13 for details of the referral pathway). A hospital-based specialist nurse
works alongside one of the GPwSIs in the community and provides a vital link between
primary and secondary care. The specialist nurses are able to deal with much of the followup workload, allowing the GPwSI to see more new patients. Both the GPwSI and nurse
involved have found joint working highly rewarding.
Initial concerns that referral thresholds might lower with shorter waiting times proved
unfounded. The average wait for an appointment with a GPwSI is currently two to three
weeks.
The maximum wait for an appointment with a consultant dermatologist has
decreased from 33 weeks in June 2001 to less than 20 weeks in June 2002.
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Box 6 Joint working in Oldham
In Oldham the lack of consultant staffing developed gradually over a number of years. To
meet the needs of a patient population of 220,000 there are currently only two consultant
sessions per week. When efforts at recruiting new consultants failed, a project group was
established to consider how flexible working arrangements could be used to better meet
demand. There was equal representation of managerial and clinical expertise from both
primary and secondary care within the project group. The group focused on several
initiatives aimed at improving the utilisation of skills amongst GPs and developing more
nurse-led services. Two initiatives in particular - the teach & treat sessions provided by the
local consultant to the GPs and the GP-led minor surgery within secondary care - bear
ample testimony to how joint working across the patch can help provide a seamless and
cohesive service to the patients. These sessions helped break down the barriers between
primary and secondary care and improved networking and sharing of information among
the clinicians.
A further initiative, in which the hospital-based nurse practitioner has worked with local
health visitors to set up community clinics, has also helped improve access to care. The
acute trust is happy that instead of resorting to short-term arrangements for tackling waiting
lists they now have a framework for providing a more cost-effective, quality service.
Hospital services
Dermatology does not generally require sophisticated equipment or facilities.
However,
supervision of light treatment, day treatment and minor surgery facilities, together with the
need to make maximum use of consultant time, call for specialist services to be provided by
consultant staff working in hospital settings.
Dermatology departments see large numbers of patients, many of whom will require minor
surgery. The provision of dedicated consulting rooms with separate examination rooms and
surgery facilities enables the maximum use to be made of staff resources. Co-location of
outpatient facilities, light treatment, day treatment facilities and administrative offices will
enhance this effect and should be the arrangement of choice.
Light treatment and day treatment for psoriasis and other conditions is a staple requirement of
local dermatology services. The nature of the equipment, the need for changing and bathing
facilities, and the requirement for expert supervision makes treatment outside hospital settings
impractical in almost all cases. Light therapy and day treatment usually requires patients to
attend for treatment two or three times a week for 10 to 12 weeks. For many patients such a
commitment is extremely difficult unless treatment is available locally. It also needs to be
available outside the normal working week: in the early morning, in the evening or at
the weekend.
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Inpatient treatment of skin disease has reduced enormously in recent years, with only the most
serious conditions now being admitted. This change has been driven both by developments in
treatments and by the overall reduction in the acute hospital bed pool. The resulting decline in
dermatological expertise amongst ward nursing staff, and the pressure on beds from acute
medical admissions, means that some dermatology departments are effectively unable to admit
for inpatient treatment unless patients are medical emergencies. This makes the provision of
high quality outpatient dermatology services essential.
Despite this low level of inpatient admission most dermatologists provide a significant level of
service to inpatients in other specialties. NHS information collection systems do not always
record this activity which needs to be recognised when considering overall service provision.
Patients with chronic conditions may need to access different parts of the care system at different
times, dependent upon their current condition. Telephone advice lines run by specialist nurses
can reduce such patients’ need to attend outpatient clinics as well as offering a means of rapid
access in the event of a sudden flare-up in their condition (see boxes 7 and 8 below).
Box 7 Patient advice line at Addenbrooke’s
Addenbrooke’s Hospital is piloting a scheme where patients with eczema, psoriasis and
other chronic conditions are given a card showing details of a nurse advice line which they
can call if they have questions about their condition or treatment. Nurses staffing the
advice line also have access to a weekly hot clinic where patients suffering from an acute
flare-up of their condition can be seen at short notice. The scheme has been well received
by patient representatives, who have described it as a “lifeline” for patients.
Box 8 Nurse-led telephone follow-up in Basildon & Thurrock
Basildon & Thurrock Hospital introduced a nurse-led telephone clinic to provide an
alternative patient follow-up system. A time-slot is agreed with each patient during which
the specialist nurse will contact them to discuss their condition and treatment. Early
indications suggest that the service has reduced the need for conventional follow-up
appointments, thus freeing up slots for new patients. The service has been well received
by patients, who have found it beneficial to discuss their condition and treatment regimen
with a nurse and appreciated the convenience of a telephone consultation. In response to
a patient satisfaction survey, 100% of all patients asked approved of the method of follow
up, and 50% said that they would have had to take the day off work to attend a
hospital appointment.
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Nurse-led services
Specialist nursing posts have existed in dermatology services for some years. The British
Dermatological Nursing Group (BDNG) provides an educational and professional forum to
assist with the development of nursing roles. Nurse-led clinics are an established part of many
services, offering time to explain and discuss complex treatments with patients and carers
(see box 9, below).
Box 9 Specialist dermatology nurses in East Kent
The East Kent pilot site used some of the Action On funding to employ two F-grade nurses
to develop nurse-led services. A nurse practitioner was already in post providing four
clinics a week for patients with chronic dermatological conditions such as eczema,
psoriasis, and acne. With the new nurses in post a further seven clinics were set up to run
either weekly or fortnightly. Many of these clinics were in smaller community hospitals
away from the main acute site resulting in a much more convenient service to patients. In
each of the clinics, patients are given 30 minute appointment slots to allow time for a full
explanation of their condition and how to apply treatments etc. The consultants receive
the referrals and then triage appropriate patients towards the nurse-led lists. Some followup patients have also been transferred to the nurse-led clinics. The nurses assess the new
patients before deciding on a treatment regime and arrange any tests, prescriptions and
appropriate follow-up or discharge.
In the first six months of the new service (which included the training period for the
nurses) the nurse-led clinics saw 197 new patients and 260 follow-up patients. This activity
has played a vital role in keeping waiting times under control over a period during which
one consultant left the trust and another had extended sick leave. At present the trust is
working on setting up primary care based nurse-led clinics and hope to get them up and
running fairly quickly. The local PCT has agreed to fund the nurses on a permanent basis.
The use of “SOS” appointment arrangements - where patients initiate a follow up appointment
if they need one - can reduce unnecessary appointments and help patients gain rapid access to
follow up support and treatment where necessary.
Nurse-led services can also provide support and development for practice and community
nurses (see box 10, page 19), and can be used to improve access to specialist services (see box
11, page 20).
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Box 10 Nurse-led services in North Staffordshire
Analysis of the dermatology waiting list at North Staffordshire hospital identified that
around 25% of the patients waiting could more appropriately be seen by a clinical nurse
specialist.
The hospital worked with local PCTs to set up a nurse-led paediatric eczema and psoriasis
service.
Community nurses and GPs refer to the service by faxing the dermatology
department and patients are given a number to call to book a convenient appointment.
Patients and their carers are taught how to manage their own conditions and each patient
seen is given a contact number for the nurse so that they have direct access back to the
service if they need it.
Waiting times for this group of patients have reduced from
approximately 140 days to see a consultant at the beginning of the project to 33 days for
the nurse-led service. Subsequently the waiting time for a consultant appointment has also
reduced to 67 days on average. Childhood eczema now only accounts for 0.2% of the
consultants’ waiting list compared with 2% at the start of the project. The service has been
very well received by patients and carers:
“I cannot praise the nurses enough. I don’t know how I would have
managed without their support and information. My child now gets a
decent night’s sleep.”
“The service ultimately reduces the medication required and the time spent
with the doctors. It is an excellent service with excellent care and a true
God-sent blessing to those as desperate as my child”.
“The doctors do not have the time to spend with their patients explaining
various ways of managing eczema. Having an eczema specialist nurse is
wonderful because with the information she gave me, I have been able to
look after my child’s skin much better than before”
The specialist nurse also trains and supports community nurses so that they can manage
patients with eczema and psoriasis in their own health centres. After initial training, the
specialist nurse sits in on approximately one in six clinics to offer support and advice.
During the 12 months in which the pilot clinics have been operating, the health centre
involved has referred no patients into secondary care for eczema and psoriasis. For the
future, North Staffordshire hope to extend the nurse-led paediatric services to adults, and
extend the practice-based care model to other community nurses.
Copies of the competency framework that North Staffordshire have developed for nurse-led
clinics, together with guidelines for the management of eczema and psoriasis in primary
care and a patient information sheet on atopic eczema are included in the resource pack.
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Box 11 Nurse-led teledermatology in East Devon
East Devon covers a wide geographical area and has an extremely high elderly population
- 22% are over 75 years. To see a consultant at the dermatology department in Exeter can
mean a round trip of over 50 miles for some patients.
Improving access to routine
dermatology care is therefore a high priority. With Action On funding, East Devon PCT and
the Royal Devon & Exeter NHS Trust decided to pilot nurse-led clinics in six community
settings across East Devon, supported by telemedicine. Previous research had shown that
with telemedicine between 30 – 40% of routine dermatology referrals could safely be
treated in primary/community care settings.
The project recruited four local community nurses, who already had a special interest in
dermatology. The nurses underwent an extensive training programme and have ready
access to the specialist team at the acute dermatology department via the use of the
telemedicine equipment. The clinics started as triage centres for all appropriate routine
dermatology referrals. Patients book themselves an appointment via a central telephone
line. At the clinic, the nurse takes the patient history and a photographic image, which are
encrypted and transmitted to the consultant for opinion later that week. Waiting time from
GP referral to the patient receiving the specialist opinion is less than three weeks on
average.
The nurses’ opinion at this stage can be a valuable source of information for the
consultants.
After five months, early results indicate that over 40% of patients are able to be treated in
primary care by their own GP. A further 26% can be triaged into other clinics, saving at least
one round trip to the acute dermatology department for those patients.
Now the triage centres are established, the clinics will be extended to provide treatment
advice and follow-up management from the nurses. The nurses are undergoing additional
training for this extended role, and will again be supported with the telemedicine
equipment and on-going supervision from a specialist dermatology nurse. The nurses will
work to treatment plans advised by the consultants, and will be supporting patients in
understanding and complying with their treatment.
The nurses have increased their skills, knowledge and confidence in these new roles and
are establishing good working relationships with their local GPs, as well as the consultants.
The project has enabled East Devon PCT and the Royal Devon & Exeter Hospital Trust to
explore a new and innovative way of offering dermatology care. Feedback from the patients
and GPs is also very positive and of the GPs randomly surveyed so far, 100% have indicated
they would like the service to continue. Copies of the clinic referral template and a patient
leaflet explaining the service are included in the resource pack
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Box 12 Southampton University Hospitals Trust and PCTs - specialist liaison nurse role
Our specialist liaison nurse was appointed in April 2000 as a 10 month service pilot. The
post was a joint appointment between the acute trust, the community trust and the local
PCGs in order to strengthen partnerships between primary and secondary care, thus
providing seamless care for dermatological patients.
The post became permanent in
April 2001.
The liaison nurse establishes chronic disease management programmes for diagnosed
conditions, and provides key education, both in regular training days, and on a one to one
basis, for GPs, health visitors, practice and district nurses.
The uptake on this
education/advice resource has been very successful and popular.
The liaison nurse also offers a source of help and advice on the management of diagnosed
conditions, and accepts referrals directly from GPs for diagnosed eczema and psoriasis in
both adults and children. These patients are generally seen in their own home, which has
helped to reduce the referrals to the hospital to see a consultant. In particular, children
have benefited from being seen at home as this is a much less stressful environment than a
hospital setting.
The liaison nurse is also helping to establish and support primary care nurse-led
dermatology clinics for diagnosed eczema and psoriasis in both adults and children.
Through education and training, the development of protocols, and ongoing support,
primary care nurses are successfully managing eczema and psoriasis patients in primary
care. The results of an ongoing audit have been very positive showing high patient
satisfaction with the clinics, and minimal need for referral on to secondary care.
In July 2002 the liaison nurse was commended in the Department of Health’s Health and
Social Care Awards in the category of primary care access. This was recognition for the
progress made to improve access to services within primary care; including faster and more
convenient services for patients and extension of services offered.
In the future the specialist liaison nurse will be undertaking audit and research into the role
to look in particular at the quality of care provided by the service, impacts on access, and
impact on secondary care services.
The liaison nurse would also like to establish a
dermatology liaison nurse support group.
Contact details - Helen Toms 023 8079 5034 [email protected]
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Chapter Three - Meeting the challenge: service providers
Nurses working across GP led and consultant led services are a valuable link between the service
elements, enhancing communication and providing patients with some continuity in their care.
Specialist nurse training is not subject to national standards, but a range of courses is available
to supplement local training. A training booklet for nurse-led minor dermatological surgery is
included in the resource pack as well as details of a range of other courses.
Linking the parts together
The development of a range of different services can offer increased access and choice to
patients and more effective use of the skills and experience of the different professionals
involved in the care services. Box 13 below describes the ambitious project underway at
Southampton University to create a “Community of Practice” for dermatology.
Another
approach, illustrated at box 11a see page 21, is to appoint a specialist liaison nurse.
Box 13 Southampton University Dermatology “Community of Practice” project
The dermatology Community of Practice (COP) project undertaken by Southampton
University and funded by the NHS Executive South East regional office drew together a
range of medical, nursing and patient stakeholders in dermatology services.
The
programme sought to examine how service providers and consumers acquire, negotiate,
adopt and use information to make decisions within the community. The work of the
dermatology COP focused on manpower issues within the specialty, and in particular the
availability of resources to meet the education and training needs of professionals. The
project successfully developed an electronic resource pack offering users links to a wide
range of educational material through the Internet. For further information, please contact
Professor Judith Lathlean, Professor of Health Research, School of Nursing and Midwifery,
University of Southampton, Nightingale Building (67), University Road, Highfield, Southampton SO17 1BJ,
e-mail: [email protected]
Developing services in this way requires effective communications between the various service
elements, and clarity as to “who does what”. Electronic record keeping and communications
offer effective solutions but can be complex and costly to implement. Alternatives based on
manual written records, fax and courier systems can be more flexible whilst new service
structures are being developed (see box 14, overleaf).
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Box 14 Different ways of handling information
Pontefract & Pinderfields Hospital and Eastern Wakefield PCT
A suite of rooms at Castleford, Normanton & District Hospital was refurbished to provide a
base for the GPwSI service and two nurses were recruited to support the GPwSIs along with
dedicated reception and clerical support.
A stand alone computerised clinical system was adapted to suit the service.
All
correspondence received is scanned into the system and an electronic copy kept with the
patient’s records. After each consultation, the GPwSI completes an electronic template
with details of diagnosis, management, treatment, follow-up and medication.
This
generates a letter to the patient’s GP, which is ready for signature by the end of the clinic.
The software can print prescriptions and also has an appointments system that generates
appointment letters, including those for partial booking.
St Mary’s Hospital and Westminster PCT
The GPwSI service based at the Soho Centre for Health & Care in Westminster PCT operates
a system of fax referral. GPs within the PCT are asked to complete a simple referral form
and fax it to the service within 24 hours. Whilst still in the GP surgery, each patient referred
is given an information leaflet explaining the role of the GPwSI, what they can expect from
their consultation and how to book an appointment. Patients are invited to call the service
the next working day after referral to arrange a convenient appointment time. Patient,
appointment and clinical details are then recorded on a modified version of EMIS (a patient
database used within primary care). Should any patients require further treatment at the
hospital, e.g. phototherapy, the GPwSI completes a “fast-track fax form” to book the patient
into a consultant appointment. A dermatology nurse works alongside the GPwSI as well as
in the hospital outpatient department, and provides an important link for patients and
clinicians between primary and secondary care.
The structure of patient care pathways should be determined by local circumstances, and can
change over time as needed. Box 15 overleaf, summarises the different referral paths used for
GPwSI led services at Addenbrooke’s, Eastern Wakefield, Southampton and West Hertfordshire.
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Chapter Three - Meeting the challenge: service providers
Box 13 Four GPwSI referral paths
Southampton University
Hospital NHS Trust
Eastern Wakefield PCT
Patient
Patient
GP
GP
Referral
Referral
Referral
Trust
GPwSI
Trust
triage
Selected
referrals
GPwSI
Addenbrooke’s NHS Trust
West Herts NHS Trust
Patient
Patient
GP
GP
All referrals
All referrals
Trust
24
Referral
Return to
trust
All referrals
GPwSI
triage
Trust
triage
Action On Dermatology Good Practice Guide
Selected
cases
GPwSI
Chapter Three - Meeting the challenge: service providers
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Guidelines on treatment: guidelines on referral
A recent BAD survey suggested that nearly half the dermatology departments in the country have
published advice on referral guidelines for GPs in recent years. A smaller proportion have also
produced guidelines which aim to help GPs in diagnosing and treating common skin conditions
in primary care. Some of these guidelines give examples or lists of conditions that are seen as
generally being inappropriate for referral to secondary care. An example of one such list,
developed by the Medway health system as part of a wider exercise (see box 16), is included in
the resource pack.
Box 16 Development of a guide to dermatology in primary care
Medway NHS Trust wanted to address waiting time problems in their dermatology
department. Rather than simply holding more clinics, a longer term plan was drawn up
between the trust and its six PCTs to ensure that GPs had the tools they needed to treat
patients themselves, rather than referring to secondary care.
Many GPs receive no pre or postgraduate education in dermatology, leaving them ill
equipped to deal with the dermatology related conditions that make up almost one sixth
of their workload.
For Medway, this led to patients waiting up to 80 weeks to see a
consultant only to be told that they needed a course of antibiotics that could have been
prescribed by their GP.
The trust identified 12 common dermatological conditions and drew up guidelines for their
treatment in primary care.
After extensive consultation, including evening meetings
between consultants and GPs, the guidelines were agreed. They were then issued to every
GP, practice nurse and practice manager in the PCTs involved. Referrals that do not follow
the guidelines, or that do not give enough information about the treatments that have been
tried, are, with the support of participating PCTs, now being returned to the GP involved.
In the period April to July 2002, dermatology referrals to Medway, excluding those for
cancer two week waits, were down 8% on the same period of the previous year. The
maximum wait for a consultant appointment at Medway has dropped from 49 weeks in
August 2001 to just over 17 weeks in July. Although this improvement was partly due to
waiting list initiative clinics, it seems likely that the implementation of the referral
guidelines also had a significant impact.
The guidelines have proved a valuable educational tool and a means of improving the
balance between primary and secondary dermatological care at Medway. Just as important,
however, has been the process of collaboration between primary and secondary care that
led to their production. A copy of the Medway guidelines is included in the resource pack.
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Whilst some of these guidelines have been produced jointly by consultants and GPs working
together, a significant proportion have been produced by consultants alone, with little or no
input from GPs. Such an approach severely reduces the potential impact and benefit.
Views on the value of both treatment and referral guidelines vary widely, and the
practical difficulties in keeping them up to date and easily accessible by GPs are significant.
However, the process of developing guidelines can prove very useful in establishing agreement
about how services should be provided and used (see boxes 16, page 25 and 17, below).
The use of standardised or pro forma referral forms has increased significantly in recent years,
particularly for suspected cancer referrals. Again, joint ownership of forms and clarity about their
use is essential if they are to be effective. An example referral pro forma, developed by West
Middlesex University Hospital and partners and a structured referral letter developed by West
Hertfordshire are included in the resource pack.
Box 17 Treatment protocols in South Manchester
Specialist nurses at South Manchester University Hospital have developed treatment
protocols covering infected eczema; non infected eczema; varicose eczema; scalp psoriasis;
psoriasis of the face, flexures and genitalia; trunk and limb psoriasis; and palmer/planter
psoriasis. The protocols are designed to provide an easy, at-a-glance guide for community
health professionals. The protocols have been very well received by community nurses
who, in some cases, are now cascading the learning to the GPs within their own practice.
Two audits have been carried out to evaluate the impact of the specialist nurse role. In the
year 2000/01 there were 462 referrals for children under five with atopic eczema, of which
43% were moderate to severe.
In the six months following the development of the
protocols and associated training, there were 45% fewer referrals, and only 1.6% were
moderate to severe. In 2000/01 specialist nurses undertook 132 domiciliary visits for
varicose eczema, of which 69% were moderate to severe. In the six months after
implementation visits were down by 58% and none were categorised as moderate to severe.
Providing appropriate education and support for community nurses and health visitors has
resulted not only in significantly lower levels of referral but also better care for patients in
a more appropriate setting.
The protocols complement a comprehensive education programme developed by the
dermatology department at South Manchester. The resource material, which forms the
basis of the education programme, has been published by South Manchester with funding
from Action On Dermatology. Details are available at www.modern.nhs.uk/action-on
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Chapter Four
Chapter Four
Making changes
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Chapter Four - Making changes
Making Changes
Where are you now?
An essential first step in planning and providing services is an assessment of where things are
now. Find out what information is available about the services currently provided. “Standard”
activity and waiting list returns are available for all NHS trusts via the Department of Health
website at www.doh.gov.uk/waitingtimes/index.htm.
An easy to use benchmarking package is included in the resource pack. This gives a wealth of
information about the way individual trusts are performing in comparison to others and to
national averages. Remember, though, that benchmarks do not indicate whether a service is
good or bad. Rather they help to highlight aspects of services which differ from the majority, and
which may be worth examining more closely.
Box 18 Using clinical information systems
In West Hertfordshire the dermatology department has been working closely with the
clinical effectiveness and audit department to develop a database with details of all
dermatology consultations and outcomes (Infoflex). Clinicians record information relating
to a limited number of diagnostic and outcome details at the time of the consultation and
the secretary then enters this as part of the process of typing the clinic letter. The system
that has been developed can be used to collect as much or as little information as is
required by the healthcare professionals in the department. The process of data collection
has been streamlined to take as little time as possible for all concerned. The analysis of the
data has proved crucial in working with the local PCTs to discuss guideline development,
establish capacity/demand shortfalls and to measure outcomes of patient care in relation to
waiting times for dermatology treatment and management of skin cancers such as
melanoma. In response to telephone enquiries from patients, the secretary is able to pull
up a full history of the patient’s visits to the department with all relevant correspondence,
reducing the necessity for accessing hospital records. A really exciting development has
been the extension of the system for the nurse-led clinics. The nurses enter patient details
immediately on to the system and are able to print out a summary clinical record and a GP
letter at the time of the consultation.
A long-term diagnostic database, such as the one in use in West Hertfordshire (Box 18 above)
will provide useful information. If this is not available, consider whether it is worth undertaking
local data collection on specific issues, such as outpatient case mix. Quick sampling exercises
(see box 19 overleaf) can be very useful in informing a discussion of current service provision,
and in monitoring the impact of any changes. Development and management of services is only
feasible with reliable casemix information.
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Box 19 Two methods of handling data
To determine how much work would be involved in clearing the backlog of patients waiting
for treatment and plan how best to organise services in the future, Medway needed to
know what conditions patients were being referred for. However, as in most hospitals,
information on the casemix of patients waiting for treatment is not routinely collected. One
reasonably simple way to get information on casemix is to look at the referral letters for
patients waiting to be given an appointment. For Medway this covers all “soon” and
“routine” referrals, but not those referred under the two-week cancer wait protocol. It was
agreed that a manual snapshot of letters would be carried out and the casemix categorised.
As the hospital provides a service to four PCTs, it was also agreed that referrals by PCT
would be counted, and, in order to get a more complete picture of demand, a note would
be made of any tertiary referrals.
A total of 738 letters were read and categorised. This took less than a day. The results were
as follows:
Eczema
29.1%
Warts/Verruccas
3.8%
Psoriasis
9.3%
Alopecia
4.2%
Acne
7.5%
Pruritus/Urticaria
3.7%
BCC/lumps
35.7%
Other
6.8%
Previously, much of the information used for planning services had been anecdotal.
Although this exercise seemed a daunting task at first, it was actually quite simple and
quick to complete and has allowed Medway to base future plans on real data and target
specific areas for action or further analysis. The information was shared with the PCTs and
it was agreed that it would be worth looking at the “lumps and bumps” in more detail to
see if there is a particular problem in this area. It was agreed that this was a useful exercise
and should be undertaken again in about six months.
One of the key lessons the dermatology department of Southampton University
Hospital Trust learned from the Action On process is that it helps to know what the
problems are before you start trying to solve them. The department undertook a manual
referral audit logging every referral to the service over a period of eight weeks. This
allowed them to develop an understanding of the type of referrals coming from each local
area and to ensure that they could provide the right number of general and specialist
dermatology clinics to match the need. This information also helped the department to
understand the need for new services, such as GPs with a specialist interest, nurse-led
surgery and other nurse-led services. The department has found the information from the
manual audit so useful in planning future services that they are currently developing a
database so that it can be collected routinely on an ongoing basis.
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Chapter Four - Making changes
Undertake basic assessment of service capacity and demand. Make allowance for variations over
time and identify the extent of any fundamental underlying shortfall in provision for debate. The
existence of special factors, which might increase the local demand for dermatology services,
such as a transplant unit, should be noted. If there is a waiting list backlog then allowance must
be made for the capacity needed to clear it within target timescales. A simple supply and demand
case study is included in the resource pack.
Box 20 Get the basics right first
When one of Southampton University Hospital Trust’s dermatologists called the Action On
project manager to complain that he was sitting in clinic without any patients to see, it
inspired the development of a simple but very useful tool – the MOT Checklist. Designed
to help determine whether a given clinic is running as efficiently as possible, the MOT
Checklist can help services diagnose problems and get the basics right, before embarking
on ambitious redesign. An example of an MOT Checklist similar to the one used in
Southampton is included in the resource pack.
PCTs can play a vital role in analysing the pattern of demand for dermatology services across GPs
and practices, as well as providing feedback and addressing outliers.
Review the way in which the current systems work.
Simple diagnostic tools can help to
determine if best use is being made of scarce resources (see box 20, above). Tools such as
process mapping (see box 21, overleaf) and the Step by Step Guide to Improving Outpatients, a
copy of which is included in the resource pack, are a good way of identifying bottlenecks and
engaging all stakeholders in making change.
Where do you want to be?
Whatever patterns of services exist, it is essential that they are integrated, so that patient care can
pass smoothly between the various elements. They should also be mutually agreed, so that all
those involved understand who provides what services (and just as importantly who does not.)
These two points are best addressed by the development of a vision or strategy for dermatology
services, developed and agreed by all of the main stakeholders. Such a plan may not reflect what
happens at present, but it will set out clearly where all those involved want to go, and how they
intend to get there. It needs to be drawn in sufficient detail to show:
30
1.
Who is going to provide what services
2.
Where they are going to provide them
3.
What they need in order to provide them
4.
What the relationships and communications systems between the various service
components are.
Action On Dermatology Good Practice Guide
Chapter Three - Making changes
4
Box 21 Using process mapping for redesign
Process mapping has been used to great effect within the North Staffordshire health
economy. A team, consisting of managers, clinic staff and primary care representatives,
process mapped the patient’s journey from GP referral through to patient discharge. They
particularly focused on groups of patients identified, through a referral and waiting list
analysis, as being patients for whom alternative pathways of care might be established, e.g.
patients with eczema and psoriasis.
The current pathway was mapped including the
administrative processes running alongside the patient’s journey. It was determined that a
patient with eczema or psoriasis could pass through as many 95 steps (including
administrative processes).
On the basis of the discoveries made during the mapping process, it was agreed that a
nurse-led clinic should be established for the treatment of patients with eczema and
psoriasis. A conscious effort was made to look at what would be the ideal process for these
patients in comparison to their original journey under the old system. In doing this, the
team was able to shorten the patient journey and instead of the original 95 steps, these
patients now only pass through 15 steps from referral to discharge from the clinic
(including administrative processes like appointment booking). This has resulted not only
in an improved service to patients but in a massive reduction of bureaucracy for staff.
Inspired by the impact of work like this, the trust has now set up an outpatient redesign
team to continue the work on dermatology and extend it to other specialties. For a detailed
description of how to use process mapping for redesign, see the Improvement Leader’s
Guide to process mapping, analysis and redesign, a copy of which is included in the
resource pack.
Community responsibility for secondary care services lies with PCTs. They also have a key role
in the management of primary and community based elements of service. Establishing an
informed dialogue with PCT commissioners at an early stage is essential.
A regular meeting between GPs, consultants, PCT and acute trust managers, specialist nurses
and patient group representatives is an excellent way of forming joint views and plans, and of
keeping them under review. This needs to be “protected time”, separate from the business
meeting which will otherwise overwhelm it. Box 22 overleaf and box 23 on page 33 describe
how having a regular forum for discussion has helped two health systems to develop a coherent
approach to service planning.
Action On Dermatology Good Practice Guide
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4
Chapter Four - Making changes
Box 22 Working together in West Kent
In 1998 there was only one full time dermatologist in the whole of West Kent. This level of
provision was clearly inadequate to meet the growing demand for specialist dermatology
services.
West Kent Health Authority decided that there would be more chance of
successfully recruiting to consultant vacancies, if prospective appointees were offered the
opportunity to work as a group rather than in isolation at each of the local hospitals. A
decision was taken to provide a “hub and spoke” service across West Kent. The hub of the
service was to be Medway NHS Trust, as this was the location of the single existing
consultant.
West Kent provided the money, and Medway appointed the doctors. Numbers waiting
reduced dramatically but as waiting times were reduced referral rates increased. Within a
year Medway had four consultants in post and a waiting list twice as long as before.
Everyone was unhappy. A blame culture took over. The health authority felt that they had
provided the money but got nothing in return. The GPs blamed the consultants and the
consultants blamed the GPs. At one particular meeting there was a “Mexican stand-off ”
where no one could agree to discuss issues let alone try to find a solution. One of the PCGs
gave notice to withdraw from the service and get their dermatology services elsewhere.
Around this time the government gave the first lot of money to be used for waiting list
initiatives in dermatology. Previously money hadn’t turned out to be a long-term solution
but this time it was used as a catalyst to start a dialogue. Everyone recognised that there
were targets to meet which the whole health economy would be measured against. The
only way forward was to talk! It became clear that everyone had the same goal and that was
to improve the service to patients.
At first everyone involved was wary of each other but as dialogue continued and positive
results were achieved trust was gradually established.
A regular dermatology service
meeting now takes place every two months. The trust and the four local PCTs are able to
discuss all aspects of the service and jointly plan for the future. The dermatology service
has had some difficult times over the last year - two consultants resigned and the maximum
26 week wait became an imperative – but the whole health system has worked together to
deal successfully with these problems.
Plans need to be clearly set out and widely understood. They must also be fully integrated into
local planning and thinking. For example, a dermatology services plan may aim to establish a
day treatment centre at an acute hospital site. If so, this needs to be reflected in the acute trust’s
site development plans. There also needs to be a plan for staffing the service, and there needs
to be an agreement at least in principle over any revenue costs. Plans that are not jointly owned
and supported in this way are less likely to be implemented, or to deliver the services needed.
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Chapter Three - Making changes
4
Box 23 Working across a complex health economy
Birmingham is a complex health economy with five acute trusts and five PCTs providing
dermatology services. The Birmingham Skin Services Group (BSSG) was developed to:
1.
Provide a strategic overview and a more constructive engagement around the future
vision of dermatology services across the city
2.
Match capacity and demand through the development of an integrated approach to
primary and secondary care
3.
Develop new roles including GPwSIs and specialist liaison nurses.
4.
Develop an educational infrastructure
5.
Provide an equitable and high standard of services across the city
6.
Minimise waiting list issues
7.
Develop a leading dermatology service
Local networks were set up to support centrally agreed developments whilst remaining
sensitive to local priorities and needs. Each local network is made up of clinicians and
managers from the relevant PCT and acute trust and formally reports back to the BSSG.
This approach has been extremely successful in balancing local needs with the need for
centralised co-ordination. Central to its success has been:
1.
Protected time for clinical staff
2.
Support from a dedicated project manager
3.
Understanding and supporting local priorities identified through processes such as
local modernisation reviews and waiting lists targets
4.
Identifying relevant building blocks and developing them
5.
Identifying champions who are willing to go the extra mile
6.
Linking developments into Service and Financial Framework negotiations by providing
a clear incremental plan for change
7.
Transparency
The main impact of the group has been the development of a dialogue between primary
and secondary care and a cohesive approach to the development of dermatology services.
It has also proved extremely useful to have a whole system view of capacity and demand
issues across the health system.
Plans need to be kept up to date. Putting a plan onto an internal or public website can be a very
effective way of keeping people informed.
Action On Dermatology Good Practice Guide
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4
Chapter Four - Making changes
Measuring progress
Service quality is of importance to all those involved in dermatology, although what the
determinants of a high quality service are may well vary from stakeholder to stakeholder.
The nature of skin disease means that many patients will have engagement with dermatology
services for many years, possibly for life, and thus will develop a good understanding of service
provision and the way in which it meets (or does not meet) their needs. It is essential that the
expertise and insights of these patients are used in planning and developing local services, and
in monitoring their long term delivery. It is also important that the different needs of patients
whose engagement with services is more fleeting are taken into account.
Various mechanisms can be used to assess patient needs. These include: questionnaires and
surveys; discovery interviews; shadowing patients and involving patients or patient group
representatives in groups that plan and manage services. Box 24, below, describes some joint
work undertaken by South Buckinghamshire NHS Trust and the Skin Care Campaign. The
resource pack contains samples of questionnaires developed and used by the Action On
pilot sites.
Box 24 South Buckinghamshire NHS Trust/Skin Care Campaign
joint dermatology patient involvement project
This project was instigated by the Dermatology Unit at Amersham Hospital and conducted
jointly by the South Buckinghamshire NHS Trust and the Skin Care Campaign (SCC). The
SCC was invited to develop means of discovering patients’ needs of the dermatology unit
and of matching dermatology services to patients’ expectations.
While recognising that there may be more sophisticated techniques for obtaining patients’
views, it was agreed that for the purposes of this study questionnaires probably offered the
most cost-effective and least disruptive means of gathering the information. A pilot study
was run at Amersham and Wycombe Hospitals through the late summer of 2002, comparing
patient-completion of questionnaires with the completion of similar questionnaires by
interviewers.
The report on the pilot study is available on the SCC website at
www.skincarecampaign.org . The outcomes from the project are being used both to assess
the practicability and efficacy of the questionnaires and procedures themselves and to
facilitate improvements in the dermatology unit’s services.
The pilot questionnaire concerns patients’ appointments with doctors. (An example (updated to reflect lessons learnt during the pilot study) is in the resource pack, as is a copy of
the protocol for the study. Similar questionnaires are being developed for outpatient
appointments with nurses and for inpatients and will be posted on the SCC website once
they have been validated.
34
Action On Dermatology Good Practice Guide
Chapter Five
5
Chapter Five
Recommendations
35
5
Chapter Five - Recommendations
Recommendations
Recommendations for local action
Vision and engagement
1.
Have a forum for debate within the health system. A regular meeting between GPs,
consultants, PCT and acute trust managers, specialist nurses and patient group
representatives is an excellent way of forming joint views and plans, and of keeping
them under review.
2.
Develop a shared understanding of which service elements are provided by which staff
and in what setting. Agree and implement guidelines for the treatment of skin disease
in primary care and for referral to secondary care.
3.
Develop a shared vision of how dermatology services should look in the future. This
should ideally be developed by the main service providers (usually the GPs and
consultants in a local system) and be explicitly supported by those who are
commissioning the services.
4.
Produce a clear and widely understood written statement of current service provision,
the shared vision for the future, and the plan for getting from one to the other. Be
prepared to sell it.
Using information to manage
5.
Compare your service to others. Included in the resource pack is a benchmarking tool,
which allows you to compare your services across a range of standard indicators.
Waiting times data for all NHS trusts is also available via the Department of Health
website at http://www.doh.gov.uk/waitingtimes/index.htm.
6.
Consider undertaking local data collection on specific issues, such as outpatient case
mix. A short “sampling” exercise can be very useful in informing a discussion of current
service provision, and in monitoring the impact of any changes.
7.
Undertake a basic assessment of service capacity and demand. Make allowance for
variations over time and identify the extent of any fundamental underlying shortfall in
provision for debate with service commissioners. The improvement leaders guide to
process mapping, analysis and redesign and a simple capacity and demand case study
are included in the resource pack.
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Action On Dermatology Good Practice Guide
Chapter Five - Recommendations
8.
9.
5
Identify trends in referral rates and casemix change.
i.
Use to inform overall capacity discussions with commissioners
ii.
Examine reasons for variation over time and across practices
iii
Consider providing targeted feedback, support and education to highreferring practices.
Look at trends in DNA rates and follow-up to new ratios, overall and at consultant and
clinic levels. Examine reasons for variations.
Organisation of services
10.
Use process mapping to take a fresh look at the way the whole service works. Simplify
and streamline processes and identify any bottlenecks.
11.
Encourage the development of GP and primary care nursing skills through educational
events, outreach “teach and treat” clinics, and the use of clinical assistant posts to
develop GP specialist interests.
12.
Develop accessible advice/support services using telephone and computer links for
GPs wishing to provide an extended range of services in primary care.
13.
Link GPwSIs to specialist departments for training, audit, clinical governance and CME
purposes.
14.
Consider developing a GPwSI service. Use clinical assistant posts to develop interested
GPs.
15.
Develop specialist nurse-led clinics both for treatment and management advice,
particularly for patients suffering from chronic conditions e.g. eczema, dressings, light
treatment etc.
16.
Set up direct referral options to GPwSIs and to specialist nurse-led clinics, and
encourage their use by GPs.
17.
If consultant time is a bottleneck, make sure that the system is set up so that the
consultants’ time is optimised. Consultants should be doing the things that only they
can do, with all necessary support services in place to ensure that their time is
used effectively.
Action On Dermatology Good Practice Guide
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5
Chapter Five - Recommendations
18.
Make sure that there is a balance between the various elements of service provision –
new outpatient appointment slots, return appointment slots, capacity for patch
testing, surgery, light treatment etc., as well as within supporting services such as
pathology.
19.
Recognise that teaching, training, and clinical governance responsibilities will have an
impact on the capacity of specialist services.
20.
Introduce one-stop services for patients requiring minor surgery by using nonconsultant staff for simple cases (specialist nurses, GPs undertaking clinical assistant
sessions, junior staff from surgical specialties).
21.
Consider introducing pooled waiting lists.
22.
Refer patients who DNA back to their GPs and remove them from the waiting list.
23.
Consider reducing consultant follow-up appointments by:
24.
i.
Developing nurse-led follow-up clinics or nurse-led telephone follow-up
ii.
Using “SOS” appointments
iii.
Offering a telephone advice service for long-term patients
iv.
Using telephone or written feedback of biopsy results.
Regularly validate long waiting lists. Ensuring that patients are still at the same address
and still want to be seen can help reduce DNA rates and wasted slots.
25.
Implement the Step-by-step guide to improving outpatient services (Dept of Health,
July 2000), a copy of which is included in the resource pack.
Physical facilities and equipment
26.
Make sure that physical facilities are not a bottleneck. Provide capacity in outpatient
settings to ensure that patient throughput is not constrained by patient ‘changing
time’. Consider development of facilities in primary care settings in order to support
development of GP led services.
27.
Make the most of staff skills by co-locating treatment areas, outpatient facilities,
and secretarial support.
28.
Provide adequate capacity for minor surgery to take place as required
during clinics.
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Action On Dermatology Good Practice Guide
Chapter Five - Recommendations
29.
5
Ideally dermatology should have a dedicated facility. If the ideal is unobtainable,
consider the art of the possible. Are there disused wards or other facilities that could
be refurbished to create a dermatology unit?
See box 2 describing the South
Manchester capital scheme.
Recruitment and retention
30.
Grow your own – develop and train existing staff.
31.
Develop local interest by providing support and training to GPs and community and
practice nurses.
32.
Build clinical networks with neighbouring providers.
33.
Be flexible in agreeing contractual arrangements with staff – use part-time and
“annualised” contracts.
Patient accessibility and involvement
34.
Involve patients and patient groups in service planning.
35.
Offer treatments such as light treatment on an “extended day” basis.
36.
Develop existing service networks in primary and community care to reduce
attendance at hospital departments. See box 11 for a description of nurse-led
teledermatology in East Devon.
37.
Develop nurse-led education to support patient self-management by educating and
motivating patients to use treatments correctly.
38.
Structure services so that long-term patients can access different elements depending
upon their needs.
39.
Provide “take away” information including contact details for local support groups.
If you are developing a new department include a patient resource centre that can
provide written, electronic and visual resources and be accessed by all the local
healthcare community (patients and healthcare professionals).
40.
Substitute patient helplines for routine follow up appointments.
Action On Dermatology Good Practice Guide
39
5
Chapter Five - Recommendations
Recommendations for national action
1.
Undergraduate Training: Consideration should be given to the provision of core
dermatology education for all medical and nursing undergraduates
2.
General Practitioner training schemes: should offer education and training in
dermatology that reflects the workload that GPs will face in practice.
3.
Specialist training places: numbers of specialist training places (national training
numbers) in dermatology should be urgently reviewed and increased to provide
qualified candidates both for existing consultant vacancies and for the expansion of
consultant posts needed over the next ten years.
I would never have
believed that eczema has the
capability to immobilise a sufferer to
the point where walking
becomes difficult.
40
Action On Dermatology Good Practice Guide
A1
Pilot site summaries
Appendix one Pilot site summaries
41
A1
Appendix 1 - Pilot site summaries
Royal Devon & Exeter Healthcare & East Devon PCT:
Development of primary care management of dermatological problems
Contacts
Beverly Stretton-Brown Action On Dermatology Project Manager, East Devon PCT
Dean Clarke House, Southernhay East Exeter EX1 1PQ
[email protected]
Dr Tessa Frost
Lead Clinician Dermatology Department,
Royal Devon & Exeter Hospital, Barrack Road, Exeter
Objectives
i.
To improve patient access to routine dermatology care and treatment, by offering nurse-led dermatology
care, supported by telemedicine, in each East Devon local community.
ii.
To improve appropriateness and priority of secondary care referrals and consequently reduce waiting times
for an initial routine specialist dermatology opinion.
iii.
To improve dermatology advice, support and education to community clinicians.
iv.
To evaluate the success of nurse-led dermatology clinics in the community in improving the management of
dermatology and if appropriate, encourage their widespread adoption.
How it was done
i.
Pilot nurse-led clinics were set up in six community settings across East Devon, supported by telemedicine.
ii.
The project recruited four local community nurses, who already had a special interest in dermatology. The
nurses underwent an extensive training programme and have ready access to the specialist team at the acute
dermatology department via the use of the telemedicine equipment.
iii.
The clinics started as triage centres for all appropriate routine dermatology referrals. At the clinic, the nurse
takes the patient history and a photographic image, which are encrypted and transmitted to the consultant
for opinion later that week. Waiting time from GP referral to the patient receiving the specialist opinion is
less than three weeks on average. The nurses’ opinion at this stage can be a valuable source of information
for the consultants.
iv.
In September 2002 the clinics will be extended to provide treatment advice and follow-up management from
the nurses. The nurses are undergoing additional training for this extended role, and will again be supported
by the telemedicine equipment and ongoing supervision from a specialist dermatology nurse. The nurses will
work to treatment plans advised by the consultants, and will be supporting patients in understanding and
complying with their treatment.
Results to date
i.
Early indications, as at June 2002, showed:
ii.
On average, patients receive a specialist opinion within three weeks from the date of GP referral
iii.
Nearly half (43%) did not require an appointment at the dermatology department in Exeter.
iv.
A further 23% were suitable to be triaged into other clinics at Exeter, which meant that those needing skin
surgery at Exeter could be operated on without having had to attend a previous appointment at the RDE.
v.
The majority (66%) were saved a round-trip to Exeter, which in turn released routine slots and consultant
time for more appropriate cases at the dermatology department at the acute hospital.
vi.
33% needed a face to face consultation with a specialist, and those patients were offered a routine
dermatology appointment at Exeter.
vii. Of the GPs that have been approached in a random survey, 100% said they would like the service to continue.
Conclusions/lessons learned
42
i.
Results to date indicate that the use of telemedicine can be successful as a support tool in community
settings, but is time consuming in terms of managing the system. A key lead person is required to liaise
with the telemedicine supplier for the duration of the project and beyond and a good working relationship
with the supplier is essential to overcome the inevitable problems.
ii.
Having a paper based referral and reply process builds unnecessary delays into the system. Compatible
electronic communication structures across the GP practices, the central booking system, the community
hospitals and the acute hospital would be the ideal situation.
iii.
Direct booking has kept the DNA rate to around 1%.
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
A1
Eastern Wakefield PCT, Mid Yorkshire Hospitals NHS Trust:
Development of an integrated dermatology service across primary
and secondary care.
Contacts
Sally Cocker
Action On Dermatology Project Manager
Dermatology Department, Pontefract General Infirmary, Southgate, Pontefract WF8 1PL
01977 606885
[email protected]
Objectives
i.
To utilise the skills of GPwSI’s in dermatology in a new primary care dermatology service.
ii.
To develop nurse-led clinics in both the primary and secondary care services.
iii.
To improve the interface between primary and secondary care including a rapid access facility between the
two and the use of teledermatology to aid prioritisation
iv.
To develop a robust framework for CME, training and accreditation for GPwSIs.
How it was done
Primary care service
i.
Referral criteria, specific qualifications for GPwSI status, CME and continuing training requirements were
agreed and a framework for appraisal and re-accreditation was developed.
ii.
A suite of rooms comprising waiting room/reception, treatment room, minor operating theatre and two
consultation rooms was refurbished to provide a base for the new service.
iii.
Satellite clinics take place around once a fortnight at a health centre which serves the south side of the PCT
patch.
iv.
Five GPwSIs provide around ten sessions per week including two minor surgery sessions. They are supported
by two nurses – both former practice nurses – who make up 1.5 whole time equivalent (WTE).
v.
The nurses currently run two cryotherapy clinics per week and are exploring other options for nurse-led
services such as psoriasis, eczema and leg ulcer clinics. There is dedicated reception and clerical support.
vi.
Referrals come direct from GPs (around 25 per week) or are redirected from secondary care. The GPwSIs
organise extra ad hoc clinics to keep waiting times low and partial booking has recently been introduced
which may contribute to lower waiting times.
Nurse-led services
i.
Secondary care nurse-led clinics have been developed for cytotoxic monitoring, minor surgery and eczema.
ii.
In primary care, the nurses run a cryotherapy clinic. Other services will be developed, but this has been
slowed by difficulties recruiting a nurse practitioner.
Interface between primary and secondary care
i.
The rapid access clinic is continuously monitored to see where patients are coming from and where they are
followed up. It also ensures that patients do not get lost in the referral process. Results show that around
12% of patients attending the rapid access clinic are referrals from the primary care service.
ii.
A digital camera has been purchased by the primary care service to facilitate teledermatology and work is
underway to install a network link to the acute trust.
GPwSI accreditation
i.
The framework for training, continuing medical education and accreditation was developed jointly by the
consultant dermatologists and the GPwSIs. BAD guidelines were used as a basis for the frequency of
educational contacts; the type of contacts was made flexible and appropriate to the service. This has the
benefit of giving the GPwSIs a more varied dermatology education.
Action On Dermatology Good Practice Guide
43
A1
Appendix 1 - Pilot site summaries
Eastern Wakefield PCT, Mid Yorkshire Hospitals NHS Trust:
Results to date
Demand for secondary care has risen since the waiting times reduced:
i.
Jan-May 2001 (before primary care service) GP referrals to secondary care totalled 1013 (average 203 per
month)
ii.
Jan-May 2002 (after primary care service) GP referrals totalled 1325 (average 265 per month)
iii.
If all GP referrals to primary and secondary care service are added together, they average 404 per month
Waiting times have reduced since the start of the primary care service, though this is also partly due to waiting list
initiative clinics held in secondary care:
i.
June 2001 – 518 patients waiting over 13 weeks
ii.
June 2002 – 92 patients waiting over 13 weeks
iii.
March-July 2001 GPwSIs saw 482 patients as part of waiting list initiatives
iv.
384 patients to date diverted from secondary care waiting list to primary care service
v.
Some of the 775 patients referred directly to primary care service would otherwise have gone to
secondary care
Conclusions/lessons learned
Improving access to services can lead to a rise in demand. When secondary care capacity was at its lowest, the
rate of referrals from GPs dropped to a low of 150 a month. Now that waiting times have improved, referrals
have risen to a high of 357 a month.
However, the figures may not be indicative of the future, as it is likely that GPs were suppressing referrals
when waiting times were high. Early indications also show that the referral rate may slow down again. In any
event, the extra capacity has meant that a previously unmet demand is now being met and that more patients
are gaining access to high quality dermatology provided by practitioners with appropriate training and skills.
44
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
A1
South Manchester PCT & South Manchester University Hospitals:
Development of primary care management of dermatological problems
Contacts
Anne Warrier Project Manager
Action On Dermatology
Tel: 0161 291 3898
Fax: 0161 291 4277
[email protected]
Objectives
i.
Improve patient access to care through the integration of secondary and primary care services.
ii.
Development of an education programme for primary care professionals.
iii.
Preparing and implementing protocols for treatment of specific skin conditions.
iv.
Establishment of GP/Community Nurse helpline.
v.
Education of patients to facilitate self-care.
How it was done
i.
With Action On capital funding, Buccleuch Lodge on the Wythenshawe Hospital site was refurbished to house
the re-designed dermatology service. It is a joint venture between SMUHT and South Manchester PCT and
staff from both areas work towards an integrated service.
ii.
All GPs in South Manchester were asked to complete a baseline data questionnaire to establish the level of
knowledge of and interest in dermatology locally. The results revealed that none of the local GPs had
undertaken any formal training in dermatology. GPs were then asked whether they would be interested in
undertaking some dermatology training.
iii.
Ten GPs attended four half-day minor surgery study days combining theory and practical techniques. Four of
the ten went on to further practical training working alongside the consultants in outpatient clinics.
iv.
The first two GPs completed initial training and started their own minor surgery clinics as GPwSIs-in-training
in June 2002. The remaining two started minor surgery clinics in August 2002.
v.
All GPwSIs-in-training complete a logbook and each section is signed off by the consultant to reach the
required competencies. An accreditation paper has been agreed with the PCT Professional Executive
Committee.
vi.
In addition to the GP minor surgery training, education programmes were written, developed and delivered
to community nurses on eczema, psoriasis and lower limb skin disease.
vii. To date 80 community nurses have attended two full day eczema and two full day psoriasis study days. 40
community nurses have attended the half day lower limb skin disease study days.
viii. Protocols to support community nurses in the treatment of eczema, psoriasis and lower limb skin disease have
been written and implemented. A dedicated helpline has been established for community nurses who have
been trained providing ongoing support and help from the specialist nurses.
ix.
The education programme is cascading from the community health professionals to the patients by means of
community eczema clinics and patient care plans prepared individually by the specialist nurses.
x.
The resource materials developed to support the GP and nurse training will be published in early 2003.
Action On Dermatology Good Practice Guide
45
A1
Appendix 1 - Pilot site summaries
South Manchester PCT & South Manchester University Hospitals:
Results to date
i.
The integration of secondary and primary care has been achieved through joint agreement and meetings
within the project team. The redesigned dermatology service has been adopted as mainstream working and
recurrent funding from 2002/2003 has been agreed through the Service and Financial Framework process.
ii.
GP referrals to the specialist nurses for atopic eczema have been reduced by 50%.
iii.
Domiciliary visits by the specialist nurses have reduced by 60%.
iv.
This has enabled the specialist nurses to start triaging secondary care referrals for psoriasis and eczema.
v.
The care pathway for patients has now extended from the consultant dermatologist to the GPwSI and
specialist nurse service.
Conclusions/lessons learned
46
i.
Establish the baseline data - identify local needs
ii.
Understand your own service-assess the casemix of conditions seen
iii.
Communicate the aims of the redesign process. This is a long term sustainable programme, not a “quick
fix”. Ensure everyone is aware of the timescales and eventual benefits.
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
A1
West Hertfordshire NHS Trust:
Joining up primary and secondary care
Contacts
Sue Gunn Project Manager,
Julia Schofield Consultant Dermatologist
Action On Dermatology
West Hertfordshire NHS Trust
West Hertfordshire NHS Trust
St Albans City Hospital, Waverley Road
St Albans City Hospital, Waverley Road
St Albans AL3 5PN
St Albans AL3 5PN
Objectives
i.
To manage demand for dermatology services effectively by improving education and training of local GPs and
developing a lead GP in each GP practice
ii.
To streamline the referral process
iii.
To improve patient access to dermatology services by developing a GPwSI led primary care clinic
iv.
To develop and evaluate disease specific nurse led clinics
v.
To improve links between primary and secondary care
How it was done
i.
A GP lead was identified for dermatology within each practice and an educational programme developed for
the lead GPs
ii.
A structured referral letter was developed and circulated to all GP practices
iii.
GPs were offered the facility to send referrals electronically, i.e. an image attached to a referral sent by email
iv.
Referral letters are triaged and prioritised
v.
Patients were seen either by a GPwSI in a primary care setting servicing the PCT, in the disease specific nurseled clinic, the dermatology outpatient clinic or the “see and treat” clinic.
vi.
The GPwSI is a member of the dermatology department and saw an agreed caseload in a primary care setting
supported by a dermatology nurse from secondary care with access to all the diagnostic and treatment
facilities in the department.
vii. The GPwSI had ready access to a consultant opinion. Some patients were not seen by the consultant at any
time.
viii. The GPwSI saw an agreed caseload of routine referrals according to an agreed protocol. In addition four slots
were allocated for patients from the GPs’ practice who were then able to benefit from the skill and expertise
of the dermatology nurse from the secondary care sector.
ix.
Patients seen in the nurse-led clinics were offered a rapid assessment appointment where initial treatment
was implemented. The nurse then prioritised whether the patient required an urgent or routine assessment
by the consultant.
x.
“See and treat” clinic: This provided a one stop minor surgery service and acted as an educational resource
for training GPs in minor surgery. Once established it is envisaged that this will move to a central community
location, under the supervision of the dermatology department.
Action On Dermatology Good Practice Guide
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Appendix 1 - Pilot site summaries
West Hertfordshire NHS Trust:
Results to date
i.
All the initiatives have been successfully implemented and have been in place for 12 months
ii.
Waiting times for patients seen in the GPwSI clinic with the agreed diagnoses have fallen significantly from
140 days to an average of 43 days.
iii.
Overall waits for the consultant clinics have also reduced, however this may be also related to waiting list
initiatives in March 2002.
iv.
Quality of care evaluations in relation to the GPwSI clinic suggest that most patients are being managed
appropriately.
v.
Patients seen in the disease specific nurse led clinics are receiving advice about their management much
earlier than in their routine clinic appointment (31 days average compared with 140 for a routine clinic
appointment).
vi.
Patients seen in the nurse-led clinics are having their clinic appointments expedited appropriately and
commencing dermatology treatment earlier than they might have done had they waited for the routine
consultant appointment.
vii. The structured referral letter is being used but not as widely as hoped. GPs remain reluctant to grade the
letters with appropriate clinical priority.
viii. There has been little or no uptake of the facility to send electronic referrals.
ix.
The educational sessions have been well supported, but not all GP practices are represented. Data on the
impact of appropriateness of referral is awaited.
x.
The “see and treat” clinic runs efficiently and the wait time for excision of benign lesions in this setting has
reduced from 217 to 39 days.
Conclusions/lessons learned
i.
The GPwSI clinic has provided additional capacity to cater for a proportion of the routine dermatology
referrals and reduced waiting times. We are now going to pilot the clinic as a one-stop clinic for patients
coded as “soon” with skin lesions (e.g. BCCs) to address current capacity/demand shortfalls in this area.
ii.
The nurse-led clinics offer an effective triage facility for patients and also enable a management plan to
be commenced.
iii.
The “see and treat” clinic for benign skin lesions is efficient. It is debatable whether this facility should be
supported in the secondary care sector and the idea is to move this into the community.
iv.
Changing practice in relation to the referral process is difficult. We need to explore further why the
uptake of the electronic referral facility and the structured referral letter was so low.
v.
The educational programme required a considerable amount of consultant time and it will be important
to evaluate the impact of the programme on referrals before deciding whether to continue with this.
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Appendix 1 - Pilot site summaries
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St Mary’s NHS Trust and Westminster PCT:
Better access and shared care in dermatology
Contacts
Mary Clegg Service Manager - Ambulatory Medicine
St Mary’s NHS Trust
[email protected]
Ursula Daee Primary Care Development Manager
Westminster Primary Care Trust
[email protected]
Objectives
i.
To increase the role of GPs with a special interest in dermatology (GPwSI), to receive referrals from other
practices in Westminster PCT
ii.
To develop specialist nurse posts to run nurse-led clinics and support GPwSIs
iii.
To redesign booking systems moving towards direct booking of outpatient appointments
iv.
To improve education and training structures for GPs and nurses
How it was done
GP Specialist dermatology service
i.
A local GP with extensive experience as a clinical assistant was recruited to provide two clinics each week in a
community health centre. The service began accepting referrals in November 2001 from GPs in the PCT
according to locally agreed guidelines.
ii.
A fax booking system was set up, so patients could book directly into the clinic within 48 hours of referral.
Administrative and IT systems were developed; a dedicated member of staff was recruited to support the
service on site.
iii.
A nurse was recruited as part of the project to support the service and provide additional links to the St
Mary’s department. The nurse is undergoing training in dermatology and will soon be providing nurse-led
treatment clinics alongside the GPwSI.
iv.
The consultant team at St Mary’s work closely with the GPwSI, providing clinical leadership, training and
support. Patients requiring further dermatology treatment at the hospital can be fast-tracked into an
appropriate appointment.
v.
The service will continue to be funded by Westminster PCT and will be re-evaluated in summer 2003. A
second GPwSI was recruited in October 2002. Work is ongoing to formalise the accreditation process.
Dermatology Nurse Specialists
i.
Two nurse specialist roles were introduced just prior to the start of the project. As part of the pilot, new
nurse-led treatment clinics and follow-up clinics for eczema and psoriasis were introduced in the hospital. The
range of treatments offered will expand with the development of a dedicated day treatment unit.
ii.
The nurse specialists have also developed an education package for non-specialist nurses throughout the
hospital.
iii.
The pilot had planned to recruit a dermatology liaison nurse to implement nurse-led clinics and education
sessions in primary care. Unfortunately, difficulties in recruiting a specialist nurse grade with non-recurrent
funding meant that this part of the project could not be pursued.
Action On Dermatology Good Practice Guide
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Appendix 1 - Pilot site summaries
St Mary’s NHS Trust and Westminster PCT:
Direct booking
i.
Referral protocols were written for electronic referral from GP surgeries to outpatient clinics. Guidelines to
manage chronic conditions in primary care were developed to assist GPs in making referrals.
GP Education
i.
A questionnaire was sent to all GPs in Westminster to assess interest in continuing medical education in
dermatology. An initial half-day session delivered by the consultant and GPwSI team is planned in 2003,
based on the responses to this survey.
ii.
To support these developments, the project has implemented regular assessment of patient experience,
through postal questionnaires.
Results to date
i.
The average wait for an appointment at the GPwSI Service was 51 days (Mar-Aug 02). However, the method
of booking appointments means that some patients did not phone for several weeks after their referral had
been received. Adjustments to the administrative processes have been made to prevent this from recurring.
The average time between patient phone call and appointment date was 35 days (Mar – Aug), which is
perhaps more representative of the actual wait.
ii.
235 new patients were seen by the GPwSI since launch (to August 2002). 78 were seen for follow-up
appointment or minor procedure. 7 patients were referred for further care at St Mary’s dermatology
department.
iii.
Both GP and patient satisfaction with the GPwSI service was high. In response to patient experience
questionnaires at the hospital, a new range of patient information leaflets were introduced for several
conditions.
iv.
Waiting times for a consultant dermatology appointment at St Mary’s has been maintained at eight to 10
weeks in the face of rising demand in the locality.
Conclusions/lessons learned
50
i.
Impact on the waiting times at St Mary’s has been difficult to assess since GPs in Westminster PCT refer to
several different acute trusts. Further analysis of GP referral patterns is required in order to establish
whether the service is meeting previously unmet demand.
ii.
The GPwSI service has had a positive impact on staff retention and development. Patient experience of the
service was better than at the hospital site.
iii.
Recruitment to specialist dermatology nursing posts can be very difficult; training existing non-specialist
nursing staff to deliver some aspects of the project has proved both successful and rewarding. By sharing
posts across hospital directorates and between primary and secondary care training costs and the
subsequent benefits can be shared.
iv.
Robust administrative and IT systems must be in place to support service developments and enable
effective audit and evaluation.
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
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Basildon & Thurrock General Hospitals:
Redesign of the patient care pathway
Contacts
Jennie Leigh Senior Dermatology Nurse Practitioner
Basildon & Thurrock General Hospitals
[email protected]
Objectives
i.
To establish a GPwSI clinic in the community
ii.
To establish practice nurse-led treatment clinics, supported by hospital specialist nurses
iii.
To provide education to community nursing staff
iv.
To develop a faster and more effective treatment pathway for leg ulcer patients by establishing a
nurse-led ulcer clinic
v.
To develop a telephone follow up clinic
How it was done
i.
The GPwSI clinic has been operational since January 2002, run by a local GP who has been working within the
department as a hospital practitioner for 18 years. The clinic operates twice weekly from the GP practice,
serving patients from the local PCT. There are ten patient slots with the capacity for minor ops. The patients
book their own appointments and then attend with a referral letter. The clinic operates independently from
the hospital but under the direction of the department.
ii.
An established, medically led leg ulcer clinic was converted to a nurse-led clinic. The frequency of the clinic
was increased from fortnightly to weekly, so enabling all leg ulcer referrals to be seen in one set clinic. The
clinic has the capacity for five patients per session and coincides with a general, consultant led clinic. The
consultant and clinic nurse grade all referrals, inappropriate referrals are discussed with the referee and
redirected to the appropriate care provider. The clinic provides training to hospital and community
nursing staff.
iii.
The telephone follow up clinic has been operational since March 2002. Referrals are booked into the weekly
clinic via the PAS system. The referral form states the patient’s clinical diagnosis, treatment and expected
clinical out come, plus any additional information the clinician wishes reiterated. Patients are notified of the
time and date of their appointment and the name of the nurse who will be contacting them. The
consultation and outcome are documented in the medical notes.
Results to date
i.
Since the implementation of the GPwSI service the reduction in referral numbers from the PCT has been
similar to the number of referrals made to the GPwSI clinic. A GP and patient satisfaction survey is currently
being undertaken. General feedback from local GPs has been very positive to date. Discussions are in progress
with the PCT for continuing funding for the next financial year.
ii.
The nurse-led leg ulcer clinic has defined the pathway for leg ulcer referrals into the department. Eighteen
general patient slots have been created each month. There has been a significant rise in community liaison
over the care of patients with leg ulcers and a local leg ulcer forum has been established. The senior nurse
visits community ulcer clinics and carries out home visits with district nursing staff.
iii.
The telephone clinic has only been operational for six months: to date a significant number of patients that
are being referred to the service are those who would have otherwise been allocated an SOS appointment.
This was not the original aim of the service, but it is still developing and further evaluation is required.
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Appendix 1 - Pilot site summaries
Basildon & Thurrock General Hospitals:
Conclusions/lessons learned
52
i.
The senior dermatology nurse acted as project manager as well as retaining some clinical duties. More
time for earlier evaluation may have been available had a dedicated project manager been employed.
ii.
A positive effect has been noted from all of the new service initiatives implemented. The only part of the
project that has not been fully implemented is the community practice nurse education programme. There
is an obvious tension between staff clinical commitments and time available to attend educational
sessions. An education programme is being devised; however, protected educational time is the only way
to ensure an effective programme can be fully implemented.
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
A1
Birmingham Health Authority & Partners:
Integrated working in dermatology in Birmingham
Contacts
Paul Gibara
Divisional General Manager
Queen’s Burton Hospital
01283 566 333 ext 5900
Objectives
i.
To develop a Birmingham system of dermatology networks
ii.
To develop new roles of specialist liaison nurses and GPwSI’s across mixed health economy of Birmingham
iii.
To establish an advanced mainstream educational programme in partnership with key educational and
workforce planning organisations
iv.
To develop treatment pathways to underpin primary care practice
v.
To work towards the development of electronic referral
vi.
To model capacity and demand for dermatology in Birmingham
How it was done
i.
Four dermatology clinical networks were set up across Birmingham which report to the Birmingham Skin
Services Group (BSSG). The BSSG represents a partnership between the five main acute trusts that provide
dermatology services in Birmingham and their respective primary care organisations. This organisation is able
to ensure a consistent approach to service delivery across the locality.
ii.
Four specialist liaison nurses were recruited, following the agreement of job descriptions and key
competencies by the BSSG. These roles involve providing nurse-led clinics in primary and secondary care,
patient advice and delivery of nurse education.
iii.
Treatment pathways for four common conditions were developed and posted on the StHA website. Each
clinical network was tasked with the implementation of these pathways.
iv.
A multi-disciplinary educational steering group was set up to include Birmingham University, The Workforce
Confederation, the BSSG and the British Dermatology Nursing Group.
v.
Initial work was undertaken to develop an accepted core curriculum for both nursing staff and GP’s. It is
expected the first components of the programme would be ready in late 2002.
vi.
A GP Skin Forum was established to support interested GPs.
vii. Guidelines for the accreditation of GPwSIs were developed by a multi-disciplinary team with representation
from primary and secondary care. The guidelines have been endorsed by the BSSG.
viii. An extensive exercise to model capacity and demand for dermatology within the Birmingham health
economy was carried out
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Appendix 1 - Pilot site summaries
Birmingham Health Authority & Partners:
Results to date
i.
Process mapping and implementation of partial booking reduced DNA rates of 25% to 7% in one trust and
reduced the waiting list for new patients to an average of 8 weeks.
ii.
Since the early work on capacity and demand was carried out, two new consultant dermatologists have been
appointed within the BSSG.
iii.
The work undertaken in Birmingham represents a long-term strategy of improvement in dermatology. It is
not expected that the full benefits will be realised in the short-term.
Conclusions/lessons learned
The work on capacity and demand has demonstrated that there are significant variations in workload across
the city, and consequential inequalities in access. It is logical that a centralised approach to booking of
patients would balance out any disparity.
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North Staffordshire Hospital & Partners:
Action On Dermatology
Contacts
Kara Thomas , Project Manager
Jacky Lee, Lead Nurse
Service Improvement
Action On Dermatology
North Staffordshire Hospital NHS Trust
Dermatology Department
North Staffordshire Hospital NHS Trust
[email protected]
[email protected]
Objectives
i.
To improve access to dermatology specialist opinion by establishing GPwSI clinics and
outreach nurse-led clinics
ii.
To improve health outcomes by implementing primary care based chronic disease
management protocols
iii.
To improve patient choice through the implementation of partial booking systems
How it was done
i.
Initially the GPwSI service was piloted as a treatment initiative. One GP had the required training and
interest, and was then accredited and a list of conditions agreed. Following the success of this initiative the
service continued, operating a direct referral protocol from GP to GPwSI. The service has since been
extended, so that three out of four 4 PCTs have a clinic operating in a community location. The fourth clinic
is due to commence in November 2002. There are now three GPwSIs with a proposed “trainee” commencing
shortly as a clinical assistant in secondary care.
ii.
The nurse-led clinics for the treatment of warts are protocol driven, operating in secondary care at this time.
Referrals are triaged as they come into the department to these clinics.
iii.
The nurse-led eczema and psoriasis clinics for children operate in four community locations. A referral and
waiting list analysis was undertaken to determine the demand for this service. Protocols and guidelines were
developed. A referral pro forma was developed and communicated to all GPs and community nurses. The
referral is faxed to the department and an appointment is made through a partial booking system. The
service focuses on treatment, demonstrations and education, for the “expert patient”.
iv.
Practice based care involves community nurses running their own eczema and psoriasis clinics for patients in
their practice or area. The community nurses have undertaken comprehensive training packages developed
by the lead nurse for the project. As part of this the nurses undertake a distance learning course in eczema
and psoriasis and have sessions with the lead nurse for training purposes.
v.
Partial booking has been implemented following the development of the Hospital Information System, to
provide an electronic solution. It now operates for all routine dermatology patients.
Results to date
i.
In the GPwSI clinics the average wait times are 14 days. Direct booking has been successful in reducing the
numbers who did not attend (DNA) but it was necessary to support the clinics with central triage while the
new booking system was communicated.
ii.
Both the children’s eczema and psoriasis clinics and the wart treatment clinics have proved successful in
reducing average waiting times. Patient satisfaction has been high, particularly in the children’s clinic, where
100% of people surveyed felt that they were now able to manage their child’s condition.
Action On Dermatology Good Practice Guide
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Appendix 1 - Pilot site summaries
North Staffordshire Hospital & Partners:
iii.
Practice based care has been successful. No patients have been referred into secondary care where this
service operates for eczema or psoriasis. In addition audit has shown that approximately 42 GP appointments
could be saved in one GP practice per annum where they have access to this service. Patients have
commented that they are now able to manage their conditions effectively.
iv.
Partial booking has reduced the DNA rates by approximately 6% and ensures that patients are seen in
chronological order.
v.
The collaborative approach to dermatology in North Staffordshire has led to a future model of care where
patients have access to primary care led services and ultimately the consultant in secondary care. This has
resulted in a 17% reduction in the referrals coming to the consultant dermatologists compared to the
previous 12 months and a 23% reduction compared to the total referrals for all services during this period.
This means that demand is now better managed across a number of services. Overall waiting times in
secondary care have reduced from an average of 140 days to 78 days at the end of the project.
Conclusions/lessons learned
56
i.
Management of change is the first point to tackle in any project, before anything else is done. Many
people put up barriers even before anything is changed.
ii.
Redesign does not happen overnight. With intense operational targets, many people will expect the
project to deliver the objectives in a short time scale. The benefits and timescales should be
communicated and made clear right at the start of the project.
iii.
Monitoring wait times, patient satisfaction and increases in care pathways as the project initiatives
develop can provide valuable evidence on impact of new services. This is also vital information to build
into business cases for the future.
iv.
New services require intense communication, sending letters about services to health care professionals
who are already “swamped” with paperwork is not effective. The personal touch through short meetings
and presentations is more effective.
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
A1
Southampton University Hospitals NHS Trust
& Southampton Primary Care Trusts:
Joint dermatology initiative
Contacts
Louise Arnett (née Goodall), Project Manager
Action On Dermatology and Dermatology Booked Admissions
023 8082 5723
[email protected]
Objectives
To work in partnership across primary and secondary care to improve the range and access to services for patients
with dermatological conditions. Specific objectives;
i.
To improve the patients’ and carers’ experience; by providing more education for patients resulting in
improved self management of chronic conditions and empowering patients and carers, providing open
access/SOS appointments in secondary care, developing one stop services to streamline the patients journey
ii.
To develop nurse-led services in surgery, primary care, liaison and skin cancer across both primary and
secondary care
iii.
To continue to develop GPwSI services in primary care and better education and training for GPs and other
primary care health professionals facilitating quicker and more local treatment
iv.
To involve staff and users
v.
To redesign existing services and processes to improve access and quality through our links with the local
Access, Booking and Choice programme.
vi.
To implement a programme of booked appointments across primary and secondary care
How it was done
i.
Four GPwSIs followed our training and accreditation programme. During this time they worked alongside a
consultant in a hospital location seeing patients triaged by the consultants. Two GPwSIs are currently being
accredited and will start their clinics, based in a GP practice, from November 2002. They will take referrals
directly from GPs, who will follow GPwSI referral guidelines. All appointments will be fully booked. The
accredited GPwSIs will continue to work one session per month in secondary care alongside a consultant
mentor for ongoing training and accreditation.
ii.
In June 2001, a specialist surgical nurse was appointed to develop a nurse-led surgery service and a training
and accreditation programme. At present she holds two fixed surgical sessions per week in addition to
providing two one stop surgical sessions. Further service developments linked to this role are planned. A
second nurse was appointed in October 2002 and is currently undertaking her training.
iii.
In March 2001, a dermatology liaison nurse specialist was appointed to help strengthen the partnership
between primary and secondary care and to promote the integration and co-ordination of dermatological
nursing services across primary and secondary care. Dermatology patients with diagnosed conditions, in
particular eczema and psoriasis, that do not require secondary care but require education and support about
their condition and treatment, can be referred to the specialist nurse. A key part of this role is to provide
education and training to primary care professionals such as GPs, health visitors and practice nurses.
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Appendix 1 - Pilot site summaries
Southampton University Hospitals NHS Trust
& Southampton Primary Care Trusts:
iv.
v.
In April 2001, two nurse-led eczema and psoriasis clinics were set up in primary care to facilitate quick access
and treatment, without patients needing to come into hospital. The clinics are led by practice nurses who
accept referrals directly from GPs. The specialist liaison nurse oversees the development and progress of these
clinics.
Linked to the Access, Booking and Choice programme of booked appointments, the redesign of outpatients
and other services has been carried out. This has included looking in detail at processes and demand and
capacity issues in outpatients and minor surgery and had led to the development of a tool for reviewing and
redesigning outpatients - the “MOT checklist”. Booking in day cases has been implemented to date ands so
far and all referrals from GPs are partially booked. Full booking across other outpatient services, and from GPs
into secondary care will commence shortly.
Results to date
i.
On average the GPwSIs in training are seeing 350 new patients and 300 follow ups per year, generally
treating conditions such as acne, eczema, psoriasis, basal cell carcinomas and papillomas, solar keratoses and
benign lesions. GPwSI service is currently being evaluated; reviewing the type of conditions seen and
procedures performed as well as the proportion and type of patients seen independently by the GPwSI and
those seen with consultant advice. This process has helped the development of the GPwSI guidelines.
ii.
The specialist surgical nurse has recently audited the first three months of the new service. Based on this
information, each trained surgical nurse will see an average of 250/300 patients per year. These patients
would have previously been treated by a doctor. The procedures undertaken in nurse-led surgery are
currently excisions, shave excisions, punch biopsies and curettage and cautery. A patient survey has shown
that all patients treated by a nurse were very satisfied or satisfied post-operatively. The development of
nurse-led surgery is helping to reduce waiting times and enabling the implementation of fully booked
appointments for minor surgery.
iii.
An audit of one of the nurse-led primary care clinics has shown the clinic saw 85 new patients and 140 follow
up treatments in the first year. The clinic saw 87% eczema patients and 13% psoriasis patients of whom 53%
were children and 47% adults. Of the 85 new patients seen, 97% were treated successfully within primary
care with only 3% being referred on to the hospital. Prior to the pilot of the nurse-led clinics, these patients
would normally have been referred to the hospital for treatment and would have waited an average of 13
weeks to be seen. The nurse-led clinic has a two week waiting time. A patient/carer satisfaction survey
showed that all patients felt they benefited from being seen by the nurse-led clinic and were particularly
pleased with the quick access and local location. Parents with young children have found it particularly
beneficial not to have to attend the hospital.
Conclusions/lessons learned
i.
Do not underestimate the data collection process. Before any new service or specialist role is developed,
it is important to understand the existing service and local needs.
ii.
Protocols, service criteria and models of provision should also be agreed prior to the start of any
new service.
iii.
Communicate well and to the right people, raise awareness, sell the idea, be clear of the benefits early on
iv.
Develop an appropriate training and/or an accreditation programme for all new specialist roles at
an early stage.
v.
58
Evaluate, audit and review on an ongoing basis.
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Appendix 1 - Pilot site summaries
A1
Medway NHS Trust:
Patient pathway development programme
Contacts
Diane Horsington
Deputy General Manager for Emergency Patient Services
Medway NHS Trust
01634 833880
[email protected] nhs.uk
Objectives
i.
To improve the quality of care in the primary care setting through the development of management and
referral guidelines
ii.
To develop and enhance the skill and knowledge of local GPs through a programme of educational sessions.
iii.
To develop a GPwSI service supported by a specialist dermatology nurse to provide dermatology services in
primary care.
How it was done
Referral guidelines
i.
Working in partnership with GPs in six local PCGs, guidelines on the most common dermatological conditions
in primary care were developed. Criteria for referral to secondary care complete each guideline.
ii.
iii.
The printed guidelines were given to every GP in November 2001.
At the suggestion of the now four PCTs the dermatology department is able to return a referral if the
guidelines have not been followed.
iv.
The consultant dermatologist and GPwSI delivered monthly education sessions based around the guidelines.
v.
Twelve local GPs joined the year long scheme and are now involved in auditing their practice in their own
surgeries.
GPwSI Service
i.
A consultant dermatologist in the department has trained two local GPs to provide intermediate care for
patients in a primary care setting.
ii.
The GPwSI is able to diagnose and treat, and a specialist nurse provides education and support at the time of
diagnosis. The patient is then returned to their GP with a management plan. A joint consultant clinic is held
fortnightly to see any difficulty cases.
Results to date
i.
The guidelines have been well received by dermatology organisations and departments across the country
ii.
The education scheme has also been well received: 30 applications have been submitted for the next course
iii.
Since the launch of the guidelines, referral rates have remained the same. However, the quality of
information within referral letters has improved.
iv.
The GPwSI service is continuing to develop. There is a new patient clinic per week in primary care seeing eight
new patients. Waiting times for these clinics are considerably shorter than for a hospital appointment but this
is because specific patients are being selected for these clinics. However the discharge rate is comparable with
the hospital clinics and only a few patients have had to return to the hospital for a consultant opinion.
Conclusions/lessons learned
i.
In order to effectively plan changes and new services, it is important to fully understand the current
situation. Sampling data on a small scale is a simple way of getting information to inform the decision
making process.
ii.
Implementing a GPwSI service is not a “quick fix”. A full training and supervision programme must be
followed and the service properly resourced.
Action On Dermatology Good Practice Guide
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Appendix 1 - Pilot site summaries
Addenbrooke’s NHS Trust in Partnership with South
Cambs and Cambridge City PCTs:
Dermatology - a 3600 service
Contacts
Ade Adigun-Harris
Service Delivery Manager, Dermatology
Addenbrooke’s NHS Trust
[email protected]
Objectives
i.
To develop and extend the role of the specialist nurse and GPwSI to reduce the time from referral to
treatment
ii.
To ensure that GP referrals are triaged so patients are seen in the most appropriate component of the service
from the beginning
iii.
To expedite access to ongoing advice and treatment for patients post-surgery and with chronic conditions
iv.
To develop a telemedicine service utilising digital photography to diagnose and treat patients, reducing the
need for consultant clinic appointments
v.
To introduce electronic referrals
vi.
To increase the throughput of day treatment service
vii. To develop confidence among GPs to retain the care of appropriate patients
How was it done
i.
Patient management criteria for specific patient groups were defined, agreed and distributed to clinical staff
ii.
Using the criteria agreed, a specialist triage nurse now triages GP referrals to the appropriate service with a
turnaround of 24 hrs
iii.
Two GPwSI clinics are in place covering two primary care organisations and partially covering a third. GP
referrals are selected by the GPwSIs from those sent to the acute trust. The GPwSIs hold two clinics each week
and one session a month at the trust for ongoing development. The specialist liaison nurse supports the
community based GPwSI clinics, undertaking patient follow-up where appropriate
iv.
A telephone hotline and associated “hot” clinics were introduced. Patients with chronic conditions are given a
card with details to call a nurse-led advice line. The nurses have access to a weekly clinic where patients with
an acute flare-up can be seen at short notice
v.
Specialist nurse-led clinics have also been set up dealing with a range of conditions and treatments, including
eczema and psoriasis
vi.
A telemedicine service was developed, utilising the skills of a specialist liaison nurse who takes photos and
patient history in an outreach clinic. A consultant and the nurse later review the image, with the referral, and
provide diagnosis and treatment advice to the GP. Where appropriate patients are brought to the consultant
clinic
vii. Protocols for several conditions were published electronically and IT links set up between primary and
secondary care. This enabled GPs to email referrals to the triage nurse
viii. Redefined care pathways provide an alternative option to an inpatient stay by offering additional day
treatments.
ix. A range of training programmes for GPs was developed
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A1
Addenbrooke’s NHS Trust in Partnership with South
Cambs and Cambridge City PCTs:
Results to date
i.
There has been a cumulative reduction in the number of GP referrals from the localities where GPwSI clinics
are held. The waiting times for GP referred patients has reduced to from 26 to 13 weeks. However, when
GPwSIs were on leave the referrals increased dramatically.
ii.
The introduction of specialist nurse-led clinics have reduced the pressure on consultants and released
consultant slots; clinical guidelines for reviewing some follow-up patients have proved effective
iii.
The triage system has meant that waiting lists for clinicians have levelled out; several consultants’ lists have
reduced and the proportion of follow-ups has reduced.
iv.
500 advice hotline cards have been given out to date and 323 calls received; only 30% of the patients that
called required appointments for a hot clinic, which subsequently reduced activity in follow-up clinics
v.
The telemedicine pilot has ceased due to inappropriate referrals
vi.
The number of electronic referrals received has been low as not many GPs have easy access to the
electronic system
vii. The new day treatments have been well received by patients and inpatient beds have been released
as a result
Conclusions/lessons learned
i.
To ensure equity of access, other local PCTs have been encouraged to develop GPwSI services
ii.
Evaluation of patient experience has been a valuable tool which has illustrated patients’ satisfaction with
the GPwSI service
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Appendix 1 - Pilot site summaries
South Derbyshire Health Community:
Southern Derbyshire Primary Care Dermatology Service
Contacts
Caroline Gaston-Parry, Project Manager, Action On Dermatology
Southern Derbyshire Primary Care Group
Tel: 01332 224000
Fax: 01332 299598
[email protected]
Objectives
i.
To improve access to care through the development of a primary care dermatology service
ii.
To utilise the skills of GPwSIs and a community dermatology nurse to provide this service with support from
the dermatology consultant
iii.
To develop and pilot protocols for common skin conditions for which treatment can be largely community
based
iv.
To enable Southern Derbyshire Health Community to achieve the two week cancer wait directive, 13 week
target for routine outpatients and reduce waiting times for minor operative procedures
How it was done
i.
A formalised training programme was developed and two GPwSIs are reaching the end of their training. A
third GPwSI began his clinics in August.
ii.
When fully trained the new GPwSI services will cover all five PCTs in Southern Derbyshire, and will be based in
GP practices and community hospitals around the locality. Referrals are triaged at the acute site according to
agreed criteria.
iii.
A community dermatology nurse was employed in November 2001. In order to maintain equality of access
throughout Southern Derbyshire, the post covers all five PCTs in Southern Derbyshire.
iv.
The role of the community dermatology nurse involves several elements. Nurse-led clinics have been set up in
community hospitals, receiving referrals triaged by the consultants. The nurse is able to provide home visits to
patients who require longer educational sessions, such as wet wrapping, as well as increasing awareness of
dermatological conditions to patient and community groups.
v.
Educational days were held for nursing groups, health visitors and other primary care staff
Results to date
i.
The Southern Derbyshire Action On Dermatology project began in November 2001 and is due to run until
March 2003. The Southern Derbyshire project began several months after many of the other pilot sites, so
evaluation of the full impact of these initiatives is not yet available. The new services have been developed in
conjunction with the consultant dermatologists in the acute trust.
ii.
The community dermatology nurse will hold further educational days for patients, awareness groups and
other nursing groups, in response to demand expressed by attendees.
Conclusions/lessons learned
62
i.
The success of the community dermatology nurse post has meant that the postholder travels extensively
providing clinics and home visits around the locality. Consideration will be given as to whether to reduce
the area covered or employ additional staff.
ii.
Working across all PCTs of Southern Derbyshire has meant that some initiatives have been slower to
establish, but the important groundwork for sustainable “joined-up” working has been put in place. It
has added time to the project, but has been invaluable.
Action On Dermatology Good Practice Guide
Appendix 1 - Pilot site summaries
A1
Oldham Primary Care Trust:
Improving Access to Dermatology
Contacts
Santhi Rajagopal, Action On Dermatology Project Manager
Oldham Primary Care Trust
Tel: 0161 621 5900
Fax: 0161 652 9127
[email protected]
Objectives
i.
To deliver clinical care in the most appropriate setting using multi-professional expertise, to ensure that
services can be delivered in a timely fashion, meeting targets of waits and access
ii.
To expand GPwSI schemes and community based nurse-led services
iii.
To improve the knowledge and skills of primary care health professionals through “Teach and Treat” sessions
iv.
To improve patient awareness and self-management of common conditions
How it was done
i.
A weekly primary care dermatology minor surgery clinic was established in March 2001 to accept referrals
from other GPs according to agreed guidelines. This service is led by two GPwSIs with previous experience as
clinical assistants
ii.
Based on the success of this service, additional GPwSI minor surgery clinics were implemented in the acute
trust to further increase capacity. A “bank” of GPwSIs has been created by the PCT to share these sessions.
iii.
A workshop was held for local GPs, nurses and consultants to identify the most appropriate way to deliver
education and training.
iv.
As a result, a programme of “Teach and Treat” sessions were introduced for GPs. “Difficult to diagnose”
patients identified by the consultant dermatologist were invited to a Saturday morning session at the Royal
Oldham Hospital, where GPs could examine each patient. A group discussion and consultant teaching session
followed. PGEA accreditation was gained and patients were reimbursed their travel costs. These sessions are
now held every two months
v.
Local study days were organised for community nursing staff led by the specialist nurse practitioner. A
distance learning module in eczema was offered to nursing staff locally in partnership with the University of
Wales. Further nurse-led study days were also held to develop practical skills.
vi.
In order to deal with waiting list pressures, the PCT has been purchasing the services of a private telemedicine
provider. In order to manage and evaluate the number and appropriateness of patients sent to this company,
a nurse practitioner began triage of all referrals to the acute trust.
vii. Nurse-led community clinics for patients with eczema were introduced in November 2002. Five health visitors
are currently being trained to run similar clinics in 2003.
viii. Patient participation events were organised through GP practices. A dermatology nurse practitioner leads the
sessions with a talk and treatment demonstration. Education classes for eczema and psoriasis patients are also
held by the nurse practitioner.
ix.
A research pilot was developed to evaluate the effect of GP led psychotherapy sessions for patients with
chronic eczema and psoriasis (Ethics Committee approval granted).
Action On Dermatology Good Practice Guide
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Appendix 1 - Pilot site summaries
Oldham Primary Care Trust:
Results to date
i.
The PCT has received excellent feedback regarding the primary care minor surgery service from both GPs and
patients
ii.
Evaluation of the service after one year revealed that the service has received 589 referrals and 537 patients
were treated since launch
iii.
The additional minor surgery sessions established within the hospital have enabled five GPs to be trained
under the consultant. This has resulted in extra capacity for minor procedures and released time for the
consultant to see more complex cases. From April to September 2002, 11 sessions were held and 83
procedures were undertaken
iv.
Nurse-led eczema and psoriasis new patient clinics and education classes have been running since April 2002.
A total of 67 new patients were booked into these clinics from April to September 2002
v.
Four patient participation events have been organised in various localities. Patient feedback has been
extremely positive
vi.
Five “teach and treat” sessions have been held to date, covering topics that were in popular demand from
the GPs; eczema, psoriasis, scalp conditions, minor surgery and skin cancer and acne. They have been very well
received by attendees, who described them as “excellent”, “well presented” and “highly informative”.
vii. The psychotherapy sessions will be evaluated in March 2003 through CORE evaluation and the Quality of Life
Index.
viii. Since the launch of these schemes, additional staff have been recruited to the Trust, including a specialist
nurse practitioner, dermatology support nurse, clinical assistant and six GPwSIs. The trust is in the process of
recruiting to a substantive consultant post.
Conclusions/lessons learned
i.
Collaborative work and effective networking can go a long way in helping to achieve the project aims at a
faster pace. A joint dermatology working group was established with equal clinical and managerial
representation from primary and secondary care.
ii.
Communicating efficiently and consistently to people at the right level can help cope with resistance while
implementing changes.
iii.
The importance of audit and evaluation within a project framework cannot be over-emphasised.
iv.
Short-term interim measures to tackle waiting list pressures need to be periodically reviewed with a view
to assessing their cost effectiveness and quality. A contract not monitored for a long time may in the long
term turn out to be a “necessary evil” that cannot be got rid of.
v.
Flexible workforce planning is the key to service redesigning and will go a long way in filling obvious gaps
in the service
vi.
Information should be used effectively to develop innovative ways of redesigning through creative
thinking
vii. Lessons learned around service redesign using the modernisation tools of process mapping, PDSA cycles
and demand and capacity have been useful. Understanding the need to analyse behavioural styles, the
processes of change and to focus on patient/carer experience have been extremely valuable in achieving
the project outcomes.
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East Kent Hospitals NHS Trust:
Name of project: Whole System Dermatology Development Project
Contacts
Nick Wight , Canterbury and Coastal PCT
01227 795090
[email protected]
Dr Hudson-Peacock
01843 225544 Ext. 62598
Liz Parrish
Dermatology Nurse Practitioner
East Kent Hospitals Trust
01843 234202
[email protected]
[email protected]
Objectives
i.
Establish an integrated care pathway across East Kent.
ii.
Review and re-issue referral guidelines.
iii.
Set up a clinical nurse practitioner post to provide support, counselling and information for patients.
iv.
Use a clinical nurse specialist to lead follow up clinics for patients seen in secondary care.
v.
Roll out teledermatology as part of a hub and spoke approach to providing specialist dermatology service
across several sites.
How it was done
i.
Co-ownership of the project by the dermatology project board was the key to the success of the project.
ii.
Trust employed first specialist nurse just prior to Action On funding.
iii.
From Action On funding employed two further nurses.
iv.
Set up 11 nurse-led clinics running either weekly or fortnightly on five sites across half of the trust.
v.
Opened a patient help line resulting in more patients being given longer return dates or discharged.
vi.
Training plan set to meet skills deficit – training funded by Action On funding.
vii. Equipment bought to support nurse-led clinics.
Results to date
i.
Eleven nurse-led clinics per week each with six half-hour appointments for new and follow up patients with
chronic diseases such as eczema, psoriasis, acne etc.
ii.
Nurses successfully completed training plan and now fully operational in clinics.
iii.
More appropriate appointments for patients with chronic illness.
iv.
Easy access to advice through patient helpline. Helpline also used by other healthcare providers.
v.
Reduced waiting times for new patients with chronic illness.
vi.
Purchase of new UVB equipment and setting up of UVB treatment clinics on two sites.
Conclusions/lessons learned
i.
Start small. Each thing you want to do doesn’t look much but it’s all added work on already over
stretched personnel. Don’t underestimate how much work goes into trying to make change happen.
ii.
Not all of our objectives were achieved. The guidelines were not reproduced or reissued due to
prioritising other work such as the nurse-led clinics.
iii.
Don’t be afraid to change direction if the service needs change. We used some of the project monies to
increase and update phototherapy equipment and set up more treatment clinics as we identified that
waiting times for treatment were increasing as we saw more patients in general clinics.
iv.
Teledermatology is still happening. Due to technical delays and other problems the start date had to
be delayed.
v.
Don’t let resistance stop you. If you cannot convince everyone that change is needed across the board,
start in a small area and lead by example. When other people see the achievements they will soon want
to be part of the action.
Action On Dermatology Good Practice Guide
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Appendix 1 - Pilot site summaries
West Middlesex University Hospitals NHS Trust:
West London Dermatology Services Development
Contacts
Geraldine Scaresbrook, Action On Dermatology Project Manager
West Middlesex University Hospitals NHS Trust
[email protected]
Objectives
To shift the focus of service provision from secondary to primary care through eight service developments:
i.
Establishment of a GP triage clinic
ii.
Establishment of a rapid access pigmented lesion service
iii.
Establishment of nurse-led community based clinics
iv.
Establishment of a primary care led biopsy clinic
v.
Implementation of direct booking to selected clinics
vi.
Piloting the use of digital imaging and teledermatology
vii. Implementation of protocols for treatment and referral
viii. Undertaking and maintaining a baseline skills assessment in local primary care services.
How it was done
i.
Local GPs who expressed interest in running biopsy and triage clinics carried out new patient clinics at
the hospital as part of their training
ii.
A weekly biopsy list was dedicated to training local GPs by a GP with a background in plastic surgery.
iii.
A referral pro forma was developed and piloted with three GP practices for the referral of skin lesions
iv.
An accredited eczema study day was run in collaboration with the University of Gwent. 25 nurses and health
visitors attended and went on to complete assignments over six weeks.
v.
Direct electronic booking into a nurse-led wart clinic was piloted with some GP practices
Results to date
i.
GPwSI still training but sees six new patients per week in secondary care. Negotiations for ongoing funding
for this service continue
ii.
Nurse-led clinics for adults and paediatrics take place in secondary care and will move into primary care when
the GPwSI service commences. Both the nurse specialist and GPwSI will see follow up patients.
iii. The biopsy training list has had limited take up.
iv. The skin lesion pro forma has been welcomed by GPs; it has assisted with the safe triage of appropriate
patients directly onto a surgical list.
v.
An eczema study day has helped to raise the local profile of dermatology. It has also established a diverse core
of health carer professionals with basic dermatological knowledge
vi. Direct electronic booking has so far had a very small impact because of technical difficulties and slow uptake
of opportunity by GPs.
vii. Rapid access pigmented lesion clinic planned to commence in the near future.
Conclusions/lessons learned
66
i.
There is scope for improving services in many innovative ways, however success is dependent on having
skilled manpower available.
ii.
Before commencing new services it is essential to ensure there is local financial commitment to the change.
Action On Dermatology Good Practice Guide
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Contact details
Appendix two Contact details
67
A2
Appendix 2 - Contact Details
1. Steering Group Membership
Name
Title
Aisling Bowman
Health Strategy Consultant
South West London StHA
Dr Alan Marsden
Consultant Dermatologist
St George’s Hospital
British Association of Dermatologists
Royal College of Physicians
Dr Brian Malcolm
General Practitioner
Barnstaple, North Devon
Primary Care Dermatology Society
Dr Denise Carr
General Practitioner
Chislehurst, Kent
Royal College of General Practitioners
Dr Julia Schofield
Consultant Dermatologist
St Albans City Hospital
British Association of Dermatologists
Royal College of Physicians
Dr Kate Dalziel
Consultant Dermatologist
Queen’s Medical Centre Nottingham
British Association of Dermatologists
Royal College of Physicians
Consultant Dermatologist
Leeds General Infirmary
British Association of Dermatologists
Royal College of Physicians
Dr Richard Mallet
Consultant Dermatologist
Peterborough District Hospital
British Association of Dermatologists
Royal College of Physicians
Dr Shaun O’Connell
General Practitioner
Tadcaster, North Yorkshire
Royal College of General Practitioners
[to January 2002]
Dr Sue Burge
The Churchill Hospital, Oxford
British Association of Dermatologists
Royal College of Physicians
Dr Valerie Day (Chair)
Director of External and Corporate Affairs
NHS Modernisation Agency
Mr Alan Robson
Head of Reducing Waiting Times Policy,
Directorate of Access
Department of Health
Consultant Plastic Surgeon
St George’s Hospital
British Association of Plastic Surgeons
[from July 2002]
[from March 2002]
[to July 2002]
Dr Mark Goodfield
[from July 2002]
[to June 2001]
[from November 2002]
Mr Barry Powell
[from April 2002]
Mr Martin Baghurst
[to August 2002]
General Manager
Clinical Support Services
Princess Alexandra Hospital
Mr Nick Evans
National Programme Director
Action On Dermatology
NHS Modernisation Agency
Mr Peter Lapsley
Chief Executive
The Skin Care Campaign
The Skin Care Campaign
Mr Ray Jobling
Chairman
The Psoriasis Association
The Skin Care Campaign
Mr Richard Griffiths
Consultant Plastic Surgeon
Northern General Hospital, Sheffield
British Association of Plastic Surgeons
Service Improvement Manager
Innovations in Care Programme
National Assembly for Wales
[to September 2001]
Ms Carol Limber
National Director - GPwSI
NHS Modernisation Agency
[from November 2001]
[to April 2002]
Ms Ann Gray
68
Nominating organisation
Action On Dermatology Good Practice Guidance Project
Appendix 2 - Contact Details
A2
1. Steering Group Memebership (continued)
Name
Ms Claire Aston
Title
Nominating organisation
Service Improvement Manager
Innovations in Care Programme
National Assembly for Wales
Ms Dawn Preston
Senior Nurse Manager
Leeds General Infirmary
British Dermatological Nursing Group
Ms Helen Toms
Dermatology Nurse Specialist
Southampton General Hospital
British Dermatological Nursing Group
Ms Jessamine Matheson
Associate Director, Action On Dermatology
NHS Modernisation Agency
Section Head Modernisation Performance Directorate,
NHS Waiting times and Bookings
Department of Heath
Director of Education & Information,
The National Eczema Sociery
The Skin Care Campaign
Professor Andrew Finlay
Consultant Dermatologist
University Hospital of Wales
British Association of Dermatologists
Royal College of Physicians
Professor Rod Hay
Consultant Dermatologist
Guy’s Hospital
British Association of Dermatologists
Royal College of Physicians
[from November 2001]
[from November 2002]
Ms Liz Lawler
[to July 2002]
Ms Ruth Carlisle
[to October 2001]
[from July 2001 to July 2002]
Action On Dermatology Good Practice Guide
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A2
Appendix 2 - Contact Details
2. Charities and patient support groups
Inclusion here does not necessarily imply support or approval by the steering board
Name
Web site address
Acne Support Group
www.stopspots.org
Bullous Pemphigoid Support Group
CancerBACUP
www.cancerbacup.org.uk
The Congenital Melanocytic Naevus Support Group
Changing Faces
www.changingfaces.co.uk
Contact a Family
www.cafamily.org.uk
Darier’s Disease Support Group (DARDIS)
www.dariers.8m.com
DEBRA
www.debra.org.uk
Ehlers-Danlos Support Group
www.ehlers-danlos.org
Hairline International, The Alopecia Patients’ Society
www.hairlineinterational.com
Herpes Virus Association (SPHERE)
www.astrabis.co.uk/sites/herpesvirussa
HSS Group - HIDE UK & Ireland
www.hssg.org.uk
www.communityzero.com/ukhsgroup
HITS (UK) Family Support Network
Ichthyosis Support Group
www.ichthyosis.co.uk
LUPUS UK
www.uklupus.co.uk/lupusuk
Lymphoedema Support Network
www.lymphoedema.org/lsn
National Eczema Association for Science & Education
www.eczema-assn.org
National Eczema Society
www.eczema.org
National Lichen Sclerosus Support Group
www.hiway.co.uk/lichensclerosus
Neurofibromatosis Association
www.nfa.zetnet.co.uk
Pemphigus Vulgaris Network
Pseudoxanthoma Elasticum Support Group (PiXiE)
www.pxe.org.uk
Psoriasis Association
www.timewarp.demon.co.uk/psoriasis
Psoriatic Arthropathy Alliance
www.paalliance.org
Raynaud’s & Scleroderma Association
www.raynauds.demon.co.uk
Scleroderma Society
www.sclerodermasociety.co.uk
Skin Care Campaign
www.skincarecampaign.org
Skin Wise
70
Tissue Viability Society
www.tvs.org.uk
Tuberous Sclerosis Association
www.tuberous-sclerosis.org
Vitiligo Society
www.vitiligosociety.org.uk
Wessex Cancer Trust’s Marc’s Line
www.wessexcancer.org
Wound Care Society
www.woundcaresociety.org
XP Support Group
www.xpsupportgroup.org.uk
Action On Dermatology Good Practice Guide
Appendix 2 - Contact Details
A2
3. Professional Bodies
Name
Web site address
Association of the British Pharmaceutical Industry
www.abpi.org.uk
Association of Medical Research Charities
www.amrc.org.uk
British Association of Dermatologists
www.bad.org.uk & www.skinhealth.co.uk
British Association of Skin Camouflage
www.skin-camouflage.net
British Dermatological Nursing Group
www.bdng.org.uk
British Lymphology Society
www.lymphoedema.org
British Red Cross Skin Camouflage Service
www.redcross.org.uk
Cosmetic Camouflage Network
EnviroDerm Services
www.enviroderm.co.uk
Genetic Interest Group
www.gig.org.uk
Health Development Agency
www.had-online.org.uk
Health & Safety Executive
www.hse.gov.uk/hsehome.htm
Long-term Medical Conditions Alliance
www.lmca.demon.co.uk
National Institute For Clinical Excellence
www.nice.org.uk
Physical Disabilities
Portcullis Research
Primary Care Dermatology Society
Royal Pharmaceutical Society
www.rpsgb.org.uk
Action On Dermatology Good Practice Guide
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Notes
72
Action On Dermatology Good Practice Guide
Notes
Action On Dermatology Good Practice Guide
73
Notes
74
Action On Dermatology Good Practice Guide
NHS Modernisation Agency
80 - 94 Newington Causeway
London
SE1 6EF
Web address: www.modern.nhs.uk/action-on
The NHS Modernisation Agency is
part of the Department of Health