Skin conditions a health care needs assessment key messages
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Skin conditions a Health Care Needs Assessment: key messages. Julia Schofield Special Lecturer University of Nottingham Principal Lecturer University of Hertfordshire Consultant Dermatologist, Lincoln. What I am going to talk about?. What is need? What is a Health Care Needs Assessment?

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Skin conditions a Health Care Needs Assessment: key messages

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Skin conditions a health care needs assessment key messages

Skin conditions a Health Care Needs Assessment: key messages

Julia Schofield

Special Lecturer University of Nottingham

Principal Lecturer University of Hertfordshire

Consultant Dermatologist, Lincoln


What i am going to talk about

What I am going to talk about?

  • What is need?

  • What is a Health Care Needs Assessment?

  • Some background to the new document

  • What does the updated Dermatology Needs Assessment for the UK tell us?

  • Recommendations for the future


What is need

What is need?

Need is ‘the ability to benefit from care’

Williams HC. J Roy Coll Physicians 1997;31:261-2

The use of isotretinoin to treat acne

The use of the biological agents to treat psoriasis


Demand and supply

Demand and supply

Demand = “that which is asked for”

Supply = “that which is provided for”

Williams, HC. J Roy Coll Physicians 1997;31:261-2

Seborrhoeic keratoses – demand or need?


What is a health care needs assessment hcna

What is a health care needs assessment (HCNA)?

1. The burden of disease

Prevalence and incidence

Impact on quality of life

Economic burden

2. Managing the burden

The services available

The effectiveness of those services

3. Recommendations for models of care and delivery of services to manage the need


Some background to the project

Some background to the project

1997

Dermatology: Health Care Needs Assessment

Hywel Williams

Radcliffe Medical Press (one of 38 chapters still available on the HCNA website)

2007

Needed revision


Some background to the project1

Some background to the project

  • BAD sabbatical fellowship April 2007

  • Additional funding PCDS, Psoriasis Association, CEBD

  • March to July 2008

  • Peer review process

  • Published by CEBD October 2009


The team

The team

Professor Hywel Williams

  • Strategic lead for the project

  • Author of original Dermatology Health Care Needs Assessment

    Dr Douglas Grindlay

  • Information Specialist, NHS Evidence – skin disorders (based at CEBD)

  • Information searching, referencing, editing

    Dr Julia Schofield

  • Lead researcher and lead author


Structure of the document chapters

Structure of the document: chapters

  • Introduction

  • Burden of skin disease

  • NHS reform and its impact

  • Services available and their effectiveness

  • Models of care and organisation of services

  • Specific skin disease areas

  • Recommendations

    Lots of references!


What does the document tell us

What does the document tell us?


Skin conditions a health care needs assessment key messages

The HCNA: key messages

  • 1. The burden of disease

  • Prevalence and incidence

  • Impact on quality of life

  • Economic burden

  • 2. Managing the burden

  • The services available

  • The effectiveness of those services

  • The cost-effectiveness of those services

  • 3. Recommendations for models of care and delivery of services

  • How to manage the need

  • Supply and type of services


Prevalence and incidence

Prevalence and incidence

Examined skin disease

Self reported skin disease

People with skin disease seeking generalist medical care

People with skin disease seeking specialist medical care


Examined skin disease in the uk

Examined skin disease in the UK

Nothing new since the Lambeth study in 1976*

  • 2180 adults studied

  • 55% population had any form of skin disease

  • 22.5% had skin disease worthy of medical care

  • Tumours and naevi commonest but 90% considered trivial

  • Prevalence of eczema 9% but 2/3 moderate or severe

    Authors concluded:

  • Skin conditions that may benefit from medical care are extremely common

  • Most sufferers do not seek medical help

*Rea et al Skin disease in Lambeth: a community study of prevalence and use of medical care. Brit J Prev Soc Med 1976;30:107-14


Self reported skin disease

Self reported skin disease

  • Proprietary Association of Great Britain (PAGB)

  • Nationwide (UK) study of minor ailments and how people manage them

  • 1987, 1997 and 2005

  • A picture of health 2005 PAGB/Reader's Digest Report*

*ww.pagb.co.uk/pagb/primarysections/marketinformation/otcconsumeresearch.htm


Self reported skin disease pagb study

Self reported skin disease: PAGB study

  • 1500 people questioned all over the UK

  • Minor ailments in the last 12 months

  • Questions related to a limited number of conditions

  • 818/1500 (54%) reported a skin condition

  • The 1500 questioned reported 1524 episodes of skin disease

  • 135 mothers reported eczema in 30% of their children


Self reported skin disease pagb study management

Self reported skin disease PAGB study: management


Pagb study of self reported skin disease limitations

PAGB study of self reported skin disease: limitations

  • Diagnostic information limited, symptom based

  • Limited range of conditions included in study

  • Respondents not asked about warts, verucca, psoriasis, dandruff, hair loss, headlice, boils, cradle cap and nappy rash.

  • No lumps and bumps, skin lesions

  • Under-estimates skin conditions


Skin disease seen in primary care

Skin disease seen in Primary Care

  • Primary care data from RCGP Research and surveillance Unit weekly returns service (WRS)

  • Data from 47 practices in England and Wales representing about 400,000 people

  • Data captured on all patient encounters

  • Incidence, prevalence and consultation rate data

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


Data capture and coding issues

Data capture and coding issues

  • ICD 9 and 10

  • Disorders of the Skin and Subcutaneous Tissues

    Does NOT include:

  • All skin tumours, benign and malignant

  • Many common skin infections including viral warts

    Seriously underestimates the amount of skin disease


Skin conditions a health care needs assessment key messages

Skin disease in Primary Care: messages

  • 24% of the population seek medical advice about a skin condition each year (12.9 million)

  • This is the commonest reason for people to consult their GP with a new problem

  • Consultation rate is 2 per episode

  • Average GP: 630 consultations per year for skin conditions

  • Under-estimate due to coding issues


Skin disease seen in primary care1

Skin disease seen in Primary Care

Prevalence, episode incidence and consultation rates for selected skin conditions per 10,000 population 2006. Source: RCGP WRS


Key messages

Key messages

  • Skin infections commonest reason for consultations

  • 20% of children under 12 months are diagnosed with eczema

  • Psoriasis not very common cause of GP consultations


Skin disease seen by specialists

Skin disease seen by specialists

  • Limited information other than numbers

  • About 6.1% of people with skin disease are referred to see a specialist

  • 35-48% referrals are skin lesions

  • Eczema, acne and psoriasis commonly seen

  • Patients still admitted


Specialists casemix by of new patient activity

Specialists casemix: by % of new patient activity

Skin lesions


Services available who sees what and where

Services available: who sees what and where?

WHY?

Primary care

Skin infections

Specialist care

Skin lesions 45-60%

31-59% are for diagnosis – skin lesions even higher


Skin conditions a health care needs assessment key messages

Epidemiology: summary of key messages

0.75 million people with skin disease referred for NHS specialist care, 1.5%

3752 deaths due to skin disease

24% population, 12.9 million seeking Primary Care (England and Wales)

Self reported/ self managed skin disease

50% population approx 25 million


The cost of skin disease in the uk

The cost of skin disease in the UK

Direct and indirect costs

  • Over the counter (OTC) sales

  • Prescribing costs for skin disease

  • Costs to the NHS of delivering services for patients with skin disease

  • The cost of disability due to skin disease


Skin conditions a health care needs assessment key messages

Coughs colds and sore throats

Skin disease

Pain relief


Primary care prescribing costs 2007

Primary Care prescribing costs 2007

BNF Chapter 13

  • 35 million items, £239 million, net ingredient cost £6.77

  • 2.85% total budget, no real change for many years

  • Excludes hospital prescribing and oral antibiotics

  • Dovobet: £21 million, NIC £54.95


Economic burden disability living allowance claims by age

Economic burden: disability living allowance claims by age


Burden of skin disease impact on quality of life

Burden of skin disease: impact on quality of life

  • 1990 Psoriasis > impact on QoL than hypertension and angina

  • 1999 Psoriasis same impact as angina or cancer

  • 2000 High DLQI scores significant in primary care patients with skin disease

  • 2003 Willingness to Pay for cure higher in acne, atopic eczema and psoriasis than angina hypertension and asthma.


Impact on quality of life new data

Impact on quality of life: new data

  • Psycho-social morbidity

  • Skin-Brain axis

  • Impact on the rest of the family: ‘greater patient’

  • Impact on life choices

  • (co-morbidities)


Skin conditions a health care needs assessment key messages

The HCNA: key messages

  • 1. The burden of disease

  • Prevalence and incidence

  • Impact on quality of life

  • Economic burden

  • 2. Managing the burden

  • The services available

  • The effectiveness of those services

  • The cost-effectiveness of those services

  • 3. Recommendations for models of care and delivery of services

  • How to manage the need

  • Supply and type of services


Services available and their effectiveness

Services available and their effectiveness

  • Self care, expert patient programme

  • Internet: e-health

  • Primary (generalist) care

  • Referral management

  • Specialist services

  • Supra-specialist services


Services available and their effectiveness1

Services available and their effectiveness

  • Self care, expert patient programme

  • Internet: e-health

  • Primary (generalist) care

  • Referral management

  • Specialist services

  • Supra-specialist services


Services available and their effectiveness self care

Services available and their effectiveness: self care

  • Patient groups important but vulnerable

  • Some evidence for social network groups

  • No Expert Patient Group Evidence

  • High sales OTC skin treatment products but limited teaching and training of pharmacists

  • No formal evaluation of pharmacists


Patient information important points

Patient information: important points

  • The digital divide: 70% of over 65s have never used the internet

  • NHS Direct: 4% of all calls skin rashes

  • Written information variable quality (Picker Institute 2006)

  • Patients not involved, clinicians still write the material

  • Health on the Net Foundation code of accreditation, none of common dermatology sites accredited


Services available and their effectiveness primary care

Services available and their effectiveness: Primary Care

  • Limited evidence

  • Evidence that teaching and training inadequate (APPGS and others)

  • Little formal evaluation

  • Some evidence that skin lesion diagnostic skills not great

  • Not a lot of evidence that up-skilling practice nurses helps


Services available and their effectiveness primary care1

Services available and their effectiveness: Primary Care

  • MISTiC study 2008

  • Hospital vs GP skin surgery

  • Some concerns about quality of GP surgery

  • Malignancies missed

  • Hospital more cost-effective

  • Patients preferred GP skin surgery


Services available and their effectiveness gpwsi services

Services available and their effectiveness: GPwSI services

  • GPwSI services are effective

  • Patients like the GPwSI services

  • Not particularly cost-effective

  • Overall may increase costs

  • May not be the most cost effective way of increasing overall capacity of specialist services (Roland 2005)


Effectiveness of specialist services

Effectiveness of specialist services

  • Little evaluation of effectiveness of ‘doctor’ services

  • Nurse services are better evaluated

  • Few specialist services measure clinical outcomes


Evidence for effectiveness of specialist services

Evidence for effectiveness of specialist services

  • Good diagnosticians

  • Supports role of Inpatient treatment

  • Manage skin cancer effectively

  • Specialist nurses are effective

  • Role in managing cellulitis


Models of care and organisation of services

Models of care and organisation of services

  • Consensus documents about models

  • Referral management ‘evidence free zone’

  • Shift : specialists in community settings and joint working improves access to care and maintains quality, no reduction in OP activity

  • Digital imaging: useful but not implemented


Education and training

Education and training

  • Not enough training for Primary Care health care professionals

  • What there is: not needs based, curriculum does not match casemix

  • Remains optional, undergraduate and postgraduate nursing and medicine


Skin conditions a health care needs assessment key messages

The HCNA: key messages

  • 1. The burden of disease

  • Prevalence and incidence

  • Impact on quality of life

  • Economic burden

  • 2. Managing the burden

  • The services available

  • The effectiveness of those services

  • The cost-effectiveness of those services

  • 3. Recommendations for models of care and delivery of services

  • How to manage the need

  • Supply and type of services


10 key recommendations

10 key recommendations

  • Improve self care: better information, community pharmacy training

  • Improve undergraduate nursing and medical training

  • Needs based educational programmes

  • Referrals should be triaged by experts in integrated teams

  • More pyramidal service needed


Skin conditions a health care needs assessment key messages

The link between the amount and complexity of skin disease and current levels of training and knowledge

Highly trained supra-specialists

Large numbers of patients managed by clinicians with limited knowledge and training

Knowledge and skill of clinicians: small number of highly trained specialists treating few patients

Increasing complexity of skin disease: fewer patients

Increasing amount of training

All patients with skin conditions

Large numbers of cases of straightforward, less complex skin disease


Skin conditions a health care needs assessment key messages

Optimising the link between the amount and complexity of skin disease and levels of training and knowledge

Specialists and supra-specialists diagnosing and managing more complex skin problems

Appropriate levels of education and training based on ‘need’ as determined by the type and amount of disease seen and its complexity

Increasing complexity of skin disease: fewer patients

Increasing amount of training

All patients with skin conditions

All patients with skin conditions

Large numbers of cases of straightforward, less complex skin disease


10 key recommendations1

10 key recommendations

6. Population based teams of health care professionals

7. Accreditation process needed

8. Dermatologists: diagnosis, management of complex skin problems

9. Cancer service led by dermatologists

10. Patient Reported Outcome Measures needed


Thank you

Thank you

Acknowledgements

British Association of Dermatology

Psoriasis Association

Primary Care Dermatology Society

Professor Hywel Williams & Douglas Grindlay


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