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“Working together better” Dermatology 12 th April 2007. Catherine Smith Clinical Lead for Dermatology St Johns Institute of Dermatology GSTT. St Johns Institute of Dermatology: what are we?. Largest UK centre for patients with skin disease Clinical service (GSTT)
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“Working together better”Dermatology12th April 2007 Catherine Smith Clinical Lead for Dermatology St Johns Institute of Dermatology GSTT
St Johns Institute of Dermatology: what are we? • Largest UK centre for patients with skin disease • Clinical service (GSTT) • Research (GKT, Kings College London) • Training and education
Clinical Service • General Dermatology • Specialist Services* • Skin Cancer: lymphoma, melanoma • Inflammatory Skin Disease: Psoriasis, Eczema Blistering disease • Cutaneous Allergy: Contact dermatitis, urticaria Mastocytosis • Genetic Skin Disease • Vulval and Oral Dermatoses • Specialised Diagnostic Laboratory services *includes all those cited in the National Specialist Services Definition Set for Dermatology
Clinical Service: Access • General dermatology • Standard referral letter • Choose and Book • Current waiting times 5-6 weeks for routine OPD • Suspected skin cancer • via standard 2WW proforma • Emergency referrals • On call SpR available 9am-9pm Monday to Friday 9am-1pm Saturday, Sunday
Current Issues for Dermatology Services: Background • ‘Our health, our care, our say: a new direction for community services’ (2006) • ‘…to ensure the delivery of the most appropriate care to patients in the most appropriate setting in clinical terms, whilst demonstrating the most effective use of available resources’ • New Targets • By 2008, no one will wait longer than 18 weeks from GP referral to hospital treatment • 5 weeks for first outpatient consultation • 6 weeks for diagnostics • New guidelines relevant to dermatology services • Improving Outcomes Guidance (IOG) for skin cancer (2006) • Management of paediatric atopic eczema (expected 2008) • New funding arrangements • Payment By Results • Practice Based Commissioning Drive for major service redesign and effective referral management
Current Issues for Dermatology Services: Background • Dermatology services remain a major focus in the context of this agenda • Two out of ‘Top Ten Tips’ in DOH guide to practice based commissioning focus on dermatology services • Nurse led community services for childhood atopic eczema • GPSI led ‘intermediary’ community services • Implications for Education, Training, Research and provision of Specialist Services not addressed in detail
Plans and progress to date • Established Dermatology Steering Group • Purpose: to develop and implement strategy to ensure continued access to comprehensive dermatology services for patients • Progress to date: • Agree referral criteria for atopic dermatitis, psoriasis, acne (checklists) • Agree conditions for which treatment is not available on the NHS • Audited current referral practice against national benchmarks to meet demand management agenda • Develop strategy for training and education of primary health care professionals
Methods • Proforma developed and reviewed by St Johns staff, PCT (Southwark and Lambeth), interested GPs • Layout and data fields revised following pilot in 2 general clinics • Period of data collection: • 2 weeks • November 13th -24rd 2006 • 16 lists cancelled due to A/L, S/L (representative) • General clinics only • Proforma attached to all clinic notes • Data entry completed by clinicians in clinic • Entered onto spreadsheet; descriptive data analysis
Type of referral • Total number of news 164 (41%) • Two week cancer wait 14 • New 150 • Re-referral 10 • Total number of follow ups 227 (59%) • New : follow up ratio 1.38 Completed proformas returned for 75% of those attending
Diagnosis* • Benign lumps & bumps 78 • Cancer 98 • Eczema 53 • Psoriasis 35 • Acne 19 • Urticaria 10 • Blisters 3 • Leg ulcers 4 • Other and not specified** 91 • *Diagnosis following dermatology consultation • ** includes where no data entry given
Inflammatory skin disease(ie: excluding benign skin lesions and skin cancer)
No. of patients seen according to diagnostic category* (*excluding benign lesions, skin cancer and ‘other’)
Number of follow up appointments No. of patients* Number of follow up appointments (* Total number of follow ups seen in any of 6 diagnostic categories given = 128)
Indications for secondary care*(*as defined by PCDS/BAD guidelines)
Summary (1) • Response rate 74% • 45% of total referrals seen relate to skin tumours (benign and malignant) • Of the remaining 55% of patients seen, 29% (n= 114) had eczema, psoriasis and acne • New to follow up ratios are below national average • A significant cohort of high need patients with skin cancer, psoriasis and eczema are currently on continued, long term follow up in secondary care
Summary (2) • Of those patients falling into one of the 6 primary diagnostic categories (eczema, psoriasis, acne, urticaria, blisters, leg ulcer, n= 131) • 81% fulfilled PCDS criteria for secondary care • 18% (n=24) no data available/no reason given • Commonest reasons cited for for secondary care (across all skin diseases) were • Diagnostic uncertainty (30%) • Failure of topicals (23%) • Need for systemic or phototherapy (22%) • Psychological co-morbidity (8%)
Training and education • 3 year GSTT charity funded bid developed in collaboration with Lambeth PCT, post graduate centre (VTS) and St Johns ‘Improving dermatology training for general practitioners’ • Dermatology Care Module (Nursing and Midwifery, KCL)
Other Service Developments • Skin Cancer • Expansion of specialised dermatologic surgery provision • Rapid access skin cancer screening clinic • one of first four services to be integrated into the new cancer centre (Guys) • Chronic skin disease • Day Centre for high need patients • Nursing: outreach team, nurse consultant • Chronic disease management pathways • Paediatric Dermatology • Paediatric Eczema Clinic • Paediatric Dermatology to be developed alongside Paediatric Allergy services • Eczema education programme • Capital projects: move of clinical services to Guys
Qualifying clinical categories for patients with severe disease* • At risk of developing (or has developed) clinically important drug-related toxicity • Intolerant to standard therapy • Unresponsive to standard therapy • Disease only controlled by repeated inpatient Rx • Standard therapy contra-indicated due to co-existent co-morbidity • Life threatening clinical situation • Associated psoriatic arthritis fulfilling the British Society of Rheumatology eligibility criteria *BJD 2005; 153:486-497
Toxicity: Anti TNFs versus Efalizumab Fewer patients treated overall with efalizumab compared to anti-TNF agents
NICE guidance on skin cancer • ‘Referral guidelines for suspected cancer’ • issued June 2005 • covers all cancers (98 pages) • includes specific recommendations on skin • www.nice.org.uk/CG027 • ‘Improving outcomes for people with skin tumours including melanoma’ (IOG) • issued February 2006 • huge document (177 pages) • www.nice.org.uk • 3 years allowed for full implementation from date of publication
Referral guidelines for suspected cancer: skin cancer • Much of the guideline content is incorporated into the IOG • Suspected melanomas and SCCs should be referred urgently (ie 2 week cancer wait proformas) • BCCs should be referred non urgently • Avoid excision of melanoma in primary care
7 point checklist Major features (2) Change in size Irregular shape Irregular colour Minor features (1) > 7mm Inflammation Oozing Sensation Referral guidelines for suspected cancer: pigmented lesions Emphasis on observation over 8 weeks prior to referral for low suspicion lesions
MDT working • Cancer Networks should establish two levels of skin cancer MDT • Local hospital based MDT (LSMDT) • Specialist MDTs based in Cancer Centres (SSMDT). • All clinicians who treat patients with any type of skin cancer should be a member of a skin cancer MDT, whether they work in the community or in a hospital setting • Expected attendance for GPs – 4x per year
Who can treat what and where? Precancerous Lesions (AKs, Bowen’s) • May be treated and followed up by any GP • If there is doubt about the diagnosis the patient should be referred to the local hospital skin cancer specialist. Low risk BCC • May be diagnosed, treated and followed up by a doctor working in the community who is a member of the local MDT, or a hospital specialist (‘normally a Dermatologist’).
Who can treat what and where? High risk BCC, SCC and MM • All patients with skin lesions which are suspicious of these skin cancers, including all suspicious pigmented lesions and skin lesions where the diagnosis is uncertain , should be referred to a hospital specialist (Dermatologist). • GPs will no longer ‘be allowed’ to treat these cancers.
Histological subtype Morphoiec/infiltrating Micronodular Basosquamous Histological features Invasion below dermis Perineural invasion Site Other factors Size, immunosuppression recurrence High risk BCCs