>> Service Provision Guidelines

GPwSI

Draft v.7 FINAL
14 December 2002

Dermatology Framework

a) The core activities of a GPwSI service

The service being delivered must be based on the needs of the local population and the skills and competence of the individual GPwSI. GPwSIs will form one of a series of integrated options for the care of patients with skin disease within a local framework. All service providers and patients with dermatological disease should be involved at all stages of service development.

The core activities will vary dependant upon local needs and resources. Models are likely to focus on the following:

1. Management of chronic diseases including acne, eczema (atopic and contact), psoriasis, (skin lesions), alopecia, urticaria and leg ulcers, as well as the assessment of solitary skin lesions including tumours.
2. Skin surgery

Core Clinical Activities

• Provide assessment, investigation and treatment of patients referred to the service by primary care practitioners with the agreed conditions.
• Provide a range of clinical interventions, including skin surgery, liquid nitrogen cryotherapy, management of leg ulcers and the use of oral and topical treatments.
• Provide follow up services as appropriate to patients seen in the service, and by agreement, to patients seen and diagnosed by the consultant dermatologist.
• Provide advice and support to local practitioners through non face-to-face contact (e.g. telephone, internet or other means) in the management of those dermatological conditions within the expertise of the GPwSI.
• Those undertaking specialized skin surgical work which involves patients with skin cancer should form a part of the local cancer service plan and have appropriate links to histopathology services as well as specialist dermatology services. This would be governed by the same rules of referral and management as the rest of the network (eg 2 week waiting list rules)

Training/Service development

• With the members of the integrated network, define referral criteria to the GPwSI service as part of an integrated dermatology service.
• Develop robust care pathways linked to the secondary care service in relation to access to secondary care services such as patch testing, dermatological treatment, specialist dermatology nursing services and rapid assessment of patients where there is diagnostic and/or management uncertainty.
• Where the GPwSI is providing a general dermatology service, it is expected that he/she will provide support and training to general practitioners, GP registrars and members of the Primary Health Care Team. This will include diagnosis and management of common conditions such that these generalist practitioners are able to develop and maintain and subsequently improve their level of competency in the management of common dermatological conditions.
• Work collaboratively with all members of the local health community to develop and implement management guidance for primary care practitioners in the care of common dermatological conditions. Develop links with other professional groups, for example pharmacists, and develop effective shared care for patients with chronic skin conditions.

a) The core competencies required

The minimum standards are those outlined by the RCGP and the British Association of Dermatologists. Dermatology for general practice trainees, RCGP 1998 ISBN: 085084 248 4. All GPwSIs must meet these competency levels before proceeding to train to provide a GPwSI service.

The core clinical competencies will then be further determined by the type of service the GPwSI will provide:

General dermatology service
The GP providing a general dermatology service should be able to diagnose, assess and take care of patients with common skin diseases to a high standard of care but recognize limitations of knowledge and competencies.  They would be expected to show knowledge and skills level reflecting a higher level than those acquired by non-specialist colleagues.

1. Demonstrate appropriate diagnostic skills.
2. Provide practical skills where necessary for dermatological conditions, including:

• Skin scraping for mycology (this would require the use of a microscope)
• Examination under Woods light
• Skin surgery techniques as appropriate to the referral casemix which might include skin biopsy, curettage and cautery,excision and closure
• Liquid nitrogen cryosurgery
• Management of leg ulcers in a multi-disciplinary setting (if offering leg ulcer services)

Providing specialist skin surgery services
Be able to carry out skin surgery beyond that expected from practice based minor operations. This should include the ability to produce good cosmetic results whatever the site of the lesion and understand the necessary histopathological techniques required for diagnosis. The exact nature of the skin surgery will depend on local need and on the expertise of the clinician.

Teaching /Training
The GPwSI should have evidence of competency in teaching and training health care professionals and a commitment to cascading knowledge and skills.

b) The types of patients suitable for the service including age range, symptoms, severity, minimum and maximum caseload/frequency and reason for referral.

Workload
The numbers of patients seen should be subject to agreed limits and service level agreements. Good practice would dictate that 15 minutes per consultation should be allocated.

Models of Service
GPs with a Special Interest in dermatology could chose from a number of different service models. Examples of schemes are given below, with further examples available from the British Association of Dermatologists and through the Modernisation Agency's Action On Dermatology Programme www.modern.nhs.uk/action-on

Examples of GPwSI services
1. Community based service with strong links to the local dermatology department aimed at supporting GPs and patients. Patients will usually be referred directly to the GPwSI service using defined referral guidelines or could be routed following consultant triage.

2. Community based clinics for patients with chronic skin problems, such as, psoriasis, eczema or leg ulcers, all within a multidisciplinary setting.
** Action On pilot work suggests that this may be best performed by suitably trained dermatology nurses in a liaison role.

3. Specialist or enhanced skin surgery performed by trained general practitioners with suitable facilities.

c) The facilities that must be present to deliver that service.

Essential

• Access to consultant dermatology support
• Access to suitably trained dermatology specialist nurse support. Ideally this would be in a liaison capacity between primary and secondary care, or with close links to a specialist dermatology nurse (e.g. as an outreach nursing provision). These models facilitate seamless care. However, development of specialist dermatology skills in a designated in-house
  (community or practice nurse) would be encouraged.
• A consultation room with good lighting with adequate facilities for diagnosis and treatment procedures.
• A private room for patient education and where clinical staff can demonstrate application of treatments and bandages.
• A fully equipped minor operating suite where skin surgery is being performed.
• Access to liquid nitrogen if cryotherapy is to be performed, with attention to Health & Safety guidance in relation to its storage and use.
• Administrative support and appropriate clinical support staff to ensure the clinics run efficiently and decontamination issues are dealt with.
• If leg ulcers are being managed then suitable couches, sink facilities, leg buckets and Doppler for assessment and management will be necessary.
• Adequate means of record keeping
• Mentoring support and clinical network facilities
• Where skin surgery sessions are performed, appropriate documentation of lesions, including photographic records and close links to the local dermatology and histopathology departments are essential.

Desirable

• A computer link to the hospital based dermatology department with telemedicine facilities
• Appropriate support to facilitate effective audit of quality.
• Additional accommodation is likely to be required in hospital dermatology departments so that local GPs with a Special Interest can attend clinics and postgraduate activities.
• The GPwSI will be expected to keep their facilities up to date and ensure that patients have access to any new innovations in dermatology treatment which are suited to the primary care setting.
• Phototherapy facilities, with appropriately trained and supervised staff (there are clinical governance issues associated with appropriate supervision of UV in any site).

d) The clinical governance, accountability and monitoring arrangements, including links with others working in the same clinical area in primary care, at PCT level and in acute trusts

It is an essential criterion of the GPwSI service that robust mechanisms for joint working and communication, including regular meetings with other service providers are in place (e.g. dermatologists, dermatology nurse specialists). This ideally should involve bimonthly joint clinical/audit meetings, a minimum of monthly joint (GPwSI/Specialists) clinics and an annual appraisal mechanism that involves the consultant dermatologist.

Once in place schemes involving GPs with a Special interest will be subject to periodic review by local and occasionally national bodies, including the BAD, appropriate GP representative groups and CHI. This audit process should involve other participants in the provision or development of services including patient groups, primary care trusts and local dermatologists.  Each local scheme will need to have a clinical governance team involving the clinicians from primary and secondary care and other interested parties.

Where the GPwSI is employed by the PCT, he/she will be accountable to the PCT Board. If employed by the secondary care service, then accountability is to the Trust Board of the secondary care organisation. Day to day accountability will be to the Clinical Governance Lead for delivery of clinical objectives and to the Chief Executive for contractual issues in whichever
organisation the GPwSI is employed.

Revalidation will be managed through the employing Trust.

e) Evidence of training for competencies

A GPwSI should present a portfolio with evidence of the following training:

Acquisition of core competencies, which may be through attendance at a recognised training course, certificate (or diploma) level qualification or through maintaining a logbook of patient contacts to demonstrate management of the common dermatological skin conditions.

It is suggested that a GPwSI in dermatology will be likely to have had a minimum attendance at 100 outpatient clinics or at least 1-2 years experience in dermatology outpatients and ideally should be able to provide documented evidence of the number of clinics attended, caseloads seen and skills acquired.

Evidence of direct observation of diagnostic, therapeutic and surgical skills is essential.

f) Evidence of successful acquisition of those competencies

This can be undertaken through a number of means, including benchmarked accredited training courses, direct observation of skills, viva or interview by specialist provider. The evidence required will depend on the specific service/s provided by the GPwSI.

The GPwSI will maintain a Professional Development Portfolio, which includes evidence of audit and continuing professional development.

Evidence of training skills will be necessary to ensure the GPwSI is adequately skilled to support and educate GP colleagues in dermatology practice issues.

g) Induction, support, appraisal and CPD arrangements for the GPwSI

The GPwSI will specify an appropriate system of mentoring and continuing professional development.

Induction
The induction process will include the following elements:

• Risk management
• Networking with other professionals
• Involvement in national clinical networks
• Clinical Governance arrangements (see section d)
• Audit and reporting mechanisms (see section i)

Support and CPD

• Continuing training and support for the GP with a Special Interest will need to be maintained by the GP continuing to work alongside the consultant dermatologist on a monthly basis.
• A minimum of 15 hours per year CPD in Dermatology.
• The CPD and support requirements will be negotiated and agreed as part of the annual appraisal process which will have input from both the PCT and the secondary care dermatology service with objectives being agreed locally.
• The necessary sessional commitment for GPwSI and supervising consultant will be agreed and included in job plans.

h) Local guidelines on the use of the service
Local guidelines for the service should reflect and incorporate nationally agreed guidelines and as such the GPwSI will demonstrate awareness of national relevant advice issued by organisations such as the BAD; NICE; Department of Health and the Modernisation Agency. This will include the
Action On Dermatology Good Practice Guide and the Baseline Standards for all dermatology departments.

i) Monitoring and clinical audit arrangements
The GPwSI will attend regular audit meetings and monitor service delivery, which should include:

• Clinical outcomes and quality of care
• Follow-up rates
• Onward referral rates of patients seen to Consultants and Allied Health Professionals by the GPwSI and other General Practitioners
• Investigations
• Access times
• Patient satisfaction
• Patients referred for surgery

Further information relating to Dermatology issues may be found at: www.modern.nhs.uk/action-on