Secondary Care - British Association of Dermatologists

Report of the Working Party on Dermatological Inpatient Services

Members of the Working Party

Professor J.A.A. Hunter [Chairman] The Royal Infirmary, Edinburgh Dr. J.N.W.N. Barker St. John's Institute of Dermatology, London Dr. C.A. Holden St. Helier Hospital, Carlshalton Dr. W.D. Paterson Cumberland Infirmary, Carlisle Dr. J.B. O'Driscoll Stepping Hill Hospital, Stockport

These members met at BAD House on Friday 22nd May 1998 and were chosen for their considerable experience of dermatological practice in a variety of settings.

Briefing materials considered:

1. H.C. Williams. Health Care Needs Assessment. Eds: A. Stevens & J. Rattery. Radcliffe Medical Press, Oxford 1997.
2. National Casemix Office Data 1994/95.
3. J.A.A. Hunter. Inpatient Dermatology: Is it important? British Association of Dermatologists Newsletter, Winter 1997; 18-19.
4. R.S. Kirsner, I.M. Freedberg & F.A. Kerdel. Inpatient dermatology: should we let it die or should we work towards regional centres? Journal of the American Academy of Dermatology 1997; 36: 276-278.
5. H.A. Kurwa & A.Y. Finlay. Dermatology inpatient admission greatly improves life quality. British Journal of Dermatology 1995; 133: 575-578.
6. C.S. Munro, J.G. Lowe, P. McLoone, M.E. White & J.A.A. Hunter.The value of inpatient dermatology: A survey of inpatients in Scotland and Northern Ireland. In press British Journal of Dermatology.
7. British Association of Dermatologists Workload Data 1997/8, BAD House on file.
8. Londoners need high quality dermatological services. A position document prepared by the London Dermatology Planning Group. BAD House on file.
9. Skin Care Campaign. Correspondence on file at BAD House.
10. RS Ayyalarugu, F. Hallam, N. Reynolds & C.E.H. Grattan. Dermatology ward weekend closure trial. British Journal of Dermatology 1995; 133: Suppl. 45, 28.
11. A. Warin. Dermatology day treatment units. British Association of Dermatologists Newsletter 1998; 2/2: 14-16.

1. Introduction

1.1 There has been a 60% increase in admissions for diseases of the skin and subcutaneous tissues from 1979 to 1994 despite a concomitant 20% reduction in dermatology beds (1). A proportion of these conditions (e.g. cellulitis) will have been under the care of non-dermatologists. It could be argued that all admissions for diseases of the skin should be cared for by dermatologists.

1.2 In 1994/95 (the most recent years for which figures are available) the mean rate for bed-days for dermatological patients in England and Wales was 4.6 per 1000 population (2). The working group is not in doubt that inpatient care for dermatological patients remains essential (3,4,5).

2. Types of Admission

Despite improved primary care and day-care management there remains a significant number of patients who require specialised inpatient management.

2.1 Those with life threatening problems who may require the care of intensive care physicians with guidance from consultant dermatologists.

2.2 Those without immediate threat to life, of whom a significant proportion will be the elderly or socially deprived and have social or general medical reasons for being in hospital (6). They will have extensive skin diseases, which are beyond the scope of hospital day treatment or community care and will require intensive inpatient management by specialists.

2.3 Children who should generally be admitted to paediatric wards with shared care from dermatologists and paediatricians according to local arrangements.

3. Beds per Population

3.1 An analysis of one hundred hospitals outside London indicates provision of 2 beds per 100,000 population (7). We recommend this as a minimum requirement.

3.2 We are aware of the dire situation which prevails in London. Whilst we endorse the London Dermatology Planning Group's recommendation to increase the bed numbers in London to a minimum of 1 per 100,000 population we do not understand why Londoners should be less well served than the rest of the country (8).

4. Provision of Inpatient Care

4.1 Current provision Outside London, 95% of dermatology care in teaching hospitals is provided in dedicated units, whereas district general hospitals provide 54% of care in dedicated units and 46% in general medical wards (7).

4.2 Our preference is for a dedicated dermatology unit staffed by trained specialists who provide high quality care. We are also aware that patients with extensive skin disease feel uncomfortable on general medical wards and benefit from mutual patient support provided on a dermatological unit (9).

4.3 Teaching hospitals need dedicated units because of tertiary referrals of patients with complex diseases and undergraduate and SpR training.

4.4 We accept that patients can be looked after in general medical wards with appropriate bathing and treatment facilities if they receive individual care from specialist nurses. In few areas of medicine is nursing care so directly related to patient progress. We are sad to see that the dermatological experience of general medical nurses is negligible. Better care of dermatology patients on general medical wards could be provided by specialist nurses from the dermatology day treatment centre.

4.5 The weekend closure of dedicated dermatological units is unsatisfactory for patients and has a disruptive effect on continuing medical and nursing care (10).

4.6 Day treatment centres should complement, not replace, dedicated dermatological units (11).

7. Summary of Recommendations

7.1 Inpatient care for dermatological patients remains essential.

7.2 Two dedicated dermatological beds per 100,000 population is the minimum requirement.

7.3 The number of dermatological beds in London should be increased to 1 per 100,000 as a matter of urgency, though the eventual target should be no different from the rest of the country.

7.4 These beds should be provided as dedicated dermatological units in all teaching hospitals and district general hospitals of appropriate size.

7.5 Dedicated dermatological beds in general medical wards are satisfactory only if they are accompanied by appropriate bathing and treatment facilities and dermatological patients using them receive individual care from specialist nurses.

7.6 The impact of poor provision of inpatient beds on patients should not be underestimated. It leads to increasing use of toxic and often expensive medications, it creates pressure on already stretched outpatient and community services and it particularly affects the elderly, poor and vulnerable members of our society (6).

7.7 Day treatment centres should complement, not replace, dedicated dermatological units.