>> Service Provision Guidelines

Job Plans for Consultant Dermatologists

A BAD Position Statement to the RCP

The RCP published guidance for job plans for consultant physicians including dermatologists in the booklet Consultant Physicians Working for Patients, June 1999. The booklet has been circulated widely. Many specialties have indicated how many consultants there should be per head of population, but politicians are cynical and believe that our figures are opinions rather than accurate calculations based on known workload. The President of the Royal College of Physicians has now asked all specialists to supplement these job plans with far more accurate estimates of numbers of consultants required to maintain good standards of care.

We are asked to follow the example set by the gastroenterology committee who have used the clinical workload to calculate how many consultants there should be working in that speciality. We should justify calculations for the consultant NHDs required to service the average workload of a district general hospital serving a population 250,000. In order to support our estimate we should supply references to studies of the provision of dermatology services including skin surgery and other specialist services.

Job Plans for Consultant Dermatologists 

For details see Consultant Physicians Working for Patients, June 1999.

Background Consultations for skin disease in general practice have risen almost 50% between 1981 and 1991 reflecting both the substantial rise in the prevalence of common problems such as atopic eczema, venous leg ulcers and skin cancer and the availability of effective treatments for diseases such as acne and psoriasis. Approximately a quarter of the population are affected by a skin disease, which would benefit from medical care and skin diseases are one of the commonest reasons for certified incapacity to work in the UK About 15% of GP consultations relate to problems with the skin and skin diseases were the fourth most common reason for people consulting their general practitioners in England and Wales in 1991/92 . GPs refer 1% to 2% of the population to dermatologists each year as new patients.

The burden of chronic skin disease in the community is considerable [3].

Although skin diseases are common, dermatology tends to have a low priority in the medical curriculum for undergraduates. Recent figures from the Joint Committee on Postgraduate Training for General Practice showed that only 5 to 6% of doctors applying to the Joint Committee for its certificate offered experience in dermatology.

1 Williams HC. Increasing demand for dermatological services: how much is needed? J R Coll Physicians Lond 1997; 31: 261-2.

2. Royal College of General Practitioners, Morbidity Statistics from General Practice. Fourth National Study 1991-2. 1995, London: HMSO.

3. Williams HC. Dermatology: Health Care Needs Assessment 1997 Ed A.Stevens and J.Raftery. Radcliffe Medical Press

Consultant NHDs required to provide a service to a population of 250,000

Calculations are based on the workload in the outpatient department since dermatology is predominantly an outpatient specialty. Recommendations on clinic size are based on recent studies [4].

4 Savin JA. Validation of the recommendations on clinic size made by the British Association of Dermatologists British Journal of Dermatology 1997; 136: 968-971

Outpatient clinics in Dermatology

New:follow-up ratio average 1 new patient to 2 follow-up patients

For population of 100,000 If 1.5 % of a population of 100,000 is referred = 1,500 new patients per year. Assume ratio of 1 new patient: 2 follow-up patients per general clinic 1,500 new patients plus 3,000 selected follow-up patients = 4500 patients per year Assume consultant works 42 weeks per year (6 weeks annual leave, 4 weeks study leave / professional leave and bank holidays).

Assume consultant works alone

4500 patients per 42 weeks = 107 patients per week at 15 patients per clinic would require 7 NHDs

In addition at least two NHDs will be required for one theatre list per week and a ward round per week.

Other NHDs would be required for:

Administration, Audit and Management - 1 NHD
Weekly review of dermatopathology - ½ NHD
CME/CPD - 1 NHD
Teaching, Training, Clinical research - 1 NHD (Variable)
On-call - ½ NHD

This does not include consultants' special interests and the need for day-care, phototherapy, or patch testing, all of which is part of a dermatology service.

Total NHDs for population of 100,000 is at least 13.0 NHDs

The number of NHDs required by a District General Hospital serving a population of 250,000 to provide a clinical service in dermatology can be calculated based on these recommendations. The total is 33 NHDs i.e. one consultant per 85,000 population.

Consultant working with assistant or trainee

The figures above assume consultants are working alone. If in every clinic a specialist registrar or an interested general practitioner assisted them under supervision, they could see 24 patients between them in the clinic.

The same logic, as used above, would suggest one consultant per 100,000 plus one whole time equivalent assistant. 2½ whole-time equivalent consultants plus 2½ whole-time equivalent assistants would be required per 250 000 population.

Assumptions

Ratio of 1 new to 2 follow-up patients
Difficult to discharge more patients if GP referrals are appropriate and needs of trainees are considered. Knowledgeable GPs will only refer complex problems that need specialist management. It is not possible to discharge these patients after one or two visits.

Trainees must follow their patients to learn how to manage disease. Therefore when trainees are present, although overall numbers of patients per clinic will increase, this will have little impact on the number of new patients seen because the consultant will see fewer patients and trainees will bring back more follow-ups. Ratio may approach 1:2.5 if phototherapy and patch testing are included.

15-18 patients per clinic
New patients who have difficult forms of common problems such as psoriasis or atopic eczema deserve more than a 10-minute consultation. Consultants certainly need more than 10 minutes when treating chronic diseases with potentially toxic therapy. It is possible to see more patients in a tumour clinic but only if surgery is not performed during the clinic.

Each Consultant works with one trainee and/ or non-training grades
No consultant should work in isolation from colleagues. All consultants responsible for a population of 100,000 should have assistance in clinics.

Specialist Services
The pattern of work will depend on the specialist services provided by individual consultants and departments e.g. skin surgery, contact allergy (patch) testing, wound healing, paediatric dermatology, phototherapy, dermatopathology.

Workforce Requirement

It is clear why the British Association of Dermatologists recommends the equivalent of one whole-time consultant dermatologists per 100,000 population to cope with the need for specialist advice i.e. an increase from 368 to 520 wte consultants in dermatology for England and Wales (agreed by BMA and RCP). The England and Wales population of 52,000,000 needs at least another 150 consultant dermatologists.

The specialty must expand at more than the historic 5% per annum to reduce waiting lists (18 months in some Trusts), cope with the needs of patients with common problems such as skin cancer and respond to increasing requests for training from registrars, GPs, nurses and medical undergraduates.

These calculations do not take into account new requirements to see cancer patients, if requested by the GP, within two weeks.