>> Service Provision Guidelines

Report of the BAD Task Force on Provision of Care in Dermatology

1 Members of the Committee

2 Introduction

2.1 Most dermatologists are fully stretched and the demands on them exceed their capacity to respond. Nevertheless it is important to be objective about the service which is provided. In a dynamic situation subject to sudden changes (e.g. skin cancer scares, new therapeutic advances, reductions in beds, general elections) we need to listen to and learn from, the experiences of others. That, intrinsically, is what 'audit' involves.

2.2 The task force was not disposed to add to the workload of dermatologists, increase the costs of running a department or to issue rigid rules but to seek out innovative practices and publicise them for others to evaluate.

2.3 Not least in the deliberations was an attempt to ensure that the service was patient centred, whilst recognising the realistic constraints on implementing any recommendations which might improve the provision of care in dermatology.

2.4 Not all changes need to cause major upheavals. If, for example a recommendation was adopted which allowed each dermatologist to see one extra patient per week that would amount to approximately 20,000 more patient consultations per annum. In turn this would require identification of the mechanisms by which such a result can be achieved and the might be different in each individual centre.

2.5 The Task Force started with a blank sheet of paper but a summary of the remit and the way it was tackled is given in Appendix 1

2.6 A wealth of information has been received from members of the BAD and other interested parties. The details are too great to include in this document but where possible arrangements are being made for them to be posted on the BAD website. Items where further information is available are marked (web) in the report.

3 Scope of the Report

3.1 This report deals exclusively with the provision of care to 'outpatients' in the broadest sense. The working definition of an outpatient used in this document is 'one who needs specialist attention which cannot be provided by the primary care team without additional help'. It does not presuppose that the care needs to be delivered at a hospital, or any other specific site, nor that it needs to be provided on an ongoing basis by the secondary care team.

3.2 The three main purposes of outpatient care are to provide:

• advice on diagnosis and treatment
• access to procedures or further care or investigation
• continuing care for patients with chronic disease

3.3 The ideal outpatient service offers:

• rapid access
• geographical access
• a pleasant environment in clinics
• adequate personnel for the allotted responsibilities
• respect and consideration for people
• good two way communication between hospitals and GP's
• clear and consistent information to patients
• the use of clinically effective tests and treatment
• access to all necessary disciplines

3.4 It is usual for patients referred for an outpatient appointment to expect that they are going to see a consultant; at least on the first visit. Patients who are aware that they are being seen by a clinical team and see evidence of it in operation more easily accept being seen by different members of the team on different occasions.

3.5 The Ministers of Health have commissioned a research study to look at outpatient services in all specialties. This is being carried out by the Clinical Standards Advisory Group (CSAG). The brief to the CSAG is to examine the delivery of OP services and make recommendations to improve standards of care. In addition they are to carry out site visits which would be beyond the capacity of the BAD task force.

3.6 The topics discussed in this report are those which have been raised either in meetings of the Task Force or as a result of a questionnaire circulated to all BAD members, patient support groups and interested nurses and GP's, for whose contributions we are extremely grateful.

3.7 Cumulatively BAD members have considerable expertise in delivering high quality care and their experiences, whilst not sufficient individually to warrant publication, can be used to assist others in improving the standards of care.

3.8 It is accepted that high quality teaching at undergraduate and post graduate level and high quality entrants to dermatology are the cornerstone of any high quality service and these are being addressed by other BAD committees.

3.9 As a result of the extensive survey of topics considered to be important by consultants, nurses and patient support groups we are in a position to identify areas in which action is most likely to result in a positive gain either in throughput, patient satisfaction or quality of patient management and ideally all three.

3.10 For convenience the topics are grouped together under broad general headings in the following sections.

4 Geography of the Department

4.1 The physical design of outpatient facilities can make an enormous difference to the delivery of care.

4.2 'Quality in the Dermatological Contract' makes it clear that there should be a dedicated area for dermatology but does not specify that it should be a separate unit although experience has shown that this is the ideal.

4.3 All departments, whatever their location should have ready access to basic equipment such as telephones, facsimile machines and computer terminals.

4.4 The physical proximity of outpatient, inpatient and day care facilities allows sharing of staff with integration of activities and far more efficient use of time for all staff.

4.5 Information on how this has been achieved in various departments is given on the BAD web site (web)

5 Day Care Centres

5.1 Day care centres provide an extension in outpatient care and, in some cases, an alternative to inpatient care but they should not be viewed as a substitute for inpatient facilities.

5.2 Day care centres should be in a position to an provide an 'out of hours' service.

5.3 In some departments phototherapy is regarded as part of the day care facility whereas in others it is separate.

5.4 Information on how they are used in different centres can be found on the BAD web site (web).

6 Departmental Organisation

6.1 It is clear that keeping the identity of dermatology separate from general medicine is beneficial.

6.2 Where the two are integrated it is usual for funds to be diverted from dermatology into general medicine.

6.3 If integration with general medicine cannot be avoided dermatologists must participate in committees etc in order to maintain a high profile within the hospital. They should not shrink from becoming clinical directors of medicine.

6.4 In larger departments, minuted business meetings every 4-6 weeks should be the norm.

7 Appointment Practices

7.1 As dermatology is mainly centred on outpatient activity appointment practices are likely to be a key area for improving the delivery of care.

7.2 The figures for attendance in the past eight years are given in table 1.

7.3 It was in this area more than any other that our questionnaire indicates that BAD members are working to improve standards and much practical advice is available (web).

7.4 It is essential that mechanisms are in place to ensure:

• Patients are properly prioritised and urgent patients are seen quickly.
• The statutory need to see cancers (including BCC's) quickly does not cause delay for other patients with acute problems.
• Chronic patients can get the advice they need when they need it.

7.5 Information on the following innovative practices is available on the BAD web site.

7.5.1 Attempts should be made to ensure that all referrals are based on genuine need. This might be improved by:

• Agreeing referral protocols (e.g. no cosmetics, warts etc)
• Returning letters for warts & molluscum and other simple conditions with information leaflets on management
• Producing a local newsletter with local guidelines, and current information
• Feedback to high referring GP's pointing out the difference
• Attempting to avoid the knock on effect of a fast track for non-urgent skin cancer.

7.5.2 Non-attenders are a source of much wasted time and effort. It is true that in most centres bookings are made on the basis of a certain percentage of 'No shows' but DNA's distort priorities and delay the treatment of others. Numbers may be minimised by:

• Introducing a telephone new patient booking system
• Giving a specific date for an appointment not just grading urgent routine etc
• Having 'In house' arrangement of appointments made by dermatology secretaries
• Having a clear policy on those who DNA
• Sending a reminder shortly before an appointment is due

7.5.3 Reducing the number of follow up appointments will allow more new patients to be seen. Between 1990 &1998 the ratio of old to new has dropped from 2.25:1 to 1.95:1 which is a trend to be encouraged. Some methods of achieving this are as follows

• Open appointments for chronic or recurrent conditions (e.g. AK's BCC's) avoid unnecessary visits
• Keeping follow ups just to an essential minimum
• Carrying out postal follow ups
• Carrying out surgery on the day of the first consultation may make further visits unnecessary such as the following (web):

One stop PLC
Concomitant treatment sessions
See & treat skin cancer clinics for reliable GP's
One stop service for biopsies and surgery
Punch biopsies at the time of attendance

• Setting aside time to deal with problems by telephone
• Informing patients about relevant support organisations which can provide ongoing information and help thereby encouraging and enabling good self management.

7.5.6 It should be recognised that many long term follow up patients are very time consuming in view of the intractable nature of their condition.

8 Smooth running of clinics

8.1 The following methods have been used to ensure that time spent in clinics is used most efficiently:

• Nursing Auxiliary in each clinic
• Adequate time for consultation
• Backward booking of clinics; urgent first less urgent later
• Preconsultation questionnaire (e.g. for allergies)
• Early cancellation of clinics e.g. 1 year in advance
• Early morning 'walk in' clinic for urgent patients to be seen rapidly
• Leaving adequate time for emergencies.
• Trying to ensure that patients expectations are realistic

9 Note Keeping

9.1 Keeping clear accurate readily-accessible information is obviously essential and has been aided in some departments by the following: (web)

• Simplified stamps, e.g. for surgery
• Phototherapy prescription Cards kept in clinics
• Summary sheets at front of notes for AD, psoriasis, multiple BCC's.
• Disease specific note keeping Charts e.g. for acne
• Use of shared care cards which are in the patients possession (cf Steroid cards)

10 Specialist Nurses

10.1 The most expensive way for dermatological care to be delivered is consultant / patient contact. If this can be reduced without the loss of, or, better still, with an improvement in, patient care this will be beneficial.

10.2 Without doubt it is the expanding role of the nurse and the development of the nurse practitioner which is the single most important advance in assisting developments

10.3 Information on the general role which specialist nurses can play is available on the web site (web) from a number of sources

10.4 Dermatology nurses can further develop special expertise in specific disease areas in which they are then able to conduct delegated independent clinics, sometimes with direct GP referral.

10.5 Areas which members have identified the details of which are on the web site: (web) include

• Warts
• Ulcers & hosiery
• Eczema
• Psoriasis
• Leg ulcers
• Chronic disease management

10.6 Nurses can develop additional skills in therapeutic and diagnostic areas (web) such as:

• PUVA and patch testing
• Wound Care
• Tissue viability
• Nurse prescribing
• Supervision of cytotoxic and cyclosporin follow ups

10.7 Liaison nurses working in the dermatology department but visiting the community can help provide a 'seamless' service as well as assisting with better training of practice nurses, centrally coordinating ulcer therapy etc.

10.8 Outlines of their roles in the various departments is available on the web site (web)

10.9 Surgery: it is increasingly recognised that simple surgical procedures can be carried out more than adequately by suitable qualified nurses. Experience in a number of centres is available on the web site (web).

10.10 Additionally nurses can offer general assistance and the following areas have been recognised:

• Eczema education clinics
• Daily dressings clinic
• Pop in treatments
• Treatment demonstrations
• Counselling in Surgical dermatology clinics

11 Specialised Clinics

11.1 Specialised clinics can be divided int

• Disease specific
• Multidisciplinary.

11.2 In the 'Disease specific' group appropriate time (either more or less) and facilities can be provided with a highly specialised focus on one particular area. Examples on the web site (web) include:

• Special eczema clinics with back up material
• Separate Inflammatory diseases clinic
• Fast track skin cancer clinic
• Melanoma screening clinic
• Fast track tumour clinics with screening held just before combined clinic with plastic surgeons etc
• Sub specialist clinics
• Separate paediatric clinics
• Follow-up clinics organised by diagnosis including diagnostic dilemma
• Clinical assistant lead disease specific clinics

11.3 The cost of multidisciplinary clinics is high but potentially they provide the highest possible standards of patient care. Costs can be minimised by ensuring that the clinics are fully utilised and held at appropriate intervals for the workload. Examples of joint clinics (web) include:

• Rheumatology
• Gynaecology / vulval
• Plastic Surgery / Radiotherapy (Skin cancers)
• Vascular surgeons Leg ulcer
• Somatic / psychiatric
• HIV
• 'Paramedics' e.g. chiropodists etc

12 Information Technology

12.1 All departments should have ready and easy access to basic facilities such as telephone, facsimile and computer terminals.

12.2 It is important that the rapid developments in information technology are harnessed for the benefit of patient care but caution needs to be exercised so that expensive unproven techniques are not adopted without proper assessment. Examples which are worthy of further investigation and audit include:

• Direct line to Internet to help diagnosis
• Simplified diagnostic coding by secretary
• Computerised storage of images with patient details
• Teledermatology
• Spread sheet for UVB & PUVA dose changes
• Information technology compatibility between departments
• Computerised departmental records e.g. for patch testing etc
• Use of patient education videos

13 Information Leaflets

13.1 The availability of printed information on their disease is appreciated by most patients and it should be readily available in all departments however small.

13 All departments should have the names and addresses of all recognised patient support groups readily available and they should drawn to the attention of the patients at an early stage.

14 Prescribing Practices

14.1 In a specialty such as dermatology the issuing of a specific prescription is, in most non-surgical cases, the key to successful management. It is vital that the best treatment is available and that the patient is aware of the best way for it to be used.

14.2 There is considerable inconvenience caused to patients by the non-availability of certain dressings etc within the community. This causes an increase in the number of hospital visits just to obtain supplies.

14.3 In the 'Skin' section of MIMS, 142 preparations need no prescription and 115 (including systemic drugs and steroids) do.

14.4There will be considerable benefit to patients if they have rapid, easy access to the correct treatment for them. The following have been identified as improving standards (web):

• Clinic specific formulary
• Test doses to dithranol
• Abolition of tar baths
• Nurse prescribing
• Emollient trial packs

14.5 It is clear that many GP's have little idea how much of any given topical preparation should be prescribed and this needs to be addressed.

15 Teaching

15.1The standard teaching of dermatology at the undergraduate or postgraduate levels is outside the remit of this task force but others can benefit from education and the following special areas have been identified (web):

• Surgical teaching programme on CD ROM for students GP's and SHO's
• Teach and treat outreach clinics rather than lectures
• Treatment protocols and tutoring of nurses on all preparations used in a department
• Proper instruction to the carers of elderly people

16 Miscellaneous

16.1 A large number of ideas have been identified which have the potential to improve the overall standard of care provided and some are included here (web):

• Standardising discharge and clinic letters
• Clinical assistant led acne and psoriasis clinics
• Reduced number of patients in teaching clinics Feed back questionnaire for all patients
• General patient support group meetings
• 'Inreach clinics' for fund holders
• Audit of Patents' expectations
• Clinical procedure coding to record activity of the department
• Cryotherapy equipment on loan rota to GP's
• Self photography for dysplastic naevus syndrome
• Polaroid camera in each clinic for assessment of pigmented lesions
• Contact number for chronic disease flares
• Patient held photographs of naevi

17 Recommendations

17.1 Any department implementing any changes, including any of those outlined here, subjects them to audit so that improvements in delivery of care can be quantified.

17.2 Integrated facilities should be the goal for all departments and the starting point for any further developments.

17.3 The BAD should explore the possibility of drawing up plans for the design of a generic integrated department which can be used as a template for local developments.

17.4 The finances of dermatology departments should always be clearly identifiable.

17.5 Dermatology should be a separate directorate or alternatively joined with other 'minor' specialties.

17.6 Informal visits to other departments should be encouraged.

17.7 The BAD should commission a survey to analyse the cost effectiveness of Day Care centres.

17.8 Outpatient appointment practices are a key area for further investigation following which the BAD should be in a position to issue recommendations.

17.9 It is important that the rapid developments in information technology are harnessed for the benefit of patient care but caution needs to be exercised so that expensive unproven techniques are not adopted without proper assessment.

17.10 The BAD should continue to develop a range of agreed patient information leaflets for wide circulation.

17.11 The BAD website should be used as a continuing forum for the publicising of innovative ideas supplemented by regular articles in the BAD Newsletter.

18 Future Developments

18.1 Better information and research into the processes and results of dermatological care including qualitative studies and evaluations of innovative practices are required. In the medium to long term different untried models of care such as those outlined by Andrew Warin and the 'hybrid' model proposed by Hywel Williams need to be assessed on a pilot basis and be subject to proper analysis and assessment.

18.2 Consideration should be given to the eduction of pharmacists in the most effective modes of OTC therapy which may reduce the need for consultations.

18.3 The BAD should, in conjunction with the RCGP, make recommendations on prescribing quantities for GP's.

18.4 The possibility of making more medications in the POM section available OTC should be explored.

18.5 The management of acne deserves special attention especially in the light of increasing bacterial resistance. Many cases are referred to dermatology departments, not on diagnostic grounds but solely for the prescription of isotretinoin. It is suggested that the BAD investigates the possibility of making isotretinoin available not only from hospitals but also from designated GP's who have a recognised interest in dermatology.

Bibliography

1. All Party Parliamentary Group on Skin. Enquiry into the Training of Healthcare Professionals who come into contact with skin Diseases. ; Jul 1998.

2. All Party Parliamentary Group on Skin. An investigation into the adequacy of service provision and treatment for patients with skin disease in the UK. ; 1997.

3. Benton EC; Hunter JAA. The dermatology put-patient service: a study of out-patient referrals in a Scottish population. British Journal of Dermatology. 1984; 110: 195 - 201.

4. Cox NH. The expanding surgical and prescribing role of nurses in dermatology departments in the UK.

5. Cox NH; Walton Y. Prescribing for out-patients by nursing staff in a dermatology department. British Journal of Dermatology. 1998; 139: 77 - 80.

6. Crowther R. Review of Good Practice in Dermatology Services. 1998(April).

7. Esser SJ; Newton JN; TaylorHR; van Onselen J; Kaur V. A Descriptive and Evaluative Study of a Dermatology Nursing Service. Oxford: Oxford Centre for Health Care Research and Development. Oxford Brookes University; 1998.

8. Finlay AY; Bryden JS. Integrated in-patient and out-patient. Clinical & Experimental Dermatology. 1989.

9. Gilmour et al. Comparison of teleconsultations and face to face consultations: preliminary results of a United Kingdom multicentre teledermatology study. British Journal of Dermatology. 1998; 139: 81 - 87.

10. Godsell G. Performing diagnostic skin biopsies. Professional Nurse. 1998; 13(6): 1 - 4.

11. Goodwin P. BAD Newsletter. 1998(Autumn): - 25.

12. Government Statistical Service. Outpatients and Ward Attenders. . 1997.

13. Harris DWS; Benton EC; Hunter JAA. The changing face of dermatology out-patient referrals in the south east of Scotland. British Journal of Dermatology. 1990; 123: 745 - 750.

14. Long Term Medical Conditions Alliance. Helping Inform Patients about Patient Organisations (HIPPO). ; 1998 Oct.

15. Newton J. CSAG Study of Outpatient Services. Personal communication. 1998.

16. Page RL; Harrison BDW. Setting up interdepartmental peer review. Journal of the Royal College of Physicians of London. 1995; 29(4): 319 - 324.

17. Russell-Jones R. Guidelines for GP referrals in Dermatology. Beckenham: Publishing Initiatives; 1996; ISBN: 1 873839 42 1.

18. Savin JA. Validation of the recommendations on clinic size made by the British Association of Dermatologists. British Journal of Dermatology. 1997; 136: 970.

19. Simpson NB; Allen BR; Douglas WS; Finlay AY. Quality in the dermatological contract. Journal of the Royal College of Physicians of London. 1995; 29(1).

20. Stewart C. Associate consultant could be the way forward. Hospital Doctor. 1998(2nd July): 15.

21. Warin AP. How can we meet the dermatological needs of the community. unpublished. British Journal of Dermatologists Newsletter 1998

22. Watts J. Nurses who practise dermatology. BAD Newsletter. 1998(Summer): 18 - 19.

23. Williams HC. Extended roles for pharmacists in caring for skin conditions: a welcome development which needs further evaluation. journal of Clinical Pharmacy and Therapeutics. 1995; 20: 307 - 312.

24. Wlliams HC. Dermatology. StevensA; Raferty J, Eds. Health Care Needs Assessment. Oxford: Radcliffe Medical Press; 1997. ISBN: 1 85775 211 2.

Acknowledgements

The Task force wishes to thank all those who have taken the time and trouble to supply the information used to draw up this document.

Appendix 1

Remit of The BAD Task Force on Provision of Care

The BAD Task Force was given the responsibility of:

"Producing guidelines on certain aspects of delivery of care and in particular to publicise good models of care that already exist in individual departments"

The Government white paper 'A First Class Service' places particular emphasis on quality and this must be an essential underlying theme in any recommendations.

It was recognised that if the Task Force was to produce recommendations which would have an immediate beneficial impact on practice an initial report was needed speedily.

Its activities should not be seen in isolation: the BAD has also reported on the provision of in-patient services and is supporting the concept of interdepartmental peer review as outlined in the paper by the British Thoracic Society.

Both of these will have an effect, directly or indirectly on the delivery of outpatient services.

Objectives
The task force had, as its major responsibility, the identification practical ways of improving the delivery of dermatological care giving realistic recognition to current constraints on funding and manpower.

It was recognised that some of the recommendations were likely to be common to the delivery of any outpatient service.

There is therefore overlap with the work of the Clinical Services Advisory Group (CSAG). and the Task Force therefore invited the participation of Dr John Newton of the CSAG.

Others recommendations were likely to be more specific to dermatology.

It was also important that the task force should take a longer term view and try to identify areas which may be the subject of further study, audit and research.

Background
The unprecedented demand for the services of accredited dermatologists far exceeds their ability to provide equitable care: consultation figures for the past 8 years are given in table 1. Reasons for an increasing referral rate might include:

a) the surfacing of unmet need
b) an increase in some conditions such as atopic eczema and skin cancer
c) technical advances (e.g. lasers and new drugs) which render previously untreatable conditions amenable to therapy.
d) an increase in demand for treatment of "cosmetic" skin conditions
e) higher awareness of skin diseases due to publicity (e.g. pigmented lesions)
f) higher patient expectations as a result of the 'Patients Charter'
g) greater pressure on GP's to refer to a specialist for medico-legal reasons.

Two initiatives in the recent White Paper which could have significant implications on the provision of services to patients with skin problems are:

a) the formation of primary care groups who purchase secondary case services
b) the formation of a National Institute of Clinical Effectiveness (NICE) which will be used to judge the quality of services.

The advantages of the BAD collecting evidence to develop a medium to long term strategy are:

a) the provision of a cohesive voice when campaigning for change
b) sharing information and experience on the different ways of delivering high quality care.
c) to strengthen the position of dermatologists subject to threatened with cuts to their facilities or changes which have been shown to be detrimental.

Methods by which the group has addressed its remit
The group has carried out its remit by:

a) gathering and collating ideas and evidence which will identify problem areas together with suggestions how they might be addressed
b) identifying and prioritising problems of service provision which need to be analysed in the medium to long term
c) considering how to publicise any suggested changes using such methods as:

• direct reports to BAD members
• items in the BAD Newsletter
• recommendations to primary care groups
• proposals to the National Institute of Clinical Effectiveness
• proposals to the All Parliamentary Skin Group.

Theory versus practice
There is a clear need to recognise that a general strategic approach must be tempered with a sense of pragmatism.

In line with the report by the British Thoracic Society, recommendations can be clearly divided into those which do not require significant resources and those which need more manpower, equipment or facilities.

The Task Force's work was more to do with framing the appropriate questions and gathering evidence than suggesting a rigid blueprint for how care should be delivered.

It is hoped that by identifying simple practical suggestions, which do not require unrealistic levels of funding and have been implemented in individual departments ideas will be generated that can be adapted to the local situation.

The need to think in terms of whole communities
It is crucial that the problem of provision of care for dermatological conditions is considered from a community perspective.

A range of professionals is involved in delivering dermatological care including community pharmacists, health visitors and community physicians as well as primary and secondary care teams together with the patients themselves, their relatives and carers.

It is important that any recommended strategy uses their services in the most effective way recognising both their strengths and weaknesses.

The purchasing of services is considered from a community perspective e.g. units of 100,000 population.

The Task Force recognised the need for a 'corporate needs assessment' so that the requirements of each group of patients needing care are considered.

Possible strategic targets
The short term goals have been to

a) produce this report for submission to the BAD Executive in April and the AGM in July 1999 which collates current experience of different ways of delivering dermatological care.
b) produce a series of recommendations for the new Primary Care Groups
c) produce some recommendations suitable for use by the National Institute of Clinical Effectiveness

The medium to long term (1 to 5 years) goals might be to

a) consider the need for a further task force which could look prospectively at the implementation and evaluation of different ways of delivering dermatological care
b) carry out an audit on changes which have been implemented
c) support and seek funding for innovative ideas in the provision of care.

Summary

This report deals exclusively with the provision of care to 'outpatients' in the broadest sense.

It does not presuppose that the care needs to be delivered at a hospital, or any other specific site, nor that it needs to be provided on an ongoing basis by the secondary care team.

The three main purposes of outpatient care are to provide:

• advice on diagnosis and treatment
• access to procedures or further care or investigation
• continuing care for patients with chronic disease

The ideal outpatient service offers:

• rapid access
• geographical access
• a pleasant environment in clinics
• adequate personnel for the allotted responsibilities
• respect and consideration for people
• good two way communication between hospitals and GP's
• clear and consistent information to patients
• the use of clinically effective tests and treatment
• access to all necessary disciplines

The following key areas have been identified:

Geography of the Department
The physical design of outpatient facilities can make an enormous difference to the delivery of care. The physical proximity of outpatient, inpatient and day care facilities allows sharing of staff with integration of activities and far more efficient use of time for all staff.

Day Care Centres
Day care centres provide an extension in outpatient care and, in some cases, an alternative to inpatient care but they should not be viewed as a substitute for inpatient facilities.

Departmental Organisation
It is clear that keeping the identity of dermatology separate from general medicine is beneficial.

Appointment Practices
It is essential that mechanisms are in place to ensure:

• Patients are properly prioritised and urgent patients are seen quickly.
• The statutory need to see cancers (including BCC's) quickly does not cause delay for other patients with acute problems.
• Chronic patients can get the advice they need when they need it.
• Reducing the number of follow up appointments will allow more new patients to be seen.

Specialist Nurses
Without doubt it is the expanding role of the nurse and the development of the nurse practitioner which is the single most important advance in assisting developments. Dermatology nurses can develop special expertise in specific disease areas in which they are then able to conduct delegated independent clinics, sometimes with direct GP referral.
Liaison nurses working in the dermatology department but visiting the community can help provide a 'seamless' service as well as assisting with better training of practice nurses, centrally coordinating ulcer therapy etc.

Specialised Clinics
In 'Disease specific' clinics appropriate time and facilities can be provided with a highly specialised focus on one particular area. The cost of multidisciplinary clinics is high but potentially they provide the highest possible standards of patient care. Costs can be minimised by ensuring that the clinics are fully utilised and held at appropriate intervals for the workload.

Information Technology
It is important that the rapid developments in information technology are harnessed for the benefit of patient care but caution needs to be exercised so that expensive unproven techniques are not adopted without proper assessment.

Information Leaflets
The availability of printed information on their disease the names and addresses of recognised patient support groups is appreciated by most patients and should be readily available in all departments however small.

Prescribing Practices
It is vital that the best treatment is available and that the patient is aware of the best way for it to be used.

Recommendations
Any department implementing changes, including any of those outlined here, should subject them to audit so that improvements in standards of care can be quantified.

Future Developments
Better information and research into the processes and results of dermatological care including qualitative studies and evaluations of innovative practices are required.

Topics for web site; included in 'raw data' folders and listed alphabetically by person submitting

Allen (ie. Godsell)
Diagnostic biopsies by nurses

Ashworth
Clinical assistant led acne and psoriasis clinics

Burova
Skin Support Group

R Charles Holmes
Common Disease Summary Sheets

Cheesbrough- awaited
Skin Surgery by nurses

Collins
UVR spreadsheets

Coulson
Internet connection

Cox
Nurse prescribing
Nurse Surgery

Cunliffe
Isotretinoin Therapy Docuymentation
Standard acne therapy documentation

English
Day Treatment unit

Ferguson
Phototherapy card

Finlay
Integrated management

Gawkrodger
In-reach clinics

Goodwin
Bournemouth review

Handfield-Jones
Postal follow ups

Hunter B
Outpatient referral patterns x 2

Kavanagh
CD Rom for minor surgery - awaited

Kirton
Pre-consultation questionnaire - awaited

Lapsley
HIPPO

Levell
See and treat cancer sessions

Logan
Minor operations surgery stamp

Motley
Outpatient telephone booking system

Newton
Evaluation of Dermatology Nursing service

Norris
In-house appointment bookings

Price
Local Newsletter

Tharakaram
Instructions to patients and carers on treatment

Thomson
Paramedic links

Walkenden
Open appointment systems

Warin
Day Treatment Units

Watts
Nurses in Dermatology: general role

White (Marion)
Standard format documentation (may need development)