>> Service Provision Guidelines

GPs with a Special Interest in Dermatology

British Association of Dermatologists' Position Statement
September 2002

Summary of Principles

1. The aim of this initiative is to improve the quality, access and equity of care for those with skin disease in their community.

2. All parties involved with the delivery of dermatological care in both Primary and Secondary care must be involved with, and agree to, any developments in GP-delivered dermatology as part of an integrated local service.

3. GPs with a special interest are not a replacement for a consultant lead service. Consultant dermatologists have the specialist training and accreditation to diagnose and manage difficult skin diseases and the facilities to offer further investigation, inpatient treatment, advanced skin surgery and phototherapy etc.

4. Consultant dermatologists will be responsible for training, accrediting and providing CME for GPs with a special interest in dermatology. Time for this must be built into the GPs' and consultant job plans and the impact on reducing service delivery anticipated.

5. Resources to support the Secondary care dermatology service must be maintained.

6. GPs with a special interest in dermatology should not work in isolation and should practise alongside the local consultant dermatologist for an agreed proportion of their work.

7. The local consultant dermatologist should be actively involved in the appointment, training and continuing practice of GPs with a special interest in dermatology in their catchment area.

8. GPs with a special interest in dermatology must be properly remunerated.

9. GPs are specialists in Primary Care. Their workloads and job plans should be compatible with this.

10. Minimum referral criteria for patients referred to GPs with a special interest in dermatology should be defined with purchasers so that they are not overwhelmed with minor skin complaints. This would waste resources and be detrimental to the service.

11. GPs with a special interest in dermatology holding clinics in the community and in hospitals must have the resources, accommodation and manpower to support them.

12. The integrated local dermatology service must include nurses with dermatological training.

13. Patients with skin disease should be involved in the development of their local dermatology services.

14. In developing the role of GPs with a special interest in dermatology it remains a priority that dermatology training should be improved for all general practitioners and GP trainees. GPs with a special interest in dermatology should take an active part in the education process. This will require resources.

Introduction

The Government sees the recruitment of general practitioners with a special interest in skin disease as a key strategy for health improvement. Both the Royal College of General Practitioners and the British Association of Dermatologists support the concept of the GP with a specialist interest in dermatology.

GPs who have developed specialist dermatological skills already actively participate together with dermatological colleagues in specialist care, either in a hospital or primary care setting. The new scheme should strengthen this system by fostering a resource of specialist skills amongst general practitioners that can improve services for patients.

A commitment to revise the current process of remuneration of general practitioners undertaking specialist work is essential.

Clinical governance issues of training, continuing education and professional development must be addressed before the scheme can be implemented. Much of this will inevitably be provided by dermatologists, locally and nationally.

Consultation with representatives of patient groups on the impact of service changes on patient care will also be an important part of the review process. Local patients should be involved in the development of the integrated service.

GPs with an interest will form one of a series of potential options for the care of patients with skin disease within a local framework.

Central to the success of these local schemes is the requirement for discussion and agreement by the interested parties, including those in primary care and local dermatologists. Since the local dermatologists will be responsible for supervision and training they must agree the accreditation and appointment of GPs with an interest in their area.

Models of Service

GPs with a special interest in dermatology could chose from a number of different service models

• They may choose to run general dermatology clinics in the community but with strong links to the local dermatology department to support both the GPs and patients needing the resources of the hospital department. Referral to these clinics run by a GP in the community may be either by consultant triage or direct referral.
• Community based chronic disease clinics for patients with psoriasis, eczema or leg ulcers. These would involve both GPs with a special interest and dermatology trained nurses.
• Skin surgery sessions may be undertaken in the community by trained general practitioners with suitable facilities. Appropriate documentation of lesions, including photographic records, is essential. Close links to the local dermatology and histopathology departments are essential.

Examples of schemes already in operation or being piloted can be obtained from the British Association of Dermatologists.

Training & CME

• A cohort of experienced general practitioners, most of whom hold clinical assistant are already providing dermatology services. These are usually clinics or operating sessions held within the local dermatology department. Such doctors may not have taken diplomas. If the local dermatologist is satisfied with the dermatological knowledge and skills after a minimum period of a year, these individuals could develop a role as GPs with a special interest if they so wished. They should not be forced to do so. They may subsequently choose to sit for a suitable diploma.
• GPs wishing to develop the role without previous dermatological experience will need to train alongside a local consultant dermatologist tutor. Training should be competency based. The period of training will depend on the nature of the skills that are necessary, and the ability of the trainee to demonstrate that they have been acquired. For individuals wishing to practice across the full range of Dermatology, it is likely that approximately 100 supervised clinical sessions would be necessary. For those needing a more limited range of competencies, eg running a specialist eczema clinic alongside a specialist nurse, less time is likely to be needed, but competency should be demonstrated. The sessions should be appropriate for the sort of service the GP intends to develop (general dermatology, chronic disease service or skin surgery). The dermatology tutor should assess competency through a combination of logbook record and in-training assessment
• It should also be understood that the purpose of this period of clinic participation is for the purposes of training and not for the provision of service.

It is anticipated that most GPs developing these roles will obtain a diploma or equivalent benchmarked qualification in dermatology. The British Association of Dermatologists is currently assessing the available courses so that the role and remit of each is clear. This will allow GPs with a special interest in Dermatology to select the diploma most suited for their particular role. Diplomas and other written qualifications should be complimentary to, not a substitute for, practical clinical experience

• Continuing training and support for the GP with a special interest would be maintained by the GP continuing to work alongside the consultant dermatologist for an agreed proportion of their time.  In addition, this will provide access for those patients seen in the community who require more specialised diagnosis, investigation or care.
• A dermatological CME session should take place regularly. Once national rules for re-accreditation are agreed these should be adapted to reflect the requirement for revalidation for those with responsibility for the care of patients in this new setting.

Levels of Skill

• The GP with a general dermatological interest 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 in general dermatology. They would be expected to show a knowledge and skills level reflecting a higher level than that acquired by non-specialist colleagues. The syllabuses of national diplomas will define the expected level of knowledge. The local tutor would be expected to provide guidance on personal learning such as reading and course work.
• For those seeking accreditation in more specialist care the requirements should be modified to reflect training in such areas e.g. psoriasis, leg ulcers. The training period would be variable depending on the level of exposure possible in the training period and, as before, the local dermatological tutor would assess competencies.
• Those performing skin surgery clinics should have been trained and assessed by a local dermatological surgeon until they are deemed competent. They should gain and demonstrate diagnostic skills on benign and malignant skin tumours. They should understand the necessary histopathological techniques required for diagnosis.
  Any GP performing skin surgery should be an integral part of the local skin cancer service and join the multidisciplinary conferences required in that process. CME, audit and revalidation criteria described above should be in place.

Audit and Clinical Governance

• Regular attendance at dermatology audit sessions is required. This may require travelling to meetings in a larger dermatology unit. These sessions should include audit of the activity of local GPs with a special interest in dermatology.
• Once in place schemes involving "GPs with an interest" must be subject to periodic review by local and/or 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. The issue of indemnity for each GP delivering defined specialist services should be clarified with the employing authority and relevant defence union.

Workload, Facilities and Personnel

Workload

• New services should be devised in collaboration with the local dermatology team as described. The numbers of patients seen in a day in general dermatology community clinics should be subject to agreed limits. Similar limits should be set for the regular clinics held with the local consultant dermatologist where space and time should be included for difficult clinical problems requiring extra time and resource.
• Those undertaking specialized skin surgical work which involves patients with skin cancer should form a part of the local cancer service plan (see above) and have appropriate links to histopathology services as well as the specialist dermatologist.

Accommodation & Facilities

• This must include a consultation room with good lighting.
• A private room for patient education where nurses can demonstrate application of treatments and bandages.
• Suitable couches, sink facilities, leg buckets etc. for leg ulcer clinics
• A fully equipped minor operating suite is required for skin surgery
• A computer link to the hospital based dermatology department is highly desirable with telemedicine facilities, if appropriate.
• More accommodation is likely to be required in hospital departments of dermatology so that local GPs with a special interest can attend clinics and postgraduate activities.

Personnel

• The GP with a special interest should work with a local nurse, either in a liaison capacity between primary and secondary care, or with close links to a specialist dermatology nurse.
• Secretarial and clerical support for the service must be adequate.

Resolving Disputes

A locally convened group consisting of at least 2 representatives from the dermatology and primary care teams should resolve any disagreement between a GP with an interest and the dermatology team.

Impact on Hospital Departments and Service Capacity

• The training, assessment and CME of GPs with a special interest will involve dermatologists to a substantial degree. Dedicated time for this work must be built into the timetable in consultant job plans.
• The impact on service must be predictable and planned. The well-documented inability of current dermatology services to meet need and demand means that developing GPs with a special interest in dermatology is likely to increase the demand for dermatological care from the local community. Since many GPs currently have little training in dermatology, they often do not know the optimum treatment or available options for patients with skin disease. Increasing the knowledge base in the community will increase the demand for specialist investigation and management in the secondary care sector and plans to ensure this is in place must be put in place simultaneously with the developments of GPs with a special interest in dermatology.