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Patients with skin disease deserve to be seen by properly trained and accredited doctors

The challenge when commissioning Dermatology services is that no matter which organisation provides the service, whether private or NHS, it may struggle to find suitably qualified medical professionals to deliver the service at primary, community and specialist levels.


In her article in BMJ Careers (21 March 2013), Julia Schofield makes the point that effective accreditation for GPwSIs (in all disciplines) needs to be addressed urgently given the imminent disappearance of PCTs. She also references an audit of Dermatology GPwSIs from 2005 that showed that nearly half had not completed the accreditation process. More GPwSIs in Dermatology would be a good thing – skin related problems are the most common reason people visit their GP - but those GPwSIs need to be properly trained and accredited; currently many are not. Dermatology is poorly taught at most Medical Schools, if at all, and Dermatology is not a mandatory component of GP training.

There are 170 Consultant Dermatologist posts vacant in the UK at present and this has led to a situation where in many cases a locum ‘Consultant’ fills the post, without necessarily holding a Certificate of Completion of Training. Such ‘Consultants’ therefore cannot be offered the post substantively. It is expedient for employers to perpetuate the situation and it is compounded by patient demand: without these under qualified and/or unaccredited ‘specialists’ the waiting lists for dermatology would be even longer than they are currently. Patient care, though, is being compromised by people working beyond the scope of their expertise and training.

There are examples of non-NHS providers tendering for services, being awarded contracts for Community Dermatology services based around GPwSIs and then finding that they cannot recruit accredited GPwSIs and so, instead, recruiting GPs who are given a quick training course.

Chris Bunker, President of the British Association of Dermatologists said recently, at the All Party Parliamentary Group for Skin at Westminster, “There are no alternative providers for Dermatology services, only alternative employers.” All employees taken on to provide a particular service should be trained and qualified/accredited for that role.

The provision of Dermatology services is threatened by these workforce issues as well as by increasing demand due to the explosive increase in skin cancer, people living longer and people developing several diseases (co morbidities). Integrated, appropriate Dermatology services are also increasingly challenged by new commissioning arrangements. Many examples of bad process and poor outcomes already exist. Patient care and interests would be better served if the voices of Dermatologists and patients with skin diseases were heard more clearly both in the commissioning process ie the National Commissioning Board (NCB) and by the Department of Health. There is no National Clinical Director for skin disease in Domain 2 of the NCB and there is no single person or unit within the Department of Health with responsibility for Dermatology despite the fact skin disease is behind 13 million consultations in primary care and over a million referrals to secondary care each year. 

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85% of skin patients could benefit from pioneering government-funded website. Tailored online psychological support for people with skin conditions – project funding announced

The British Association of Dermatologists (BAD) has been awarded government funding for a groundbreaking project that will bring together two major areas of healthcare, to benefit the lives of millions of people.

The Department of Health Innovation, Excellence & Strategic Development Fund grant, of £97,000 over three years, will enable the BAD to develop a website that will act as a hub for psychological support specifically targeted at skin disease patients.

The project, which was highlighted in a speech by Jeremy Hunt on Wednesday*, will be the first of its kind to unite the specialties of dermatology and mental health, which have a significant overlap. The causal link between mental health issues and skin disease is twofold – skin disorders cause psychological traumas, and conversely, psychological factors like stress can trigger or worsen certain skin diseases. However, Psycho-dermatology services (which provide emotional support specifically for skin disease patients) are extremely limited in the UK and very few dermatology departments even have direct access to general psychiatrists.

The website will bring together, and link to, existing disease specific resources, support groups, forums and help-lines. The BAD aims to work in partnership with a mental health charity to assist skin disease patients in need of immediate psychological help to find it more easily.

Currently, support materials and services directed specifically at skin disease patients are sporadic and disparate, and those that do exist are not always easy to find or access. While there are both patient support groups, centred on individual skin diseases, and also mental health charities, there is no centralised hub that provides coordinated resources, appropriate to people with problems that transcend dermatology and are psychological or psychiatric.

Skin conditions are the most frequent reason for people to consult their GP. It is not just the physical symptoms that affect sufferers’ lives – diseases that are visible, disfiguring or long-term can carry a multitude of psychological and social effects, including isolation and depression. In the UK, psoriasis alone is linked to 300 suicide attempts annually. A British Association of Dermatologists’ survey in 2011 revealed that 85 per cent of patients indicated to their dermatologist that the psycho-social aspects of their skin disease were a major component of their illness.

Stress, as well as being a frequent by-product of skin conditions, is also known to cause and exacerbate skin disease; psychological and self-help interventions can be crucial not only for easing mental distress but also for improving many of the physical symptoms of the skin disorder. It may be difficult for a variety of reasons for skin disease patients to access mental health services directly, one being that they may not identify themselves as having a mental health issue, but they may still understand that the skin disease or disorder is having an adverse effect on their mental wellbeing.

The BAD believes that for patients to have access to self-help materials specifically tailored to their skin disease, as well as being signposted to appropriate support services, will have a huge impact on many people’s lives. Through use of these tools it is hoped that the vicious cycle of stress, that is exacerbating an existing skin condition and subsequently increasing stress levels, will be broken.

President of the British Association of Dermatologists Professor Chris Bunker, said: “We think that this project will be an innovative approach to a largely unmet health burden. We know that there is under provision of specialist Pyscho-dermatology services and, whilst a website cannot replace this kind of specialist care, it may help to raise awareness of the services that are available and of resources for both patients and medical professionals that are specific to skin disease.
“By being able to see easily the range of options available, skin patients will be able to make better informed choices about their health and care and understand how to access the help that they need.
“Our proposal to create an interactive, mobile-phone accessible website for sufferers of skin conditions seeking psychological support, will help people by providing guided, personalised access to self-help tools, information on support groups and networks, and advice on types of guided therapies and other psychological interventions that may be of benefit to them.”

Dr Linda Papadopoulos is one of the most well-known psychologists in the UK and has been working in the field of Psychodermatology for 15 years. She said: “Illnesses do not occur in a vacuum, their ramifications have the potential to affect us not only physically but socially and emotionally too. The social significance of our skin in relation to our body image and the mythology that skin disease is contagious can take a significant emotional toll on people, which is why this project is hugely welcome and, indeed, imperative to give people the right type of well rounded care.”

To create the online hub the BAD will set up a multi-disciplinary advisory group and consult widely to create the best possible resource for people with skin disorders.

Key statistics and notes:

A national survey undertaken by the BAD in 2011 to assess the availability of psycho-dermatology services, revealed poor provision, despite dermatologists reporting:

• 17% of dermatology patients need psychological support to help with psychological distress secondary to a skin condition.
• 14% of dermatology patients have a psychological condition exacerbating their skin disease.
• 8% of dermatology patients present with worsening psychiatric problems due to concomitant skin disorders.
• 3% of dermatology patients have a primary psychiatric disorder.
• 85% of patients have indicated that the psycho-social aspects of their skin disease are a major component of their illness.

*Jeremy Hunt’s speech on innovation in healthcare: http://mediacentre.dh.gov.uk/2013/03/13/13-march-2013-jeremy-hunt-innovation/

The “Working Party Report on Minimum Standards for Pscyho-Dermatology Services 2012” published in December 2012 highlighted the following: Dedicated psycho-dermatology service provision (both psychology and psychiatry) in the UK is scarce despite a need for such services. There is currently only one service in which a psychiatrist and dermatologist see patients concurrently, and there are very few dedicated psychologists working jointly in dermatology clinics.

Long-term skin conditions can cause considerable isolation for many people. According to a study of 2,579 skin disorder patients, at least one in four also suffer from a significant psychological disorder [Picardi, A. et al, BJD, 2000]

Multiple international studies have identified an even higher level of psychological disorders in dermatology patients, generally ranging from 40% to 60% [Hughes JE et al, Br J Psychiatry, 1983; Wessely SC et al, Br J Psychiatry,1989; Attah Johnson FY & Mostaghimi H, Int J Dermatol,1995; Aktan S et al, Dermatology,1998; Carney O et al, Genitourin Med,1994]. Studies attribute much of the psychological distress to disfigurement, perceived social stigma or undesirable changes in life-style resulting from skin disease [Picardi, A. et al, BJD, 2000].

Acute diseases, including skin disorders, are also associated with depression and in some cases suicide [Depression with a chronic physical health problem: NICE guideline CG91].

Dermatologists manage over 2,000 diseases of the skin, hair and nails in adults and children.

Each year 54% of the population are affected by skin disease, and 23 to 33% at any one time have disease that would benefit from medical care.

Ends

For more information, please contact the British Association of Dermatologists Press Office:
email comms@bad.org.uk or call 0207 391 6355 / 6094

References:

“Skin Conditions in the UK: A Health Care Needs Assessment”
Schofield J, Grindlay D, Williams H. Skin Conditions in the UK: a Health Care Needs Assessment. Centre of Evidence-Based Dermatology, University of Nottingham 2009, 1-158.
Published in September 2009, Skin Conditions in the UK: a Health Care Needs Assessment is the first official publication of the Centre of Evidence Based Dermatology. It is a much expanded update of the original 1997 Dermatology Health Care Needs Assessment by Professor Hywel Williams

“Skin Conditions are the commonest new reason people present to general practitioners in England and Wales”
Br J Dermatol. 2011 Nov;165(5):1044-50. doi: 10.1111/j.1365-2133.2011.10464.x. Epub 2011 Sep 22.
Schofield JK, Fleming D, Grindlay D, Williams H.
Source Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus, Nottingham NG7 2NR, UK. j.k.schofield@herts.ac.uk 

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Section 75 Revisions may not be enough to save our skins

The British Association of Dermatologists welcomes any revisions to the Regulations that make clearer that patient care, integration and co-operation are of greater importance than competition but still have concerns regarding the way in which specialist services will be commissioned and the exact nature of clinical input.

The report ‘United Kingdom Performance on Health: Implications from the Global Burden of Disease Study 2010’ published in the Lancet last week was particularly timely. The information it provided on chronic disability in the UK shows that Skin Diseases in the whole population directly cause a high level of disability greater, for instance, than other important illnesses such as diabetes, breast cancer or sensory impairment (eye disease and hearing loss) and unlike many other causes of disability has shown little improvement since 1990. This is can be put down to under provision and underfunding as well as lack of training in primary care.

With Dermatologists being prevented from providing input into the Commissioning Process it is unlikely that this burden of disability will change.  

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