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British Association of Dermatologists, Response to Francis Inquiry

Background
The British Association of Dermatologists is a charity funded by the subscriptions and activities of its Members. Its objects concern the teaching, training, research and practice of Dermatology to benefit patient care.
Robert Francis QC chaired a public inquiry into the failings at Mid Staffordshire NHS Foundation Trust; his report was published in February 2013. The key failures identified were:
• Professional disengagement
• Patients not heard (complaints)
• Poor governance
• Lack of focus on standards of service
• Inadequate risk assessment of staff reduction
• (Poor) Nursing standards and performance
• Wrong priorities (of finances over quality of care)

Officers of the BAD met with Mr Francis in June 2013 and this document is the BAD's response to his report and its recommendations.


Response to relevant recommendations
“All commissioning, service provision, regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work”
“No provider should provide, and there must be zero tolerance of, any service that does not comply with fundamental standards of service. Standards need to be formulated to promote the likelihood of the service being delivered safely and effectively, to be clear about what has to be done to comply, to be informed by an evidence base and to be effectively measurable.”
Through its clinical services unit, the BAD has been supporting Dermatologists in challenging poor commissioning that could potentially lead to services not fit for purpose. BAD has published a 'Lessons learned' document highlighting the problems encountered and the response and outcome of intervention. The BAD has started to formulate service standards for core Dermatology services and continues to work with NICE and other stakeholders to develop these further.
The BAD has been developing and financing enhanced data collection and outcome measures including patient reported outcomes (PROMs).
The BAD has been developing and financing radical models of service redesign to deal with the demands of ageing demographics, chronic disease and comorbidities (including psychological) with quality, compassion and continuity of care at the heart of evidence-based diagnostic and therapeutic services.
“There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory.”
The BAD has worked with and supported the British Dermatology Nursing Group over many years and will continue to work with the BDNG in supporting training education and professional development.
“Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, must be required to inform the relevant training regulator of those concerns.”
There is Trainee representation on the Executive Committee of the BAD. The BAD also provides training and educational days for specialist registrars, other trainees and medical students. These educational events provide an opportunity for trainees to voice any concerns about training.
Response to Key Failures
Professional disengagement
• BAD will explore a programme of peer reviewing hospital departments/teams with a view to identifying excellence and spreading good management/practice.
• BAD will fund a 'Department of the Year' award to give an incentive to good management/practice.

 Patients not heard (complaints)
• BAD will use its relationship with patient support groups to help patient voices to be heard including the use of its publicity mechanisms to highlight areas of concern.

Poor governance
• BAD will support its Members in tackling concerns over poor governance through its Clinical Services Unit

Lack of focus on standards of service
• BAD will continue the process of developing standards of service for core and specialist Dermatology through updating the clinical services specification document and the publishing of service standards in specialist Dermatology.
• The BAD will continue its efforts in enhancing data collection and developing credible quality based outcome measures including PROMs.

Inadequate risk assessment of staff reduction
• BAD will work with Royal College of Physicians to collect census data on staff shortages and continue to highlight areas of concern including the use of long term locums.

(Poor) Nursing standards and performance
• BAD will continue to support nursing colleagues in developing standards and will support the BDNG in a 'dermatology nurse team of the year' award.

Wrong priorities (of finances over quality of care)
• BAD will continue to challenge poor commissioning decisions which prioritise finances over quality of care and will support its members in such issues.

Training
• BAD will make the evaluation of professionalism an important part of the training day for trainers and STC chairs
• BAD will continue to make the case for a 'Dermatology Deanery' to Health Education England in order to promote best practice in leadership/management as well as clinical skills.

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Response from Chris Bunker, President of the BAD, to Global Burden of Skin Disease in 2010: An Analysis of the Prevalence and Impact of Skin Conditions

This is a fascinating study demonstrating the true impact of skin disease, which is often perceived by those responsible for providing healthcare services as a trivial health concern. In the UK alone, around 24% of the population consult their GP with a skin condition each year, making it the most common reason for people to see their GP with a new issue. However, we have an insufficient number of Dermatologists - if we were to have the same provision as the USA, Germany, Italy or France, we would need around 6,000 Consultant Dermatologists, currently we have 684. The problem is exacerbated by the fact that GPs have very little training in Dermatology, around six days on average. This leads to extra referrals in hospitals, or delays in treatment and diagnosis.

Studies like these should be used by health providers when deciding on training and budget allocation for different medical specialties.

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World Psoriasis Day – the UK situation

An audit conducted by the British Association of Dermatologists (BAD), looking at the way in which newly published NICE guidelines on assessment and management of psoriasis patients are being implemented across the UK, is being released to mark World Psoriasis Day on Tuesday (29th October 2013).

On the whole the results were very positive. However, despite NICE prioritising holistic assessment of people with psoriasis, the audit revealed that psychological support for psoriasis patients in Britain has more than halved in the past six years compared to a similar audit in 2007. Where psychological support is available, psoriasis patients commented that waiting lists were often lengthy with actual access to treatment being sparse. Furthermore, psoriasis patients are often presented with issues of fairness when seeking psychological assistance, with limited resources being reserved for the most severe cases.

The British Association of Dermatologists, representing UK dermatologists, undertakes audits of services for psoriasis patients to make sure that they are getting the right treatments and that guidelines are being followed. In many respects, the UK is a world-leader in psoriasis treatment with dermatologists in the UK producing world class research into the disease and its treatment. However the audit highlights some important areas for improvement, most notably in the area of psychological support. This is an area of concern for the BAD which is currently in the process of creating a government-funded website to provide psychological support for people with skin conditions, in addition to this the association runs a web-based register of biologic and conventional therapies for psoriasis (BADBIR).

The BAD has also frequently raised the issue of an insufficiency in the number of dermatologists compared to the number of people requiring treatment for skin diseases, including psoriasis. If we were to have the same provision as the USA, Germany, Italy or France we would need around 6,000 consultant dermatologists, currently we have 684.

The problem is exacerbated by the fact that GPs – who see around 13 million people each year presenting with a skin problem – have very little training in dermatology, around six days on average. This leads to extra referrals to hospitals, or delays in treatment and diagnosis. Lack of training and awareness of psoriasis in primary care is also recognised as a key barrier to effective implementation of the NICE guidelines. The British Association of Dermatologists has raised these concerns with the Department of Health, the Royal College of GPs and Health Education England.

Psoriasis is a common autoimmune disease that affects 2% of the UK population. The condition causes rapid skin cell growth, most frequently appearing as raised, red, scaly plaques. Ranging in severity, psoriasis is a chronic and often painful condition which affects all age groups and both sexes. People with psoriasis may also develop psoriatic arthritis.

Beyond the physical implications, the debilitating effects of psoriasis are known to expand into the realms of depression, anxiety and suicide. In a recent national study 10,400 psoriasis patients in the UK were found to suffer from depression, 7,100 from anxiety and 350 from suicidal tendencies*. UK psoriasis patients are 39% more likely to succumb to depression than non-sufferers, with those who are severely inflicted being 72% more likely to possess mental health issues.

In spite of this, state provided psychological care for psoriasis patients in the UK appears to have decreased in the past six years (as discovered in the BAD’s ‘The assessment and management of patients with psoriasis – where are we?’ - conducted 2013 with over 1000 respondents), having fallen from 44% of hospitals providing dermatological psychological support to just 20%. The situation is further exacerbated by the fact that just over half of hospitals record psoriasis sufferer’s Dermatology Life Quality Index (DLQI) – the benchmarking system which ranks and monitors skin condition sufferers’ current life satisfaction, serving as a warning signal when a ranking crosses the threshold.

Positive steps

• In March 2013 The British Association of Dermatologists (BAD) was 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 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 British Association of Dermatologists’ Biologic Interventions Register (BADBIR), a web-based register of biologic and conventional systemic therapies for psoriasis. Many patients find that conventional topical and systemic treatments will help them to control their psoriasis, however, for some with moderate or severe psoriasis these treatments are ineffective. New therapies called biologics have been developed by pharmaceutical companies to help control these more severe cases of psoriasis. As with most drugs, there are risks and side effects. Because this type of drug is new these risks and side effects need to be monitored carefully. Five years ago the British Association of Dermatologists set up BADBIR to do just that.
It currently involves over 7551 patients and 140 dermatology departments. The data it will provide over the coming years will be invaluable for the safe use of biologics in clinical practice. A UK and Ireland-wide dermatology clinical research network has been established that provides a framework for future studies in other diseases. The patient database also provides a useful resource for further research into psoriasis and some new studies have already begun as a result of this.


Nina Goad, of the British Association of Dermatologists said: “More often than not treatments of skin conditions focus on the visible symptoms, completely overlooking the equally impactful psychological consequences of disease. It is increasingly evident that the UK is in serious need of a robust psycho-dermatological infrastructure where patients suffering with psychological conditions originating from skin disease can seek accessible, comprehensive care. Currently the opposite is occurring, and whilst organisations such as the BAD are taking action, more needs to be done across the public health system. Specifically, funding needs to be allocated for Clinical Psychologists dedicated to dermatology patients.”

World Psoriasis Day is on the 29th of October.
*OLIVIER C, ROBERT P, DAIHUNG D, et al. The Risk of Depression, Anxiety, and Suicidality in Patients With Psoriasis: A Population-Based Cohort Study. Arch Dermatol. 2010;146(8):891-895. doi:10.1001/archdermatol.2010.186.

-ENDS-

For more information please contact the British Association of Dermatologists’ Press Office
Email: comms@bad.org.uk Tel: 0207 391 6084 / 6094 

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Dermatologists develop non-surgical treatment to reduce unwanted chin fat

Scientists have developed a pioneering way to remove unsightly chin fat without the need for surgery,according to research released today in the British Journal of Dermatology.

The novel treatment targets aesthetically unappealing fat deposits underneath the chin, otherwise known as submental fat, or more colloquially as a ‘double chin’.

Dermatologists from the UK, France, Germany, Belgium and Spain have investigated a potential new treatment involving the injection of ATX-101 (a specific, synthetically derived formulation of deoxycholic acid) into submental fat. ATX-101 reduces submental fat by irreversibly disrupting fat cell membranes and causing adipocytolysis (destruction of fat cells). Following injection of ATX-101, an inflammatory response is induced, triggering the recruitment of highly specialised cells (macrophages) which remove the cellular debris resulting from destruction of the fat cells over time.

Submental fat deposits under the chin can be treated effectively with neck and face lifts or with liposuction. However, these treatments are not suitable for everyone, and the need for anaesthesia, an operating room and qualified staff substantially increases costs and risks. There are other non-surgical treatments for submental fat, but there is limited clinical evidence to prove their effectiveness.

The study included 363 men and women aged 18 to 65. Only those who presented with moderate to severe submental fat and expressed dissatisfaction with the appearance of their face and chin were eligible to take part. All the patients agreed to undergo clinical evaluations and laboratory tests and to maintain stable body weight, diet and exercise practices during the study.

The primary goals of the trial were to demonstrate at least a one point improvement in submental fat on the 5-point Clinician-Reported Submental Fat Rating Scale and for patients to show satisfaction with their face and chin appearance on the 7-point Subject Self-Rating Scale (SSRS).

On both the clinician and patient scales (above), significantly more ATX-101 recipients met the primary goals of the trial than a group receiving a placebo treatment. The trial used two different dosages of ATX-101 (1 mg cm-2 and 2 mg cm-2) as well as a placebo.

With the higher dosage of ATX-101, 65.3% of patients had a reduction in submental fat of at least one point on the Clinician-Reported Submental Fat Rating Scale compared with 23.0% with the placebo, and 66.1% of patients were happy with their face and chin appearance, versus 28.7% for the placebo.
In addition, calliper measurements showed a significant reduction in submental fat, with no apparent worsening of skin laxity. Following treatment, patients also reported a reduction in the psychological impact they felt due to the appearance of their face and chin. The treatment was found to invoke just a mild inflammatory response and the procedure was well tolerated by patients.

Matt Gass, of the British Association of Dermatologists, said: “This research is a very exciting step towards a safe and non-surgical solution to removing unwanted chin fat. For people experiencing negative psychological effects of this unwanted fat on their appearance, this procedure, if approved, may open up the option of minimally invasive treatment with proven efficacy.”

Professor Berthold Rzany (Berlin, Germany), the lead author, said: “This study demonstrates that subcutaneous injections with ATX-101 yield a clinically meaningful and statistically significant reduction in unwanted submental fat, decrease the psychological impact on patients, and are well tolerated. This study and three additional phase III clinical trials of ATX-101 will provide the first true evidence base for non-surgical submental fat reduction.”


-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was published in the British Journal of Dermatology.
For more information please contact: Matt Gass, Communications Officer, Phone: 0207 391 6084, or Nina Goad, Head of Communications, 0207 391 6094, Email: comms@bad.org.uk, Website: www.bad.org.uk.

Study details: “Reduction of unwanted submental fat with ATX-101, an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study”;
B. Rzany,a T. Griffiths,b P. Walker,c, S. Lippert,d, J. McDiarmid,e, B. Havlickovad
aDivision of Evidence-Based Medicine in Dermatology, Charité-Universitätsmedizin, and
RZANY & HUND, Privatpraxis und klinisches Studienzentrum für Dermatologie, Berlin,
Germany;
bSalford Royal NHS Foundation Trust and Dermatopharmacology Unit, Faculty of
Medical and Human Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK;
cKYTHERA Biopharmaceuticals, Inc., Calabasas, CA, USA;
dGlobal Clinical Development Dermatology, Bayer HealthCare, Berlin, Germany;
eMcDiarmid-Hall Clinic, Derriford, Plymouth, UK DOI: 10.1111/bjd.12695
This study was one of two identically designed phase III clinical trials of ATX-101 conducted in Europe

The article in the BJD can be viewed online: http://onlinelibrary.wiley.com/doi/10.1111/bjd.12695/abstract
The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. For further information about the charity, visit www.bad.org.uk
Wiley-Blackwell, created in February 2007 by merging Blackwell Publishing with Wiley's Global Scientific, Technical, and Medical business, is now one of the world's foremost academic and professional publishers and the largest society publisher. With a combined list of more than 1,400 scholarly peer-reviewed journals and an extensive collection of books with global appeal, this new business sets the standard for publishing in the life and physical sciences, medicine and allied health, engineering, humanities and social sciences. For more information visit www.wiley.com 

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