>> Access to Care

1. Dermatology and the National Health Service

In the United Kingdom, most dermatological health care is provided by the National Health Service (as is the case for all other branches of medicine). Under this scheme, every patient is registered with a General Practitioner who provides most of their everyday healthcare needs.

15% of all the patients who see a GP, will be seeking help for a skin condition, and most patients will have their skin disorder diagnosed and treated by their GPs. Thus, training in dermatology for GPs is very important for patients with skin diseases, and the British Association of Dermatologists (and other organisations) has made GP training in dermatology a priority.

A minority of patients with particularly severe skin disease, or skin problems which their GP has difficulty diagnosing or treating, have traditionally been referred to a consultant dermatologist, usually in the nearest hospital. The UK has about 580 dermatologists working in NHS hospitals.

Healthcare professionals working in a dermatology unit under the supervision and direction of a consultant dermatologist may include associate specialist or staff grade doctors, doctors training to become consultant specialists in dermatology, and GPs with a special interest in dermatology (clinical assistants and hospital practitioners). Most departments also employ experienced dermatology nurses who provide specialised treatments, manage leg ulcers or assist with testing for certain types of allergy.

The training of the members of a dermatology team mentioned above is outlined in the separate section ‘What is a Dermatologist’.

2. Dermatology in the private health system

Alternatively, patients can of course seek dermatological care in the private health system. Although a few consultant dermatologists work only in the private system, the vast majority work part-time in private practice but also work in an NHS hospital. Although patients can refer themselves directly to a dermatologist in the private system, private health insurance will not consider paying the fees unless a patient is referred by their GP. It is probably best anyway for patients to see their GP initially since the GP may be able to treat the condition, or may have knowledge about the most appropriate dermatologist to see privately for a particular type of skin problem. Like other consultants, some dermatologists work in private hospitals whilst others may practice from their own consulting rooms.

3. ‘Intermediate Dermatology Clinics’ where ‘expert’ does NOT mean an accredited, fully trained Dermatologist

Traditionally a patient would consult a GP, but if the patient had a condition that was difficult to diagnose or manage, the GP would refer the patient to an NHS consultant in the local hospital.  

Recently, however, the Government has launched a number of reforms:

-Care Closer to Home

The government believes that many people with mild to moderate skin problems should be managed nearer their home in community clinics, rather than having to travel to a hospital. 

-Choose & Book

If you require a hospital appointment, the government believes that you should be able to choose which hospital you would prefer to attend. Your GP should help you to weigh up the advantages and disadvantages that might influence your choice. For example you should know the qualifications or expertise of the doctor(s) to whom you may be referred, as well as the waiting times for the appointment in each hospital. (If you choose to go outside your local area, your doctor may not know the areas of expertise and the ‘track record’ of the doctor). You may wish to know other things about each hospital - for example if you are likely to meet medical students, if there is any public transport or if you will be able to park your car.

-Payment by Results

Hospitals are financed by a fixed payment (tariff) for each patient that is seen or each operation that is performed. If your GP refers you to hospital, his or her Primary Care Trust (PCT), which is the body which contracts on behalf of the GPs, will be billed by the hospital when you are seen.

How these changes may affect you

Most Primary Care Trusts (PCTs) are trying to save money and reduce hospital bills by asking GPs to refer fewer patients to specialists working in hospitals.  

Many PCTs are setting up ‘intermediate services’ that are not covered by the Choose & Book system outlined above and which they perceive to be cheaper.  Patients referred to these services will not be offered choice, nor are they likely to be seen by a fully trained and accredited dermatologist on the GMC (General Medical Council) specialist register. You may be seen by a GP with a special interest in dermatology and perhaps a dermatology diploma, a doctor trained elsewhere in Europe or perhaps a specialist nurse. Some, but not all, of the individuals working in intermediate services may also work closely with a consultant dermatologist in the local hospital department.

If your GP suggests that you are referred for a dermatology opinion, you should be offered a choice of hospital under the Choose & Book scheme. If you are not offered any choice, then it is likely that you are being referred to an intermediate clinic.

What you can do

You can ask about the qualifications of the individual to whom you are being referred, as, if you are being referred to an intermediate clinic it is most unlikely that you will be seeing a specialist consultant dermatologist. However well set up and supported these new services may be, most are NOT provided by fully trained, accredited NHS dermatologists.

You can exercise your rights and demand to see a specialist the FIRST TIME to get the correct diagnosis and a treatment plan, after which your GP or a doctor in an ‘intermediate clinic’ may be able to continue your care.