Transcript The political importance of a the dermatology needs assessment in

Skin conditions a Health Care
Needs Assessment: key messages
Julia Schofield
Special Lecturer University of Nottingham
Principal Lecturer University of Hertfordshire
Consultant Dermatologist, Lincoln
What I am going to talk about?
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What is need?
What is a Health Care Needs Assessment?
Some background to the new document
What does the updated Dermatology Needs
Assessment for the UK tell us?
• Recommendations for the future
What is need?
Need is ‘the ability to benefit from care’
Williams HC. J Roy Coll Physicians 1997;31:261-2
The use of isotretinoin
to treat acne
The use of the biological
agents to treat psoriasis
Demand and supply
Demand = “that which
is asked for”
Supply = “that which is
provided for”
Williams, HC. J Roy Coll Physicians
1997;31:261-2
Seborrhoeic keratoses –
demand or need?
What is a health care needs
assessment (HCNA)?
1. The burden of disease
2. Managing the burden
Prevalence and incidence
Impact on quality of life
Economic burden
The services available
The effectiveness of
those services
3. Recommendations for models of care and delivery
of services to manage the need
Some background to the project
1997
Dermatology: Health Care
Needs Assessment
Hywel Williams
Radcliffe Medical Press
(one of 38 chapters still
available on the HCNA
website)
2007
Needed revision
Some background to the project
• BAD sabbatical
fellowship April 2007
• Additional funding
PCDS, Psoriasis
Association, CEBD
• March to July 2008
• Peer review process
• Published by CEBD
October 2009
The team
Professor Hywel Williams
• Strategic lead for the project
• Author of original Dermatology Health Care
Needs Assessment
Dr Douglas Grindlay
• Information Specialist, NHS Evidence – skin
disorders (based at CEBD)
• Information searching, referencing, editing
Dr Julia Schofield
• Lead researcher and lead author
Structure of the document: chapters
1.
2.
3.
4.
Introduction
Burden of skin disease
NHS reform and its impact
Services available and their
effectiveness
5. Models of care and
organisation of services
6. Specific skin disease areas
7. Recommendations
Lots of references!
What does the document tell us?
The HCNA: key messages
1. The burden of disease
• Prevalence and
incidence
• Impact on quality of life
• Economic burden
2. Managing the burden
• The services available
• The effectiveness of
those services
• The cost-effectiveness
of those services
3. Recommendations for models of
care and delivery of services
• How to manage the need
• Supply and type of services
Prevalence and incidence
• Examined skin disease
• Self reported skin disease
• People with skin disease seeking generalist
medical care
• People with skin disease seeking specialist
medical care
Examined skin disease in the UK
Nothing new since the Lambeth study in 1976*
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2180 adults studied
55% population had any form of skin disease
22.5% had skin disease worthy of medical care
Tumours and naevi commonest but 90% considered trivial
Prevalence of eczema 9% but 2/3 moderate or severe
Authors concluded:
• Skin conditions that may benefit from medical care are
extremely common
• Most sufferers do not seek medical help
*Rea et al Skin disease in Lambeth: a community study of
prevalence and use of medical care. Brit J Prev Soc Med
1976;30:107-14
Self reported skin disease
• Proprietary Association of Great Britain (PAGB)
• Nationwide (UK) study of minor ailments and
how people manage them
• 1987, 1997 and 2005
• A picture of health 2005 PAGB/Reader's Digest
Report*
*ww.pagb.co.uk/pagb/primarysections/marketinformati
on/otcconsumeresearch.htm
Self reported skin disease: PAGB
study
• 1500 people questioned all over the UK
• Minor ailments in the last 12 months
• Questions related to a limited number of
conditions
• 818/1500 (54%) reported a skin condition
• The 1500 questioned reported 1524 episodes
of skin disease
• 135 mothers reported eczema in 30% of their
children
Self reported skin disease PAGB study: management
advice
chemist
2%
advice GP
12%
nothing
17%
self care
69%
nothing
self care
advice GP
advice chemist
PAGB study of self reported skin
disease: limitations
• Diagnostic information limited, symptom
based
• Limited range of conditions included in study
• Respondents not asked about warts, verucca,
psoriasis, dandruff, hair loss, headlice, boils,
cradle cap and nappy rash.
• No lumps and bumps, skin lesions
• Under-estimates skin conditions
Skin disease seen in Primary Care
• Primary care data from RCGP Research and
surveillance Unit weekly returns service (WRS)
• Data from 47 practices in England and Wales
representing about 400,000 people
• Data captured on all patient encounters
• Incidence, prevalence and consultation rate data
http://www.rcgp.org.uk/clinical_and_research/rsc.aspx
Data capture and coding issues
• ICD 9 and 10
• Disorders of the Skin and Subcutaneous
Tissues
Does NOT include:
• All skin tumours, benign and malignant
• Many common skin infections including viral
warts
Seriously underestimates the amount of skin
disease
Skin disease in Primary Care:
messages
• 24% of the population seek medical advice
about a skin condition each year (12.9 million)
• This is the commonest reason for people to
consult their GP with a new problem
• Consultation rate is 2 per episode
• Average GP: 630 consultations per year for
skin conditions
• Under-estimate due to coding issues
Skin disease seen in Primary Care
Condition
Prevalence
785
Episode
incidence
656
Consultation
rate
1131
Skin
infections
Eczema
Acne
Psoriasis
Urticaria
413
164
69
53
274
125
33
40
557
251
109
70
Prevalence, episode incidence and consultation rates for selected
skin conditions per 10,000 population 2006. Source: RCGP WRS
Key messages
• Skin infections
commonest reason for
consultations
• 20% of children under
12 months are
diagnosed with eczema
• Psoriasis not very
common cause of GP
consultations
Skin disease seen by
specialists
• Limited information other than numbers
• About 6.1% of people with skin disease are
referred to see a specialist
• 35-48% referrals are skin lesions
• Eczema, acne and psoriasis commonly seen
• Patients still admitted
Specialists casemix: by % of new patient activity
14
Skin lesions
12
10
8
6
4
2
0
eczema
mole
BCC
seb wart
Pboro
Sheff
solar
keratosis
WHHT
acne
M/cr
psoriasis
wart
Services available: who sees what and
where?
Primary care
Skin infections
WHY?
Specialist care
Skin lesions 45-60%
31-59% are for diagnosis – skin lesions even higher
Epidemiology: summary of key messages
3752 deaths
due to skin
disease
Self reported/ self
managed skin
disease
50% population
approx 25 million
0.75 million people with
skin disease referred for
NHS specialist care, 1.5%
24% population, 12.9
million seeking Primary
Care (England and
Wales)
The cost of skin disease in
the UK
Direct and indirect costs
• Over the counter (OTC) sales
• Prescribing costs for skin disease
• Costs to the NHS of delivering services for
patients with skin disease
• The cost of disability due to skin disease
Trends in over the UK counter sales market
(£M) 2007 skin sales £413.9 million
600
500
Coughs colds and sore
throats
Skin disease
Pain relief
400
300
200
100
0
2001
Pain relief total
2002
Cough/cold/sore throat
2003
Skin treatments total
2004
2005
Gastro-intestinal & travel sickness
2006
Smoking cessation
2007
Hayfever remedies
Primary Care prescribing
costs 2007
BNF Chapter 13
• 35 million items, £239 million, net
ingredient cost £6.77
• 2.85% total budget, no real change for
many years
• Excludes hospital prescribing and oral
antibiotics
• Dovobet: £21 million, NIC £54.95
Economic burden: disability living
allowance claims by age
Burden of skin disease: impact on
quality of life
• 1990 Psoriasis > impact on QoL
than hypertension and angina
• 1999 Psoriasis same impact as
angina or cancer
• 2000 High DLQI scores significant
in primary care patients with skin
disease
• 2003 Willingness to Pay for cure
higher in acne, atopic eczema
and psoriasis than angina
hypertension and asthma.
Impact on quality of life: new data
• Psycho-social morbidity
• Skin-Brain axis
• Impact on the rest of the
family: ‘greater patient’
• Impact on life choices
• (co-morbidities)
The HCNA: key messages
1. The burden of disease
• Prevalence and
incidence
• Impact on quality of life
• Economic burden
2. Managing the burden
• The services available
• The effectiveness of
those services
• The cost-effectiveness
of those services
3. Recommendations for models of
care and delivery of services
• How to manage the need
• Supply and type of services
Services available and their
effectiveness
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Self care, expert patient programme
Internet: e-health
Primary (generalist) care
Referral management
Specialist services
Supra-specialist services
Services available and their
effectiveness
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Self care, expert patient programme
Internet: e-health
Primary (generalist) care
Referral management
Specialist services
Supra-specialist services
Services available and their
effectiveness: self care
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Patient groups important but vulnerable
Some evidence for social network groups
No Expert Patient Group Evidence
High sales OTC skin treatment products but
limited teaching and training of pharmacists
• No formal evaluation of pharmacists
Patient information: important points
• The digital divide: 70% of over 65s have never
used the internet
• NHS Direct: 4% of all calls skin rashes
• Written information variable quality (Picker
Institute 2006)
• Patients not involved, clinicians still write the
material
• Health on the Net Foundation code of
accreditation, none of common dermatology
sites accredited
Services available and their
effectiveness: Primary Care
• Limited evidence
• Evidence that teaching and training
inadequate (APPGS and others)
• Little formal evaluation
• Some evidence that skin lesion diagnostic
skills not great
• Not a lot of evidence that up-skilling practice
nurses helps
Services available and their effectiveness:
Primary Care
• MISTiC study 2008
• Hospital vs GP skin
surgery
• Some concerns about
quality of GP surgery
• Malignancies missed
• Hospital more costeffective
• Patients preferred GP
skin surgery
Services available and their effectiveness:
GPwSI services
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GPwSI services are effective
Patients like the GPwSI services
Not particularly cost-effective
Overall may increase costs
May not be the most cost effective way of
increasing overall capacity of specialist
services (Roland 2005)
Effectiveness of specialist services
• Little evaluation of
effectiveness of ‘doctor’
services
• Nurse services are
better evaluated
• Few specialist services
measure clinical
outcomes
Evidence for effectiveness of
specialist services
• Good diagnosticians
• Supports role of
Inpatient treatment
• Manage skin cancer
effectively
• Specialist nurses are
effective
• Role in managing
cellulitis
Models of care and organisation of
services
• Consensus documents about
models
• Referral management ‘evidence
free zone’
• Shift : specialists in community
settings and joint working
improves access to care and
maintains quality, no reduction in
OP activity
• Digital imaging: useful but not
implemented
Education and training
• Not enough training for Primary Care health
care professionals
• What there is: not needs based, curriculum
does not match casemix
• Remains optional, undergraduate and
postgraduate nursing and medicine
The HCNA: key messages
1. The burden of disease
• Prevalence and
incidence
• Impact on quality of life
• Economic burden
2. Managing the burden
• The services available
• The effectiveness of
those services
• The cost-effectiveness
of those services
3. Recommendations for models of
care and delivery of services
• How to manage the need
• Supply and type of services
10 key recommendations
1. Improve self care: better information,
community pharmacy training
2. Improve undergraduate nursing and medical
training
3. Needs based educational programmes
4. Referrals should be triaged by experts in
integrated teams
5. More pyramidal service needed
Large numbers of
patients managed
by clinicians with
limited knowledge
and training
Knowledge and skill of
clinicians: small
number of highly
trained specialists
treating few patients
All patients with
skin conditions
Large numbers of cases of straightforward, less
complex skin disease
Increasing amount of training
Increasing complexity of skin disease: fewer patients
The link between the amount and complexity of skin disease and current levels of
training and knowledge
Highly trained supraspecialists
All
Allpatients
patientswith
with
skin
skinconditions
conditions
Large numbers of cases of straightforward, less
complex skin disease
Increasing amount of training
Increasing complexity of skin disease: fewer patients
Optimising the link between the amount and complexity of skin disease and
levels of training and knowledge
Specialists and supraspecialists diagnosing
and managing more
Appropriate levels of
complex skin problems
education and training
based on ‘need’ as
determined by the
type and amount of
disease seen and its
complexity
10 key recommendations
6. Population based teams of health care
professionals
7. Accreditation process needed
8. Dermatologists: diagnosis, management of
complex skin problems
9. Cancer service led by dermatologists
10. Patient Reported Outcome Measures
needed
Thank you
Acknowledgements
British Association of Dermatology
Psoriasis Association
Primary Care Dermatology Society
Professor Hywel Williams & Douglas Grindlay