Dr Angelika Razzaqu
Executive Chair, Primary Care Dermatology Society
70 years of the NHS has seen many changes. What has not changed is the way services for people with skin disease are delivered. There remains a lack of dermatological education for all doctors in medical school.
GP speciality training, in particular, is not matching the fact that up to a quarter of GP consultations with patients are for a skin-related matter. Patient experiences and outcomes are inadvertently compromised.
GP services are under pressure. Trying to provide access for unscheduled care and, at the same time, organise planned reviews for chronic disease management (namely under the Quality and Outcomes Framework, under which skin disease does not feature), is a resource-consuming balancing act.
How are GPs learning more about skin health?
GPs are addressing the lack of training within their Continuous Professional Development (CPD) by attending already-existing educational events such as those organised by the Primary Care Dermatology Society (PCDS) or using the PCDS website for information.
Some take it even further to gain additional diplomas and become GPs with Extended Roles (GPER) under consultant mentorship. This has, in some areas around the country, led to a model of care in which community dermatology services have supported primary and secondary care in taking the burden of diagnosing and managing skin disease. However, there is great variation of such provision, which results in health inequalities.
Hospitals prioritise cancer patients over dermatology
Hospital-based dermatology services face challenges too. With a lack of consultants, vacant posts remain unfilled and services are often outsourced to private providers.
The pressure on providing access for suspected skin cancer within a two-week time frame leads to increased waiting times for patients with other skin conditions, namely inflammatory skin conditions such as eczema, psoriasis and acne.
Lacking dermatological knowledge delays diagnoses
Pharmacy First is one initiative to redirect the flow of minor skin conditions towards pharmacists in the community. This is faced with the same challenge of a general lack of education about skin disease.
Equally, other community-based services, such as podiatry, district nursing, practice nursing and physician’s assistants, midwifery and health visiting, all healthcare professionals that may see skin disease early on in its presentation, share the same predicament: a general lack of dermatological knowledge, which results in delay of diagnosis and management.
Families and the wider community feel diseases burden
The psychosocial impact of skin disease on individuals and their families as well as financial implications, including for the wider economy, has been very well demonstrated. People with eczema, for example, consider the impact on their quality of life to be greater than that felt by people who have diabetes1. Advances in treatments for severe skin disease have resulted in better quality of life and a reduction in morbidity and mortality.
However, prescribing incentive schemes and local formularies, on the other hand, restrict prescribing for much-needed treatments for the majority of mild and moderate skin diseases.
Online tools and mobile phone apps have been developed to improve diagnosis with the intention of addressing the lack of education and to enable faster access to treatment. This does not address the fact that the gold standard is a face-to-face consultation with dermatology also being very much a three-dimensional discipline.
Minimum of four-weeks’ dermatology teaching
How could this evident ‘dermatological crisis’ potentially be addressed? A call for all medical schools to incorporate a minimum of four weeks’ dermatological teaching with evidence of competency achieved is paramount to raise standards in education.
Furthermore, incorporating dermatological exposure in GP training through sit-in clinics during hospital rotation or in community clinics during GP placements as well as increased education during VTS half days should ensure competency in diagnosis and management among future GPs.
Bridging the gap between primary and secondary care by standardisation of community services provision will reduce health inequalities. Investment in technology and resources, including education of the wider healthcare team, is needed to improve clinical efficiencies and improve patient experience.