Skin conditions a Health Care Needs Assessment: key messages

1. Skin conditions a Health Care Needs Assessment: key messages Julia Schofield Special Lecturer University of Nottingham Principal Lecturer University of Hertfordshire Consultant Dermatologist, Lincoln

2. What I am going to talk about? • 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

3. 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

4. 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?

5. What is a health care needs assessment (HCNA)? 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 3. Recommendations for models of care and delivery of services to manage the need

6. 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

7. 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

8. 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

9. Structure of the document: chapters • Introduction • Burden of skin disease • NHS reform and its impact • Services available and their effectiveness • Models of care and organisation of services • Specific skin disease areas • Recommendations Lots of references!

10. What does the document tell us?

11. 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

12. 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

13. Examined skin disease in the UK Nothing new since the Lambeth study in 1976* • 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

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/marketinformation/otcconsumeresearch.htm

15. 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

16. Self reported skin disease PAGB study: management

17. 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

18. 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

19. 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

20. 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

21. Skin disease seen in Primary Care Prevalence, episode incidence and consultation rates for selected skin conditions per 10,000 population 2006. Source: RCGP WRS

22. 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

23. 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

24. Specialists casemix: by % of new patient activity Skin lesions

25. Services available: who sees what and where? WHY? Primary care Skin infections Specialist care Skin lesions 45-60% 31-59% are for diagnosis – skin lesions even higher

26. Epidemiology: summary of key messages 0.75 million people with skin disease referred for NHS specialist care, 1.5% 3752 deaths due to skin disease 24% population, 12.9 million seeking Primary Care (England and Wales) Self reported/ self managed skin disease 50% population approx 25 million

27. 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

28. Coughs colds and sore throats Skin disease Pain relief

29. 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

30. Economic burden: disability living allowance claims by age

31. 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.

32. 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)

33. 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

34. Services available and their effectiveness • Self care, expert patient programme • Internet: e-health • Primary (generalist) care • Referral management • Specialist services • Supra-specialist services

35. Services available and their effectiveness • Self care, expert patient programme • Internet: e-health • Primary (generalist) care • Referral management • Specialist services • Supra-specialist services

36. Services available and their effectiveness: self care • 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

37. 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

38. 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

39. 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 cost-effective • Patients preferred GP skin surgery

40. Services available and their effectiveness: GPwSI services • 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)

41. Effectiveness of specialist services • Little evaluation of effectiveness of ‘doctor’ services • Nurse services are better evaluated • Few specialist services measure clinical outcomes

42. 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

43. 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

44. 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

45. 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

46. 10 key recommendations • Improve self care: better information, community pharmacy training • Improve undergraduate nursing and medical training • Needs based educational programmes • Referrals should be triaged by experts in integrated teams • More pyramidal service needed

47. The link between the amount and complexity of skin disease and current levels of training and knowledge Highly trained supra-specialists 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 Increasing complexity of skin disease: fewer patients Increasing amount of training All patients with skin conditions Large numbers of cases of straightforward, less complex skin disease

48. Optimising the link between the amount and complexity of skin disease and levels of training and knowledge Specialists and supra-specialists diagnosing and managing more complex skin problems Appropriate levels of education and training based on ‘need’ as determined by the type and amount of disease seen and its complexity Increasing complexity of skin disease: fewer patients Increasing amount of training All patients with skin conditions All patients with skin conditions Large numbers of cases of straightforward, less complex skin disease

49. 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

50. Thank you Acknowledgements British Association of Dermatology Psoriasis Association Primary Care Dermatology Society Professor Hywel Williams & Douglas Grindlay