DRAFT. The National Clinical Programme for Dermatology. Clinical Strategy & Programmes Division, HSE & the Royal College of Physicians of Ireland

Transcription

1 DRAFT The National Clinical Programme for Dermatology Clinical Strategy & Programmes Division, HSE & the Royal College of Physicians of Ireland Model of Care for Dermatology September 2017 September 2017 DRAFT V3.0 1

2 Contents Acknowledgements... 4 Abbreviations Contributors & Stakeholders Working Group Clinical Advisory Group Executive Summary Dermatology overview Description of the specialty Skin Cancer The National Cancer Control Programme Skin Cancer Psoriasis Dermatitis Acne Acute Dermatology Service Paediatric Dermatology Background of dermatology in Ireland Consultant Dermatologists Specialist Registrar Training in Dermatology Dermatology Nursing Psychodermatology and allied health professionals The Irish Association of Dermatologists The Irish Skin Foundation Overarching aims of the dermatology programme Quality Access Value Models of Care Rationale General Principles underlying Service planning in dermatology Key elements of Model of Care Dermatology Clinical Networks Current Organisation of the service and patterns of referral: Patient Journey Primary care Secondary Care Dermatology services Supra-specialist care

3 10.0 Managing outpatient access Triage of referrals Demand Management and follow up in dermatology Efficient and Innovative ways of dealing with demand Quality and Clinical Governance Clinical governance Clinical leadership Clinical effectiveness Use of information and information technology Education, training and continuing professional development (CPD) Clinical audit Risk management Collection of data from dermatology departments Education Primary Care Secondary Care Conclusion References Appendix 1 Exclusion Letter Appendix 2 Waiting lists Appendix 3 Mapping Survey of Dermatology Services

4 Acknowledgements Abbreviations AMNCH BAD BCC BIU CAG CME CNS DNA DNC DNE DOH GP HIQA HIV HSE HSH IAD ICGP ICHMT IDNA IMCSR ISF LOS MDT MMS MMUH NCCP NCHD NHS NICE NP OLCHC Adelaide & Meath Hospital incorporating National Children s Hospital Tallaght British Association of Dermatologists Basal Cell Carcinoma Business Intelligence Unit Clinical Advisory Group Continuing Medical Education Clinical Nurse Specialist Did not attend Dermatology Networking Centre Dublin North East Department of Health General Practitioner Health Information and Quality Authority Human Immunodeficiency Virus Health Service Executive Hume Street Hospital Irish Association of Dermatologists Irish College of General Practitioners Irish Committee on Higher Medical Training Irish Dermatology Nursing Association Irish Medical Councils Specialist Register Irish Skin Foundation Length of Stay Multidisciplinary team Mohs Micrographic Surgery Mater Misericordiae University Hospital National Cancer Control Programme Non-consultant hospital doctor National Health Service National Institute for Health and Clinical Excellence New patient Our Lady s Children s Hospital Crumlin 4

5 OLOL OPD OTC PILS PSG PUVA RCPG SCC SDU SIVUH SJH SVUH UCD UCHG UVL WRH WRS WTE Our Lady of Lourdes Out-patients department Over the counter Patient Information Leaflets Patient Support Group Psoralen Ultra Violet therapy Royal College of General Practitioners Squamous cell carcinoma Special Delivery Unit South Infirmary Victoria University Hospital St James Hospital St Vincent s University Hospital University College Dublin University College Hospital Galway Ultraviolet Light Waterford Regional Hospital Weekly Return Service Whole Time Equivalent 5

6 1.0 Contributors & Stakeholders 1.1 Working Group Dr Anne Marie Tobin Consultant Dermatologist and National Clinical Lead Kellie Myers Programme Manager Sheila Ryan Nurse Lead Prof Brian Kirby Consultant Dermatologist Dr Sinead Collins Consultant Dermatologist Dr Annette Murphy Consultant Dermatologist Dr Caitriona Hackett Consultant Dermatologist Dr Johnny Burke Consultant Dermatologist Dr Patrick Ormond Consultant Dermatologist Prof Alan Irvine Consultant Dermatologist Susan O Dwyer Community Pharmacist Caroline Irwin Patient representative 1.2 Clinical Advisory Group Dr Michelle Murphy- Chairperson Dr Anne Marie Tobin Clinical Lead Dr Alan Irvine Dr Annette Murphy Dr Aoife Lally Dr Bairbre Wynne Dr Bart Ramsay Dr Brian Kirby Dr Brid O'Donnell Dr Catherine Gleeson Dr Catriona Hackett Dr Cliona Feighery Dr Dermot McKenna Dr Emma Shudell Dr Fergal Moloney Dr Fiona Browne Dr Gillian Murphy Dr Grainne O'Regan Dr John Bourke Dr Kashif Ahmad Prof Louise Barnes Dr Marina O'Kane Dr Mary Frances Bennett Dr Mary Laing Dr Maureen Connolly Dr Muireann Roche Dr Nicola Ralph Dr Patrick Ormond Dr Patsy Lenane Dr Paul Collins Dr Pauline Marren Dr Rosemarie Watson Dr Rupert Barry Dr Sinead Collins Dr Sinead Field Dr Trevor Markham 6

7 2.0 Executive Summary Skin disease is extremely common, 54% of the population are affected by skin disease annually with 23-33% at any one time having disease that would benefit from medical care. Some of the commonest skin diseases continue to increase in frequency, in particular rising rates of skin cancer. There has also been a significant improvement in the treatments available for skin disease, and thus in the expectations of a successful outcome to treatment. Thus there is a need to develop dermatology services in Ireland which have been historically underfunded. The proposed model of care for Dermatology, when implemented will bring service provision for patients with skin conditions in line with evidence-based practice and international standards of care. Dermatologists diagnose patients with rare skin disorders, manage patients with moderate to severe common disorders such as psoriasis, eczema and acne and also treat patients with skin cancer. General Practitioners manage a wide range of dermatology conditions in primary care and act as gate-keepers for those patients who require treatment by a dermatologist. The Dermatology Programme aims to: improve access and services for patients who require care by a dermatologist support and promote the provision of care for dermatology patients in primary care promote public awareness, particularly of skin cancer and measures to avoid same, and self-management of skin disease In this Dermatology model of care document, we outline a model to ensure that the dermatology patient is seen and assessed and treated by the right person, in the right place and in the timeliest manner. The model envisions close collaboration between primary and secondary care, between GP s and their local dermatology department by promoting and supporting dermatology care in primary care through the provision of education. Current work is underway with ICGP to ensure as many GP registrars receive dermatology training as part of their postgraduate training programme. Based on international best practice, we set out both personnel and infrastructure requirements to ensure that all patients in Ireland will receive the same standards of quality care wherever they present. This model of care will allow for increased access to dermatology expertise for patients with skin cancer, chronic inflammatory skin conditions, rare genodermatoses by increasing the number of consultant dermatologists to 1 per 80,000. This 7

8 will require an additional 15 consultant appointments over 5 years and the development of the advanced nurse practitioner role in all dermatology services. This will achieve an extra 15,000 new patients being seen. Based on current figures, no patient would wait longer than 8 months (appropriate wait time should be 3-4 months for routine referrals), some patients are waiting up to four years at the moment. New Peripheral/Outreach Clinics would be established or supported and specialist services would be supported. Investment in infrastructure is required over the next five years, the following departments are in urgent need of physical infrastructure; South Infirmary Victoria University Hospital, Cork, Beaumont Hospital, Dublin, Tallaght Hospital, Dublin, Galway University Hospital, Galway. This current model will undoubtedly evolve and the, future service development is mapped for the next five years only. Updates of this model and enhancements will require performance measurement of activity, supply versus demand and ongoing audit of clinical outcomes. There will also be a requirement for consistency of data collection and a robust reporting and monitoring system. The timely and equitable access to the full range of high quality dermatology services with care delivered at a level appropriate to the severity and complexity of their condition is a fundamental overarching principle of care. 8

9 3.0 Dermatology overview 3.1 Description of the specialty Dermatologists manage diseases of the skin, hair and nails in adults and children. As over 2,000 skin disorders are recognized, of which 100 are common, accurate diagnosis is fundamental to successful management. 54% of the population are affected by skin disease annually with 23-33% at any one time having disease that would benefit from medical care. Skin diseases represent 34% of disease in children; atopic eczema affecting 20% of infants 1. Skin cancer is the most common cancer in Ireland. Basal cell carcinoma (BCC) numbers equal all other malignancies combined ( Skin diseases such as psoriasis, eczema and hidradenitis suppurativa cause significant impairment of Quality of Life equivalent with that seen in conditions such Chronic Obstructive Pulmonary Disease. Patients with inflammatory skin disease also have increased co-morbidities such as elevated cardiovascular risk and diabetes 2. Paediatric dermatology is a subspecialisation within dermatology with care delivered in the three paediatric hospitals in Dublin (soon to be the National Children s Hospital) and in paediatric clinics in Cork, Galway, Waterford, Limerick, Sligo, Mullingar and Drogheda) 3.2 Skin Cancer Skin cancer (melanoma and non-melanoma skin cancer (basal cell carcinoma, squamous cell carcinoma)) is the most common form of cancer in Ireland. Between 1994 and 2011, an average of 6,899 cases of invasive skin cancer were diagnosed per year in Ireland, the figure for 2015 will exceed 10,000. Malignant melanoma accounted for just over 8% of this number with 100 melanoma-related deaths annually; the vast bulk of all invasive skin cancers being non-melanomatous subtypes, of which over 6,300 were diagnosed each year. Over 95% of these non-melanoma skin cancers were histologically diagnosed and almost all were either basal (68% approximately) or squamous (30%) cell carcinomas (BCC and SCC respectively). The remaining non-melanoma subtypes were all very rare by comparison and included Kaposi sarcoma and cutaneous lymphomas, principally mycosis fungoides and T-cell lymphomas. From the mid 1990 s to early 2000 s there was little overall change in incidence rate for NMSC, with rates in females remaining fairly level and a slight decline in males. However rates of both 9

10 subtypes have subsequently increased, and for both sexes current rates (2011) are between 33% and 39% higher than those in An annual percentage change of between 3% and 4% has been recorded during the last 10 years (Cancer Trends. Exposure to ultraviolet radiation is known to be the major risk for developing skin cancer. The link between cumulative lifetime exposure and the risk of developing non-melanoma skin cancer is well-established, whereas melanoma appears to be linked to intermittent intense exposure in a less defined manner. Sunburn in childhood increases the risk of melanoma in later life and sunbed users are known to be at increased risk of developing skin cancer. 3.3 The National Cancer Control Programme Skin Cancer In 2012, the National Cancer Control Programme published Guidelines for the management of melanoma with the aim of preventing and treating melanoma. All patients with a suspected melanoma must be referred to a consultant dermatologist or plastic surgeon via a standardised electronic referral form and all patients with a diagnosis of melanoma must be discussed at a multi-disciplinary skin cancer meeting. This has streamlined the care of patients with melanoma and work is currently ongoing to establish key-performance indicators for the management of melanoma to promote standardisation of care nationally. An electronic referral form for such suspected lesions has been rolled out nationally. Since its introduction all dermatology departments operate rapid access pigmented lesion clinics on a fortnightly or weekly basis Many of these clinic function as see and treat clinics with many patients having suspected lesions removed at initial presentation. Just under half of the workload of UK Dermatologists is related to skin cancer 3 Guidelines for the Management of patients with non-melanoma skin cancer have been developed. This will have similar aims of streamlining patients with NMSC care and also facilitating the discussion of patients with high risk NMSC particularly SCC at MDT. It is recommended that all melanomas, squamous cell carcinomas and high risk basal cell carcinomas are managed in a hospital setting. General practitioners act as gatekeepers and are critical in recognising skin cancers and treating pre-malignant skin cancers such as actinic keratoses and Bowen s Disease and basal cell carcinomas as per the NCCP Guideline. 10

11 3.4 Psoriasis Psoriasis is a chronic cutaneous immune-mediated disease with a complex pathogenesis. It affects 2-3% of the population, and is associated with an inflammatory arthropathy in up to 30% of patients 4. It has been recognised by the World Health Organisation as a chronic systemic disease 5. Patients with more severe psoriasis also have increased cardiovascular and metabolic risk 6. It is estimated that there are 77,000 patients with psoriasis in Ireland 7. Approximately 30% of patients with psoriasis with moderate to severe disease require care in a dermatology department with either phototherapy or systemic treatments. Patients with mild disease can be managed in primary care with topical therapy. Psoriasis has significant psychosocial impact on patients lives and it is imperative that those patients who require phototherapy or systemic treatment have timely access to same. The advent of biological treatments for psoriasis since 2005 has improved outcomes for patients with psoriasis and the imperative to treat patients has increased. Dermatologists in Ireland apply the BAD/NICE Guidelines for the management of psoriasis ( and adhere to the principles of NICE in the prescription of phototherapy, photochemotherapy and systemic treatments ( 3.5 Dermatitis Up to 12% of adults suffer with atopic eczema and 20% of paediatric patients 8. Eczema causes significant sleep deprivation and can be extremely stressful for families who, because of its genetic nature, may have several family members affected. Understanding of the pathogenesis of eczema has advanced and it is apparent that early intervention can alter its natural history 9. New therapies are also coming on stream which will improve treatment options for patients with severe eczema. Occupational dermatitis is an important occupational hazard for certain professions including healthcare professionals, hairdressers, and workers with exposure to chemicals or irritant such as cutting oils. Hand dermatitis is one of the commonest reasons for disablement benefit. 11

12 3.6 Acne Acne is a very common complaint among adolescents and young adults. It causes significant distress and also has the potential to leave permanent scars. Most acne is managed in primary care (ICGP Guidelines for treatment of acne). Certain types of acne such as scarring acne, acne conglobata and fulminant acne require urgent and timely treatment in secondary care with Isotretinoin. 3.7 Acute Dermatology Service Dermatologists provide important in-patient consultation service in acute hospitals and are critical to the care of patients with skin failure secondary to severe drug reactions, vasculitis, graft versus host disease. It must also be recognised that patients with severe skin disease such as patients with epidermolysis bullosa, erythrodermic psoriasis or eczema may require hospital admission and treatment. This service ensures that such patients receive the correct diagnosis and are appropriately managed. 3.8 Paediatric Dermatology Children attend with severe atopic dermatitis, vascular anomalies, genodermatoses and other inflammatory skin disorders. There are approximately 10,000 referrals for paediatric dermatology annually with pressures on the services ever increasing (the number of 0-4 year olds living in Ireland increased by 17.9% between 2006 and 2011, giving Ireland the highest proportion of children with the EU. 25% v 19%). A National Clinical Programme for Paediatrics and Neonatology has been established and clearly outlines a model of care that promotes all children having access to safe, high quality services in an appropriate location, within an appropriate timeframe, irrespective of their geographical location or social background. Currently Paediatric dermatology is delivered regionally in Cork, Limerick, Galway, Mullingar, Drogheda and Waterford. In Dublin, paediatric dermatology is currently delivered in Our Lady s Hospital Crumlin, Tallaght Hospital and Temple Street Children s Hospital, this service will be centralised in the new National Children s Hospital. 12

13 4.0 Background of dermatology in Ireland 4.1 Consultant Dermatologists There has been a considerable move in recent years to improve the national dermatology service as service delivery has been hampered by lack of resources and lack of standardised care pathways. The dermatology outpatient service in Ireland was reviewed by the HSE in early 2010 as part of the Outpatient Programme of the Quality & Clinical Care Directorate (QCCD). The stimulus for inclusion of dermatology in that programme was the lengthy outpatient waiting lists for new patient appointments. Between 2010 and 2012, an additional 10 consultant dermatologists were employed by the HSE bringing the number of dermatologists to 45. This investment has led to significant improvements and innovation in the provision of dermatology services: An additional 12,224 new patients being seen and a 42% increase in new patient activity between 2009 and The rate of returning patients also fell from 2.08 to 1.6 in the same time period, as patients are increasingly being educated in self-management of what may be a chronic condition. The development of regional dermatology clinics and thus the inception of an integrated service which supports a local network of GP s and ensured regional selfsufficiency as was recommended in a Comhairle Report on Dermatology in There are now dermatology clinics in Bantry Hospital, Kerry General Hospital, South Tipperary General Hospital, Naas General Hospital, Nenagh Hospital, Portiuncula Hospital, Mayo General Hospital, Cavan General Hospital. Some of these centres also provide phototherapy (Bantry, Nenagh) which has greatly increased access to this modality for patients who hitherto could not avail of this service because of geographical constraints. * The establishment of pigmented lesion clinics nationally, there are now screening clinics regionally for all patients with suspected pigmented lesions which has improved access for such patients and more standardised care in common with international standards and with other cancers. * The development of a specialist centre for Mohs micrographic surgery in Cork. 13

14 * The establishment of other dedicated clinics: Dedicated transplant clinics for patients who have received a solid organ transplant to detect patients who develop skin cancer, these are run in conjunction with the transplant team and reduce the number of hospital visits for patients. Combined rheumatology/dermatology clinics for patients with connective tissue disorders, this has obviated the need for patients to attend multiple clinics and has introduced efficiencies in the management of patients with a multisystem disorder. Systemic treatment clinics for patients with severe inflammatory skin disease such as psoriasis and eczema. Combined clinics for the management of patients with hidradenitis suppurativa who require both medical and surgical input. Dedicated systemics, vascular, laser, thermography and genodermatoses clinics for paediatric patients in Our Lady s Hospital Crumlin. There are currently 16 training places in the RCPI, ICHMT Dermatology Specialist Registrar Training Programme with an average of twenty trainees in the programme at any given time as many engage in clinical research during their training which lasts 5 years. Table 1 Hospital Group Estimated population No. of Dermatologists Midlands 800, Dublin East 1000, Dublin North East: RCSI 800, South / South West 1000,00 8 West / North West: Saolta 700,00 6 University of Limerick 400,00 3 National Children s Hospital 5.6 (if all posts filled) *Location and no. of dermatologists as per hospital groups There are currently 45 dermatology posts (when all are in post in the public system), this represents a ratio of 1 per > 100,000 (4.75 million) (ref census 2016). There is a need for sustained expansion in consultant numbers to bring this ratio to 1 per 80,000 initially and then 62,500 as per BAD Guidelines. 14

15 4.2 Specialist Registrar Training in Dermatology The Irish Committee on Higher Medical Training (ICHMT) programme for dermatology specialist registrars was established in 1999 and is formally accredited by the Irish Medical Council. The training schedule is 5 years duration with formal annual appraisals to meet requirements for entry to the Irish Medical Council s Specialist Division of the Register in dermatology. There are currently 16 training places in the RCPI, ICHMT Dermatology Specialist Registrar Training Programme with an average of twenty trainees in the programme at any given time, as many engage in clinical research during their training. As of July doctors will have completed Specialist Training in Dermatology. The programme has a well-established teaching structure lead by the National Specialty Director Dr Michelle Murphy. 4.3 Dermatology Nursing It is well recognized that dermatology nurses play a key role in delivering dermatology services (BAD 2014, Comhairle na nospidéal 2003). There are currently 3 Registered Advanced Nurse Practitioners, 28 Clinical Nurse Specialists and approximately 26 staff nurses in Dermatology. Staff nurse posts in dermatology vary from sole specialisation in dermatology and allocation to the service for a specific time allocation (e.g. outpatient nurses allocated to dermatology clinic). In Ireland dermatology nurses are mainly employed in dermatology departments with 3.8 posts in peripheral hospital services. There are no dermatology nurses in Ireland in primary care. The allocation of dermatology trained nurses is considerably lower than their counterparts in the UK and Northern Ireland even in dermatology departments. There are some dermatology services where there is no dermatology nurse specialists and restricted access to staff nurses trained in dermatology. These services often rely on general trained nursing staff. Services that rely heavily on general trained nursing staff are often unable to develop and operate appropriately essential dermatology services such as phototherapy, patch testing, disease education clinics, topical treatment clinics. To meet current patient demands there is a need to develop and expand the dermatology nurse role. Academic programmes that facilitate the training of dermatology nurses in the specialty and also that allow progression to the clinical nurse specialist role and advanced nurse practitioner role is needed in Ireland. There are no educational programmes in Ireland. Nurses wishing to train in the specialty can only access courses in the UK. 15

16 There is also significant scope to expand the role of dermatology nurses so that they can take on additional roles that will help meet the current long waiting times for dermatology services. In the UK dermatology nurses are employed in both primary, and secondary services taking on advanced roles in patient consultations, nurse surgery, skin cancer management, chronic disease management. Sub-specialisation in the UK includes Paediatrics, Skin Surgery, Skin Cancer, Phototherapy, Biologics, Contact Dermatitis, Community, Teaching, Laser, and disease-specific posts (Epidermolysis Bullosa, Xeroderma Pigmentosa, Psoriasis and Eczema). In the UK dermatology and oncology nurses are employed in skin cancer nursing posts. In relation to secondary care there is a lack of dermatology nurses employed in peripheral services. However it is worth exploring developing dermatology services here to bring key dermatology services closer to the patient. One dermatology service (ULHG) has developed a day treatment service (providing phototherapy, patch testing, wound care and nurse education) at their secondary care site by employing 1.8 dermatology staff nurses. The service is supported by staff from the dermatology department for leave and clinical supervision. There are several advantages in developing dermatology nursing services Provision of dermatology treatment services (Comhairle na nospidéal 2003) 10 Increasing patient capacity in dermatology services (Gradwell et al 2002) 11 Provision of services closer to the patient (Courtenay and Carey 2007) 12 Improving chronic disease management (Cork et al 2003) 13 Improved co-ordination of patient pathways especially in skin cancer. There is scope to expand the role of dermatology nursing. To do so the pool of dermatology trained nurses needs to be increased. In addition academic training in the speciality and development of subspecialist skills (phototherapy, paediatrics, surgery and skin cancer recognition and management) needs to be developed in Ireland. For further development dermatology nurses will need support to access nurse prescribing and masters programmes already available in Irish Universities. The Irish Dermatology Nurses Association The Irish Dermatology Nurses Association (IDNA) was established in 2002 to provide support for the practice and development of dermatology nurses on the island of Ireland. It is a cross border organisation in which all nurses working in dermatology can become members. It has 16

17 currently over 70 members. The group holds an annual conference and offers educational bursaries to members. 4.4 Psychodermatology and allied health professionals Cutaneous disease may be the manifestation of psychological disease e.g. in conditions such as dermatitis artefacta and delusional parasitosis or other monodelsuional presentations. Furthermore patients with severe common skin diseases such as psoriasis and hidradenitis suppurativa are known to suffer increased levels of anxiety and depression. This in addition to adverse health behaviours such as smoking, excess alcohol consumption, lack of exercise and obesity are over-represented in patients with psoriasis and hidradenitis suppurativa. While there has been Irish clinicians involved in research in this field for many years, there is a dearth of access to psychology, dietetics, smoking cessation programmes for patients with cutaneous skin disease in all dermatology departments. This is a deficit that must be addressed to promote self-care and quality of life in a significant number of dermatology patients. 4.5 The Irish Association of Dermatologists The Irish Association of Dermatologists is the professional organisation of which all Irish Dermatologists are members. It is a cross-border organisation and is affiliated with the British Association of Dermatologists. The organisation holds bi-annual meetings promoting clinical education and research. 4.6 The Irish Skin Foundation The Irish Skin Foundation (ISF) is an independent organisation and has charitable status. Patient advocacy at all levels including the Health Service Executive and the Department of Health is a key aim of the ISF, as well as supporting education (patients, the public, primary care practitioners, non-dermatology hospital medical and nursing staff). 17

18 5.0 Overarching aims of the dermatology programme The national clinical programme in dermatology, in line with all the clinical programmes from the Clinical Programme & Strategy Division, has 3 main goals; the delivery of improved quality of care and improved access to care for patients to dermatology services while at the same time delivering on value which will ensure the sustainability of the programme into the future. These goals will be realised over the next 5 years. 5.1 Quality Increase OPD capacity Additional new consultant dermatologist appointments Improve productivity by ensuring availability of key resources Establishing the new GP e-referral system as recommended by HIQA Nurse led clinics for chronic skin disease Facilitate and support the self-management and primary care management of patients with skin problems as appropriate 5.2 Access To facilitate the right person, right place, first time assessment of patients with skin disease Primary care To reduce the overall numbers of patients referred to dermatology OPDs by promoting dermatology education and improving the management of patients in primary care Introduce standardised referral criteria to secondary care dermatology services and improve access for those patients who require dermatology care in a secondary care setting in a timely fashion. Secondary Care To reduce the OPD waiting lists for all dermatology referrals to < 6 months To fast track patients with suspected melanoma and rapidly growing skin cancers To fast track patients with severe inflammatory skin disease To increase and make more effective the satellite /hub dermatology service delivery in smaller hospitals under the supervision of the larger/hub hospital departments of dermatology 18

19 To ensure that the majority of patients can access care closer to home 5.3 Value To identify potential efficiencies and savings within the system To avoid more expensive options by providing local Day-Care services e.g. patient with psoriasis attending for UVL locally rather than commencing systemic medications as a first step Improve overall efficiency of outpatient management Maximise use of existing staff, space and resources 19

20 6.0 Models of Care Models of care for people with skin conditions should be developed to ensure that patients are seen by the right person, in the right place, at the right time and can move readily between the levels of care as necessary. The underpinning principle of all guidance documents published in this area is that services should be integrated and are best designed by stakeholders based on local assessment of need. Broad stakeholder engagement and enthusiastic clinical engagement by GPs, consultant dermatologists, dermatology nurses is essential for the success of this process. 6.1 Rationale The current traditional service model of care for dermatology in Ireland has been under strain especially in the past decade, due to a crisis in the numbers of trained dermatologists; a significant increase in demand; and a dramatic increase in the treatments available. The result of these changes has been unacceptable waiting times for new appointments. 6.2 General Principles underlying Service planning in dermatology An equitable and patient centered service Regional self sufficiency Collaboration between primary and secondary care It is essential that service models are patient driven and orientated. The starting point for quality of care, wherever it is based and however organised, is an accurate diagnosis Care should be delivered as close to the patient s community as is consistent with safety and cost effectiveness. This means that primary care will continue to take responsibility for the more straightforward parts of the management of long term skin diseases, and in particular to facilitate effective, safe and informed patient self-management. Dermatology needs to be a core element of general practitioner training. It is helpful for trainee general practitioners to attend dermatology clinics and for more interactive teaching to be developed between local dermatology consultants and GPs. Those functions and facilities that are limited to hospital practice must continue to be supported and the educational role of secondary care acknowledged and developed. Outreach clinics in smaller peripheral hospitals deliver excellent care when connected to a 20

21 dermatology department. In the Comhairle 2003 report it was emphasised that since dermatology is an outpatient based service that there should be regional sufficiency and that a network of peripheral or outreach clinics should be developed. The current economic environment makes the proposed improvements to the delivery of care challenging, however it can also be used to advantage as a stimulus for change. 21

22 7.0 Key elements of Model of Care To develop a series of Dermatology Networks within each Hospital Grouping to ensure equitable provision of high quality, clinically effective services. Primary care treatment and screening of a majority of skin diseases and skin lesions and referring on, if necessary, for diagnosis and management to the network of hospital services in that area. Maximise health promotion and reinforcement of self-management. Secondary Care: Outreach clinics in peripheral hospital to support a local network of GP s, provide care closer to home for patients and provide onsite dermatology consultations for inpatients. It is also envisioned that phototherapy would be provided in peripheral clinics, this is currently available in certain peripheral clinics. Dermatology departments in teaching hospitals with OPDs, day-care, patch testing, management of complex skin diseases, surgery for skin cancer, multidisciplinary care of chronic skin disease and skin cancer MDTs. Supra specialist services - provision of highly specialised care for specific disease investigation/care: Mohs micrographic surgery (St James s Hospital and South Infirmary Victoria University Hospital) Phototesting Mater University Hospital. The skills and knowledge of the healthcare professionals should always match the level of care provided, whatever the location. 22

23 8.0 Dermatology Clinical Networks Table 2. Dermatology Networks Hospital Dermatology Grouping Departments Ireland East St Vincent s University Hospital Peripheral Clinics St Michael s Hospital Dun Laoghaire, Kilkenny University Hospital Dublin Mid Leinster Dublin North East University of Limerick Hospitals Ireland South Mater University Hospital Tallaght Hospital St James s Hospital Beaumont Hospital Our Lady of Lourdes Hospital Drogheda Limerick University Hospital, South Infirmary Victoria University Hospital Midlands Regional Hospital Mullingar (MRHM) Naas Hospital Connolly Hospital Cavan University Hospital Ennis Hospital Nenagh Hospital Kerry General Hospital Tralee Bantry Hospital Mallow Hospital Saolta Waterford University Hospital University Hospital Galway South Tipperary General Hospital Clonmel Portiuncula Hospital Ballinasloe Mayo University Hospital Sligo University Hospital Letterkenny University Hospital 23

24 9.0 Current Organisation of the service and patterns of referral: Patient Journey 9.1 Primary care The community pharmacists Community Pharmacists are often the first point of contact for patients with a dermatological condition and provide a vital form of contact for patients who are self-managing, 75% of the Irish population use community pharmacy at least once a month. The majority of pharmacists are confident in the day to day management of common skin conditions. Advice and sale of non-prescription items (OTC sales) and dispensing of prescription items with advice about their correct usage is all part of an important role that pharmacists play. Expanded scope of practice in recent years includes medication management and monitoring (e.g. INR management), parenteral administration of medicines (e.g. flu, pneumococcal and shingles vaccinations), emergency administration of medicines (e.g. adrenaline, glucagon, naltrexone). Increased education at undergraduate level and post-graduate level could support and promote self-management in particular sign-posting of available information and patient support groups. Examples of Pharmacist Delivered Dermatology Services; Self-management support for chronic disease such as psoriasis, eczema, acne Medication adherence support Medication management examples include, supply of Dovonex without Rx in accordance with guidelines from PSI Rational/cost effective use emollient use, adherence, cost considerations Health promotion e.g. structured smoking cessation programmes General Practitioners A large proportion of dermatological conditions are managed in primary care by general practitioners. Studies in the UK show that up to 24% of the population see their GP each year for skin disease and approximately 5.5% of these patients were referred for specialist advice, the vast majority within the NHS system. The skin complaint may not be the sole reason for the visit to the general practitioner 13, 14. There are no available similar figures in Ireland however it is likely to be representative of the numbers of patients visiting their GPs as the 24

25 same gatekeeper system prevails. Thus with a population of 4,757,976 (2016 census) primary care in Ireland could currently be accounting for >1,000,000 visits each year. If, as in the UK some 6% of those who attend their GPs are referred for specialist advice that would lead to approximately 68,000 new referrals to consultant dermatologists annually in Ireland. In 2016 there were 42,493 new patients seen at dermatology outpatients and 70,753 return patients, thus there is likely to be considerable unmet needs particularly in more rural areas. There is an urgent need to promote dermatology education at undergraduate and postgraduate level for general practitioners. Given the ubiquity of skin conditions presenting to primary care it is important that GP s feel confident in managing and diagnosing the most common skin conditions. Work is currently underway devising a dermatology module with ICGP to facilitate GP registrars receiving clinical training in dermatology. Written patient information: involving patients in choice and decision-making about their care has been improved by quality information such as BAD Patient Information Leaflets (PILS) available at and other websites such as the These are available in all departments of dermatology, they are reliable excellent sources of information for patients and should be made available to patients in primary and secondary care. 9.2 Secondary Care Dermatology services Secondary care is delivered by consultant dermatologists, dermatology registrars or registrars working in either a teaching hospital or outreach/peripheral hospital. Peripheral Clinics: There are a number of examples of clinics delivered in outreach hospitals (Cavan, St Michael s Hospital, Midlands Regional Hospital, Naas Hospital, Nenagh Hospital, Clonmel Hospital, Bantry Hospital and Kerry General Hospital). The service provision varies from a monthly to twice weekly clinics, ward consultation, UVL (Bantry, Nenagh, Naas) or other day care treatments. This brings the service closer to the locality of the patient and also provides education and support for regional GP s. Patients requiring patch testing, complex surgery are sent to the hub or base hospital dermatology department. 25

26 Requirements at peripheral/outreach clinics Adequate OPD clinic rooms Adequate Clerical support Nursing which can include clinical nurse specialists attending from the base hospital Day Care to include UVL therapy with adequate staffing Minor surgery equipment as necessary Secondary Dermatology Services Skin cancer clinics - dermatologists screen over 90% of skin cancer referrals and treat approximately 75%. Facilities for dermatological surgery, cancer multi-disciplinary teams (MDTs) and data collection compliant with NICE guidance. Medical or surgical dermatology for complex problems, often in MDT clinics with other specialties such as rheumatology, gynaecology, plastic & reconstructive surgery, maxillo-facial surgery allergy specialists and paediatrics In-patient care of sick patients with severe skin diseases or skin failure, sometimes requiring intensive care. Phototherapy, wound care and other day treatments Paediatric dermatology services including laser surgery Investigation of cutaneous allergy and occupational skin disease by patch and prick testing. Investigation of photodermatoses, which affect 18% of the population reducing quality of life, psychological welfare and employability. Management of skin problems in hospital patients with other illnesses thereby reducing length of stay (LOS). Skin cancer screening for organ transplant recipients Genital skin diseases. Diagnosis and management of genodermatoses. Cutaneous infections, tropical diseases and HIV skin diseases. Teaching, training and assessment of medical students, GPs, trainee dermatologists and other healthcare professionals. Collection and analysis of clinical data, clinical audit and compliance with clinical governance requirements Clinical research including therapeutic trials 26

27 Requirements of hospital-based service A dermatology service should provide patient-centred care focusing on outcomes that meet national standards. To achieve this, all staff must be correctly trained and accredited. Staffing 16,17 Hospital-based services require at least one whole-time equivalent consultant dermatologist per 80,000 population. This is less than the currently stated requirement in the UK of one dermatologist per 62,500 population, where there is a shortfall of over 250 WTE dermatology consultants for a population of 61,800,000. A sustained expansion in the number of dermatologists will lead to: o A reduction in waiting times and waiting lists for patients o Continued improvement in the clinical management of patients with skin cancer: o Diagnostic accuracy of skin lesions is highest among dermatologists which results in efficient triage of patients with skin cancer and avoidance of unnecessary treatments in patients who have benign lesions. o Improved treatment for patients with severe inflammatory disease and patients with rare skin disorders Dermatologists treat skin cancer and pre-cancerous lesions with a number of modalities including surgery, topical treatments and photo-dynamic therapy. Dermatologists are most expert at recognising and monitoring patients at high risk of skin cancer e.g. transplant recipients. Innovations in service delivery and the development of a truly integrated service e.g. e-referrals provide the opportunity for dermatologists to provide advice to GP s and deflect referrals to secondary care. Expansion of consultant numbers with dedicated clinical time to such a service could provide a significant efficiency saving to the health service. NCHDs including senior house officers, registrars and specialist registrars form an integral part of the team in many hospital units. In some dermatology units there are no NCHDs, this must be taken into account when assessing what services can be delivered. The drive to a more consultant delivered service and the reduction in the number of NCHD s should be seen as an overall improvement as a result of the more senior and experienced clinical decision making. Specialist trained Dermatology Nurses who; o Treat patients in day-care units and onwards o Provide and supervise phototherapy 27

28 o Assist / perform patch testing under consultant supervision. o Perform surgical procedures o Nurse prescribe o Run monitoring clinics for isotretinoin and biological/systemic treatments for inflammatory skin diseases. o With paediatric training, run hospital/outreach services for children with chronic skin disease. o Establish and run community clinics. o Co-ordinate the patient journey in skin cancer including provision of psychological support o Provide skin cancer support and skin surveillance services o Manage and care for wounds and ulcers. o Provide patient information, demonstrate and apply treatments, dress wounds, remove sutures and review follow-ups. o Assist in operating theatres and advise patients undergoing surgery. o Advise and train professional colleagues caring for patients with skin diseases in the hospital/community. Clerical staffing sufficient to support all the department activities. Pathology support is a vital component with weekly review conferences and teaching of registrars. Pathology review of skin cancers discussed at MDT. Physics support of activities such as phototherapy Structural facilities required at hospital level A fully integrated department with outpatient clinics, outpatient Day - Care treatment centre and dedicated day surgery facilities is the gold standard in hospital dermatology service delivery. In Ireland there are remarkably few such well integrated departments with the notable exceptions of the dermatology department in St. Vincent s University Hospital and OLCHC, both of which benefited from additional external funding. Below is an outline of the necessary structural provisions for a modern integrated department. Dedicated outpatient units with rooms for patient education. Areas for contact allergy testing with storage areas for allergens meeting national published standards. Surgical facilities meeting national standards for space, cleanliness and equipment, with storage for liquid nitrogen. 28

29 Laser-safe areas where required Facilities for Mohs' micrographic surgery where required, meeting national standards. Day-care centres staffed by dedicated dermatology nurses. Phototherapy units for adults and children staffed by trained dermatology nurses who can also provide skin care, meeting national standards for equipment and safety. Medical physicists should monitor UV output. A named consultant dermatologist should be responsible for the service. Hospital beds staffed by trained specialist dermatology nurses with 24 hour medical care is the gold standard. This is difficult to attain with an increasing demand upon acute medical beds and thus there are few or no dedicated dermatology beds. Dermatology patients require a specialised dermatology nurse to apply treatments and provide education, with adequate bathing and treatment rooms. Diagnostics Laboratory support including chemical pathology, haematology, microbiology, mycology, histopathology and immunopathology and radiology. IT hardware and software that is robust, modern, reliable, fast, in the right place and immediately available. Medical photography services Appropriate accommodation for paediatric dermatology clinics and inpatient care in a dedicated paediatric area, staffed by paediatric trained nurses. 9.3 Supra-specialist care This type of care usually takes place within an acute hospital and is carried out by consultant dermatologists and a range of other healthcare professionals with special skills in the management of complex and/or rare skin disorders. Identified links should be established within each network though there are a few national supra-specialties which will require linking. Examples include the following: Table 3. Supra-Specialist Services Supra-specialist Types of conditions service seen Genetic Rare and severe dermatology inherited skin diseases Services offered Diagnostic and genetic counselling service, outreach (to community and Current Locations OLCHC, Accredited National Rare Skin Disease Centre and member of the 29

30 Photodermatology Skin disorders related to sunlight, including rare conditions such as porphyria and xeroderma pigmentosum Epidermolysis Sub types of Bullosa and Epidermolysis Fragile Skin Bullosa and Fragile Skin disease Dermatological Complex, large and surgery difficult to manage skin cancers. Vascular Venous, lymphatic, anomalies clinic arterial and overgrowth disorders general hospital ) nursing service Specialist diagnostic services, including light testing. Diagnosis and Multidisciplinary management Access to Mohs micrographic surgery and complex reconstructive surgery involving joint working with a range of specialist plastic and reconstructive surgeons. Multidisciplinary management, including radiology, plastic and reconstructive surgeons, haematology, occupational therapy and specialist nurse European Reference Network for rare and undiagnosed skin disease MMUH OLCHC (paediatrics) SJH (adults) South Infirmary Victoria University Hospital St James s Hospital OLCHC 30

31 Paediatric Connective tissue Multidisciplinary OLCHC connective tissue disease and management, disease clinic Autoinflammatory including disorders rheumatology consultants and nurse specialists. Paediatric atopic Atopic dermatitis Multidisciplinary OLCHC eczema clinic clinic management, with consultant allergist and clinical nutritionist and nurse specialist 31

32 10.0 Managing outpatient access Referrals to hospital dermatology departments are increasing. In order to deal with the demand there has to be some form of referral management but care must be taken to ensure that the process works well for patients Triage of referrals Referrals to specialist services should be triaged by experienced clinicians working as part of the same dermatology team in order to facilitate the right person, right place, first time approach. Within each department there will be dedicated clinics and the experienced clinician will know where best to direct each referral. It is essential that GPs can have immediate access to senior decision makers within the department. It is envisioned that e-referral may enhance communication between primary and secondary care and that advice could be returned to the referring GP and might obviate a visit to the dermatologist. At the moment this clinical activity is undertaken by many consultants but is not recorded as clinical activity this must be addressed. In a health care system such as the HSE resources are inevitably limited, thus an arbitrary line has to be drawn on who can and cannot access and benefit from HSE provided care. The National Clinical Programme for Dermatology has introduced an exclusion letter for benign lesions that will not be treated or seen in secondary care unless there is diagnostic uncertainty (Appendix 1) Demand Management and follow up in dermatology Patients should have rapid access to re-enter the OPD system when needed. This process can be facilitated with active management Efficient and Innovative ways of dealing with demand Pigmented lesion clinics with one-stop treatment Skin Lesion clinics Urgent new patient clinics Rapid re access clinics e.g. patient with a chronic disease such as psoriasis Specialised review clinics e.g. psoriasis, eczema Nurse triage clinics National Haemangioma referral pathway 32