Good Practice Framework Dermatology
Greater Manchester Health and Social Care Partnership
1 Contents Introduction...2 Overview of Dermatology Interventions...4 Descriptions of the Dermatology Interventions...6 Further Information per Intervention...10 Supporting Case Studies...15 Good Practice Framework Dermatology
2 Introduction This Good Practice Framework outlines elective care interventions for Dermatology that Localities should consider implementing locally in collaboration (commissioners and providers and other organisations) to effectively manage the increased demand for elective care services. Interventions outlined in this document should inform the Locality planning and prioritisation process for 2019/2020. The document forms part of the following suite of inter-related documents, but also can be used as standalone document: 1. Overview and Introduction to the Elective Care Good Practice Frameworks and Interventions 2. GM Elective Care System Wide Interventions (non-specialty specific) 3. Implementation Considerations A Stepped Approach 4. Evidence Document from national/local information, good practice and impact data emerging from NHS England Specialty Based Transformation pilots from across England, and/or actual integrated service offers in place in GM Further information pertaining to our vision for Elective Care in Greater Manchester, our GM Elective Care Outcomes and Standards, and our approach to the development of Good Practice Frameworks can be found in the Overview and Introduction document. Further information regarding approaches to implementation is detailed in the Implementation considerations document. This Good Practice Framework for Dermatology covers: Overview of Dermatology Interventions and alignment with GM Elective Care Standards Dermatology Interventions details on what is required to be implemented Further Information Supporting examples, benefits, resources Supporting Case Studies - from Localities across GM and from National elective care pilot sites 100 Day Challenge Teams Greater Manchester Health and Social Care Partnership
3 Introduction continued The interventions broadly fall into three main areas: Supported Self Management & Shared Decision Making Rethinking Referrals Transforming Out-Patients We have also included public health interventions, which are consistent with the GM Population Health Plan and gives a whole system approach to commissioning Dermatology elective care services. Interventions regarding workforce/education and training for dermatology are featured in the GM Elective Care System wide interventions. Good Practice Framework Dermatology
4 Overview of Dermatology Interventions and Overview of Dermatology Elective Care Intervention Public Health Community/web based readily accessible patient information Social prescribing Self Management & Shared Decision Making Readily Available Community Pharmacy advice Information to support medication adherence High quality patient education technology to support self-manageme GM Dermatology Referral Guidelines Rethinking Referrals Community Champions GM Standards for clinical education Teledermatology Community rapid access hot clinics Transforming Outpatients GP run community dermatology clinics - routine specialist care and Virtual reporting and follow up (default position) Greater Manchester Health and Social Care Partnership
5 Alignment with GM Elective Care Standards s How they Align with Elective Care Standards The public should have access to well-publicised resources which enable self care at all stages of the elective care pathway People should be able to obtain advice through a variety of mechanisms including self referral, social prescribing and community options nt Patients should be involved in shared decision making throughout the elective care pathway and feel in control of their care Mechanisms should be in place to support clinicians to make the right referral decision Referring clinicians should have access to specialist advice without the need for the patient to visit a hospital setting All referrals should be triaged to ensure patients arrive in the right place with the right information follow up Wherever possible follow up should be virtual and undertaken by the most appropriate member of staff Good Practice Framework Dermatology
6 Dermatology Interventions Intervention Descriptor Public Health Community/web based readily accessible patient information - prevention, SDM and EUR Readily accessible information should be made available to support prevention, support early detection and treatment of Dermatological conditions, and supporting patients to be medication compliant. This should be made available in a range of formats including the use of online portals. Social prescribing Social prescribing should be embedded within all dermatology pathways - approaches include incorporation of community networks and expert patient support into dermatology pathways. Self-Management & Shared Decision Making Community Pharmacy Advice Pharmacy expertise should be made available to provide local support for the patient to self-manage for minor conditions, as well as to provide advice on more specialist medications to help improve adherence. Information to support medication adherence Patients should be offered a range of information, and support to ensure adherence to medication. This includes information on what may happen and when, and when to seek further advice and who that may come from. Pt education to support patients to self-manage Patients should be offered a range of educational materials (in a range of formats such as video/other tech) to support the patient to self manage and provide information on treatment options. Mechanisms should be put in place to follow up patients who are self-managing, to encourage and support the adoption of self management techniques. Greater Manchester Health and Social Care Partnership
7 Dermatology Interventions continued Intervention Descriptor Rethinking Referrals GM Dermatology Referral Guidelines Commissioners and providers should work jointly together to ensure the implementation of the GM Dermatology Referral Guidelines and that they are embedded within existing pathways and on ers. An implementation plan should be developed for doing this with a phased action plan. This should be supported by a rolling education programme with referrers and embedded within patient information (as they may be seen by a specialist nurse, not a consultant). Community Champions A network of community champions (including GPs) should be in place to provide support, advice, and training in supporting the patient getting a diagnosis. GM standards for clinical education Commissioners, providers and GPs should work jointly to implement standardised education across GM that demonstrates change in practice and improved population outcomes through effective decision making. An implementation plan with a phased action plan should be developed to enable this. Teledermatology (Teledermatology enables GPs to share an image of the affected skin area securely with a specialist clinician for advice and review.) Advice and guidance should be introduced as an integral step, pre-referral in elective care dermatology pathways. e-rs/telederm should be used as the platform for doing this. The referrers should be educated about the referral criteria and clinical assessment findings that should prompt onward referral of patients for diagnosis and treatment. This includes the inclusion of a feedback loop so that common request for A&G are used to identify education needs/ guidelines and thus reduce the need to seek advice and guidance for that issue in the longer term. Good Practice Framework Dermatology
8 Dermatology Interventions continued Intervention Descriptor Transforming Out-patients (Note new service models should work across the entire pathway) Community rapid access hot clinics (Hot clinics - patient comes back when they need to they are discharged with an open self-referral appointment which means that only the patients that need to be seen are seen. ) Community rapid access dermatology hot clinics should be in place for assessment, diagnosis, and treatment including cognitive behavioural therapy and biopsychosocial model. A population health approach of segmentation and standardisation should be taken focusing on high volume patients with less complex needs. Mechanisms should be in place to enable patients with chronic skin conditions to re-access specialist advice and treatment directly, rather than having to wait for a GP referral. GP run community dermatology clinics - routine specialist care and follow up GP run community dermatology clinics should be in place as an intermediary service to support and improve the diagnosis and treatment of skin conditions. The service should embed timely feedback and communication to GPs, including about the patient s management plan, to facilitate knowledge transfer and engage GPs in dermatological conditions. Virtual reporting and follow up (default position) supported with online support materials Virtual reporting and remote/virtual follow up should be made the default position with face to face appointments offered only when clinically needed or when it is deemed not appropriate for the patient to receive follow up virtually. Patient information should be made available to advise that follow up will by the most appropriate clinician who may not necessarily be the consultant. Greater Manchester Health and Social Care Partnership
9 Dermatology Interventions continued In addition to the dermatology interventions listed we recognise that there is a need to improve the quality of dermatology knowledge in primary care through a programme of continued education and training (inclusive at the undergraduate level), as well as look at new models of care and redesigning whole system pathways. Segmenting the overall workload and deploying staff such as GPwER (GP with extended roles), specialist nurses and specialty doctors offer opportunities to improve the flow of patients and to create new and more effective models. This could include segmentation by treatment type as well as thinking about how referral, diagnosis, treatment and follow up should be managed. For example, there is evidence that a significant proportion of the workload is follow-up care, which can be managed differently to referral and diagnosis, where there is a need for more specialist expertise. Work is underway in the GM North West Sector to develop a set of proposals for redesigning pathways and models of care for managing dermatological demand and capacity. It is intended to revisit this approach along with the workforce strategy that is being developed as this work unfolds. The interventions in this document, along with the system wide mandated interventions will support the development of experts in larger practices; along with improved education and training, including targeted continuing professional development, could help address this deficit. Good Practice Framework Dermatology
10 Further Information Examples, Benefits, Resources Public Health Examples Benefits References Community Web-based Information Online tools are freely available such as clinically approved websites and webinars, workshops to upskill patients and enable a better understanding of their condition. Good consistent (trusted/ approved) information made available in regular places e.g.media/hairdressers/barbers/ schools/nursery The use of Community health ambassadors have been effective in GM cancer and Vanguards Social Prescribing The VCSE should be part of the pathway and service offer to support self management education; peer support; health coaching; group activities and supporting wider asset based approaches Supports a population level focus Increases quality and amount of information available to patients Increases patient understanding of their condition Increases patients ability to self manage Supports a population level focus GM Population Health Plan Greater Manchester Health and Social Care Partnership
11 Further Information continued Examples, Benefits, Resources Self Management and Shared Decision Making Examples Benefits References Pharmacy Advice Supports patients to self manage and medication adherence (reduced adherence to dermatological treatment occurs in 34-45% of patients) Information to support medication adherence Patient education videos on common skin conditions, to support patients after diagnosis focusing on application of the common treatments. Supports patients to self manage and medication adherence. Patient Education Patient education delivered by: Ladders, Web, pharmacy, health professionals, Mapmypsoriasis (Health innovation Manchester) Patient Passports help to educate and empower patients to self-manage their condition. If taken to appointments, patient passports can provide a written record of the steps patients are already taking to self-manage their condition and have the potential to support shared decision making about their care. The majority of people with dermatological conditions self-care: some estimates put this as high as 86%. Health education videos play an important role in getting patients engaged and activated in their care. When patients are engaged, they become more actively involved in their own healthcare, leading to lower costs and better outcomes. Good Practice Framework Dermatology
12 Further Information continued Examples, Benefits, Resources Rethinking Referrals Examples Benefits References GM Dermatology Referral Guidelines Implementing GM dermatology education pathways acne, psoriasis, eczema, actinic keratosis, warts. Community Champions Practices or groups of practices would benefit from having a GP with further training and links to the consultant service to help them keep up to date provide advice and training. This could be a networked arrangement or on a wider sector level footing. In addition to champions peer review and audit are effective in improving diagnosis and referral. Dermatoscopes Roll out in Stockport Provides a consistent and standardised guidance for patient referral management. Over time this contribute to supporting a continued programme of education and training Education and communication to primary care to improve the knowledge of GPs and support patients being managed appropriately within primary care GM Pathways Rightcare DoH Greater Manchester Health and Social Care Partnership
13 Further Information continued Examples, Benefits, Resources Telederm Tele-dermatology should be supplementary to a specialist service, but there are areas where a robust teledermatology service could enable limited consultant resources to go further. Clinician-to-clinician support (either by email or real time communication) is valuable. Tele-dermatology to support primary care education, improve the triage of referrals and to provide better access to specialist opinion in rural and remote areas Supports triage and referral management to facilitate patients being streamed into the right service The Kings Fund Transforming Out-patients Examples Benefits References Community Rapid Access Hot Clinics Face to face appointments with hospital specialists should be reserved for those patients who will benefit from this encounter, either because there is a need for delivery of significant diagnoses / management discussions that would not be appropriate to be discussed by other means or because there are procedures/ diagnostics which need to be undertaken. One-stop clinics, where patients may receive tests, diagnostics and in some cases treatment within a single appointment in one location, reducing the total number of appointments required Improves the accuracy of referral destination. Clinical triage can be successful in diverting referrals to alternative out-of-hospital services. Avoids inappropriate referrals Improves the quality of referrals and ensures that patients are directed to the right setting first time. GM Pathways Good Practice Framework Dermatology
14 Further Information continued Examples, Benefits, Resources Transforming Out-patients Examples Benefits References GP community dermatology clinics Virtual Reporting and follow up Alternatives to traditional faceto-face clinics include: virtual clinics over email, skype or telephone; group consultations more than one patient or clinician; nurse or other healthcare professional led consultations The range of consultation types will be most effective at managing demand and improving experience, when combined with mechanisms to allow patients to choose when and how they will receive care Strengthens dermatology assessment and care in primary care Virtual interactions have the potential to free up clinician time and appointment slots, by reducing the time and space required for patient interactions and reducing DNA rates Greater Manchester Health and Social Care Partnership
15 Supporting Case Studies Stockport 100 Day Challenge Team (Source NHSE Dermatology Elective Care Handbook) Telederm What was the idea? To expand the use of a tele-dermatology app from five to 10 GP practices in Stockport. Why here, and why now? Under the wider Stockport Together programme there is an ambition to reduce outpatient attendances by 55 to 65% over the next three years. As part of the dermatology team s work towards this, they aimed to redesign the traditional dermatology GP to hospital pathway of care, where patients can wait 16 weeks to be seen at the hospital. With five GP practices already using teledermatology, it was felt that the 100 Day Challenge was an ideal opportunity to roll this platform out further. Headlines achievements/impact From the five practices piloted: 68 referrals to consultants for advice and guidance were made during 100 days. Of these, 71% were deflected back to primary care with appropriate advice and guidance given. Nearly all (99%) of referrals to consultants for advice and guidance were responded to in the same day (compared to a three or four month waiting list for a face-to-face outpatient appointment). GPs supplied good-quality images only 12% of referrals were rejected due to inadequate images. Three skin cancer patients were identified via teledermatology. How did you do it? Software used was integrated with NHS IT systems already in place and relationships built with the technology provider team. Demonstrations given at the GP practices by the software provider MDSAS who ran a short training and Q+A session for the pilot practices. Communicated updates with the team, such as when GP practices have gone live with teledermatology so dermatologists expected additional referrals. Filmed and shared an information video for local practitioners explaining teledermatology through working with the CCG communication lead, including filming a person with lived experience who had used the service. Tested and adapted the referral process in response to feedback from clinicians. Good Practice Framework Dermatology
16 Supporting Case Studies continued Lincolnshire 100 Day Challenge Team (Source NHSE Dermatology Elective Care Handbook) One-stop Clinic What was the idea? To trial consultant-led triage (spot clinics) in the community that GPs can refer to directly for those patients where the GP believes the issue is not cancerous but is unsure of the diagnosis. Why here, and why now? Since 2005/06, outpatient appointments in Lincolnshire have doubled. Two week wait referrals have increased 57% in the last five years and now account for a third of referral activity. This leads to significant delays in the standard pathway. A significant part of the workload in dermatology includes skin tumours (benign, precancerous and malignant lesions) many of which can be addressed in a spot clinic. The spot clinic model is being used as a basis to develop a one stop clinic and a self-referral clinic. It is hoped that as the clinics develop, GPs will be able to join the consultations for education purposes. Headlines achievements/impact 73 patients were seen at four spot clinics, held over a four-week period. 43% of cases were diverted away from secondary care (either requiring no further treatment or treatment from GP only). A further 9% of people were referred directly for surgery in the community. Patient satisfaction scores were very high on every area: 100% of patients rated the clinic as good or excellent Cost saving of 4,688 was recorded across the four weeks. This figure was calculated by subtracting the cost of running the clinic from the money saved through avoided referrals. How did you do it? The weekly clinics involve short consultations enabling consultants to see and triage around 24 patients in two hours. Triage is consultant-led in the spot clinic. Patient pathway was developed, staff trained in the process, and GPs engaged with. Worked with the Choose and Book team to agree a process for referrals to be made directly into the spot clinics by GPs. Patients have clear next steps if an onward referral was required. If no further appointments were necessary, it was ensured patients understood this. Greater Manchester Health and Social Care Partnership
17 Supporting Case Studies continued Stockport 100 Day Challenge Team One Stop Clinic for 2 week referrals What was the idea? To offer patients being seen in an outpatient clinic the opportunity to have their procedure done on the same day as their clinic appointment. Why here, and why now? Under the wider Stockport Together programme, there is an ambition to reduce outpatient attendances by 55 to 65% over the next three years. The dermatology team also wanted to focus on addressing the current long waiting times. Stepping Hill Hospital has high demand for dermatology theatre appointments in the two week wait service (approximately 15 days) and as a result, patients can experience delays in this pathway. By offering two week wait patients a same-day procedure, the aim was to reduce their overall pathway length by up to 14 days. Headlines achievements/impact Over a 6 week period: Of 100 patients listed for a procedure, 68 had their procedure done on the same day as their clinic appointment. Average theatre waiting time for two week wait patients fell by 13 days from 15 days to two days (15 patients audited in March 2017 compared to 15 in March 2018). Positive response from patients, clinicians, nurses, administration and management teams: 90% of one stop patients surveyed said they preferred having the procedure done on the same day compared to coming back another time How did you do it? The team employed a whole-system approach including input from consultants, nurses, a service manager, commissioners, a representative from the British Association of Dermatologists and administrative staff. Letters including specifically designed clinic information sent to the patient in advance. A one stop rota for a trial month, designated theatres that could be used as part of one stop clinics. Encouraged live feedback from clinicians to management team and made changes for next clinics throughout 100 days. Completed a qualitative telephone survey with 10 patients attending a one stop clinic to get their feedback. Good Practice Framework Dermatology
18 Supporting Case Studies continued Wigan Community Rapid Access/Hot Clinic What was the idea? A Community rapid access/hot clinics. Why here, and why now? Headlines achievements/impact Only the patients that need to be seen are seen. Supports early and quick diagnosis How did you do it? Joint clinics (consultant/gpsi/nurse/psychologist) offering a holistic, including psychosocial aspects. Patients are discharged with an open appointment and so can self-refer when they need to. They will then be seen within two weeks Greater Manchester Health and Social Care Partnership
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