Skin conditions a Health Care Needs Assessment: key
messages
Julia Schofield
Special Lecturer University of NottinghamPrincipal Lecturer University of Hertfordshire
Consultant Dermatologist, Lincoln
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
What is need?Need is ‘the ability to benefit from care’Williams HC. J Roy Coll Physicians 1997;31:261-2
The use of the biological agents to treat psoriasis
The use of isotretinoin to treat acne
Demand and supply
Demand = “that which is asked for”
Supply = “that which is provided for”
Williams, HC. J Roy Coll Physicians 1997;31:261-2
Seborrhoeic keratoses – demand or need?
What is a health care needs assessment (HCNA)?
1. The burden of disease
Prevalence and incidenceImpact on quality of lifeEconomic burden
2. Managing the burden
The services availableThe effectiveness of
those services
3. Recommendations for models of care and delivery of services to manage the need
Some background to the project
1997Dermatology: Health Care
Needs AssessmentHywel WilliamsRadcliffe Medical Press
(one of 38 chapters still available on the HCNA website)
2007 Needed revision
Some background to the project
• BAD sabbatical fellowship April 2007
• Additional funding PCDS, Psoriasis Association, CEBD
• March to July 2008• Peer review process• Published by CEBD
October 2009
The teamProfessor Hywel Williams• Strategic lead for the project• Author of original Dermatology Health Care Needs
AssessmentDr Douglas Grindlay• Information Specialist, NHS Evidence – skin disorders
(based at CEBD)• Information searching, referencing, editingDr Julia Schofield• Lead researcher and lead author
Structure of the document: chapters1. Introduction2. Burden of skin disease3. NHS reform and its impact4. Services available and their
effectiveness5. Models of care and
organisation of services6. Specific skin disease areas7. RecommendationsLots of references!
What does the document tell us?
The HCNA: key messages
2. Managing the burden• The services available• The effectiveness of
those services• The cost-effectiveness
of those services
1. The burden of disease• Prevalence and
incidence• Impact on quality of life• Economic burden
3. Recommendations for models of care and delivery of services
• How to manage the need• Supply and type of services
Prevalence and incidence
• Examined skin disease• Self reported skin disease• People with skin disease seeking generalist
medical care• People with skin disease seeking specialist
medical care
Examined skin disease in the UKNothing 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
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
Self reported skin disease: PAGB study
• 1500 people questioned all over the UK• Minor ailments in the last 12 months• Questions related to a limited number of
conditions • 818/1500 (54%) reported a skin condition • The 1500 questioned reported 1524 episodes
of skin disease• 135 mothers reported eczema in 30% of their
children
Self reported skin disease PAGB study: management
advice GP12%
nothing17%
advice chemist
2%
self care69%
nothing self care advice GP advice chemist
PAGB study of self reported skin disease: limitations
• Diagnostic information limited, symptom based
• Limited range of conditions included in study• Respondents not asked about warts, verucca,
psoriasis, dandruff, hair loss, headlice, boils, cradle cap and nappy rash.
• No lumps and bumps, skin lesions• Under-estimates skin conditions
Skin disease seen in Primary Care
• Primary care data from RCGP Research and surveillance Unit weekly returns service (WRS)
• Data from 47 practices in England and Wales representing about 400,000 people
• Data captured on all patient encounters• Incidence, prevalence and consultation rate data
http://www.rcgp.org.uk/clinical_and_research/rsc.aspx
Data capture and coding issues• ICD 9 and 10• Disorders of the Skin and Subcutaneous TissuesDoes NOT include:• All skin tumours, benign and malignant• Many common skin infections including viral
wartsSeriously underestimates the amount of skin
disease
Skin disease in Primary Care: messages
• 24% of the population seek medical advice about a skin condition each year (12.9 million)
• This is the commonest reason for people to consult their GP with a new problem
• Consultation rate is 2 per episode• Average GP: 630 consultations per year for
skin conditions• Under-estimate due to coding issues
Skin disease seen in Primary Care
Condition Prevalence Episode incidence
Consultation rate
Skin infections
785 656 1131
Eczema 413 274 557Acne 164 125 251Psoriasis 69 33 109Urticaria 53 40 70
Prevalence, episode incidence and consultation rates for selected skin conditions per 10,000 population 2006. Source: RCGP WRS
Key messages
• Skin infections commonest reason for consultations
• 20% of children under 12 months are diagnosed with eczema
• Psoriasis not very common cause of GP consultations
Skin disease seen by specialists
• Limited information other than numbers• About 6.1% of people with skin disease are
referred to see a specialist• 35-48% referrals are skin lesions• Eczema, acne and psoriasis commonly seen• Patients still admitted
Specialists casemix: by % of new patient activity
0
2
4
6
8
10
12
14
eczema mole BCC seb wart solarkeratosis
acne psoriasis wart
Pboro Sheff WHHT M/cr
Skin lesions
Services available: who sees what and where?
Primary careSkin infections
Specialist careSkin lesions 45-60%
WHY?
31-59% are for diagnosis – skin lesions even higher
Self reported/ self managed skin
disease
0.75 million people with skin disease referred for
NHS specialist care, 1.5%
50% population approx 25 million
24% population, 12.9 million seeking Primary
Care (England and Wales)
Epidemiology: summary of key messages
3752 deaths due to skin
disease
The cost of skin disease in the UK
Direct and indirect costs• Over the counter (OTC) sales • Prescribing costs for skin disease• Costs to the NHS of delivering services for
patients with skin disease• The cost of disability due to skin disease
Trends in over the UK counter sales market (£M) 2007 skin sales £413.9 million
0
100
200
300
400
500
600
2001 2002 2003 2004 2005 2006 2007
Pain relief total Cough/cold/sore throat Skin treatments total Gastro-intestinal & travel sickness Smoking cessation Hayfever remedies
Skin diseasePain reliefCoughs colds and sore throats
Primary Care prescribing costs 2007
BNF Chapter 13• 35 million items, £239 million, net
ingredient cost £6.77• 2.85% total budget, no real change for
many years• Excludes hospital prescribing and oral
antibiotics• Dovobet: £21 million, NIC £54.95
Economic burden: disability living allowance claims by age
Burden of skin disease: impact on quality of life
• 1990 Psoriasis > impact on QoL than hypertension and angina
• 1999 Psoriasis same impact as angina or cancer
• 2000 High DLQI scores significant in primary care patients with skin disease
• 2003 Willingness to Pay for cure higher in acne, atopic eczema and psoriasis than angina hypertension and asthma.
Impact on quality of life: new data
• Psycho-social morbidity• Skin-Brain axis• Impact on the rest of the
family: ‘greater patient’• Impact on life choices• (co-morbidities)
The HCNA: key messages
2. Managing the burden• The services available• The effectiveness of
those services• The cost-effectiveness
of those services
1. The burden of disease• Prevalence and
incidence• Impact on quality of life• Economic burden
3. Recommendations for models of care and delivery of services
• How to manage the need• Supply and type of services
Services available and their effectiveness
• Self care, expert patient programme• Internet: e-health• Primary (generalist) care• Referral management• Specialist services• Supra-specialist services
Services available and their effectiveness
• Self care, expert patient programme• Internet: e-health• Primary (generalist) care• Referral management• Specialist services• Supra-specialist services
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
Patient information: important points
• The digital divide: 70% of over 65s have never used the internet
• NHS Direct: 4% of all calls skin rashes• Written information variable quality (Picker
Institute 2006)• Patients not involved, clinicians still write the
material• Health on the Net Foundation code of
accreditation, none of common dermatology sites accredited
Services available and their effectiveness: Primary Care
• Limited evidence• Evidence that teaching and training
inadequate (APPGS and others)• Little formal evaluation• Some evidence that skin lesion diagnostic
skills not great• Not a lot of evidence that up-skilling practice
nurses helps
Services available and their effectiveness: Primary Care
• MISTiC study 2008• Hospital vs GP skin
surgery• Some concerns about
quality of GP surgery• Malignancies missed• Hospital more cost-
effective• Patients preferred GP
skin surgery
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)
Effectiveness of specialist services
• Little evaluation of effectiveness of ‘doctor’ services
• Nurse services are better evaluated
• Few specialist services measure clinical outcomes
Evidence for effectiveness of specialist services
• Good diagnosticians• Supports role of
Inpatient treatment• Manage skin cancer
effectively• Specialist nurses are
effective• Role in managing
cellulitis
Models of care and organisation of services
• Consensus documents about models• Referral management ‘evidence free
zone’• Shift : specialists in community
settings and joint working improves access to care and maintains quality, no reduction in OP activity
• Digital imaging: useful but not implemented
Education and training
• Not enough training for Primary Care health care professionals
• What there is: not needs based, curriculum does not match casemix
• Remains optional, undergraduate and postgraduate nursing and medicine
The HCNA: key messages
2. Managing the burden• The services available• The effectiveness of
those services• The cost-effectiveness
of those services
1. The burden of disease• Prevalence and
incidence• Impact on quality of life• Economic burden
3. Recommendations for models of care and delivery of services
• How to manage the need• Supply and type of services
10 key recommendations
1. Improve self care: better information, community pharmacy training
2. Improve undergraduate nursing and medical training
3. Needs based educational programmes4. Referrals should be triaged by experts in
integrated teams5. More pyramidal service needed
The link between the amount and complexity of skin disease and current levels of training and knowledge
Incr
easi
ng c
ompl
exity
of s
kin
dise
ase:
few
er p
atien
ts
Large numbers of cases of straightforward, less complex skin disease
Highly trained supra-specialists
Incr
easi
ng a
mou
nt o
f tra
inin
g
Knowledge and skill of clinicians: small
number of highly trained specialists
treating few patients
Large numbers of patients managed by clinicians with
limited knowledge and training
All patients with skin conditions
Optimising the link between the amount and complexity of skin disease and levels of training and knowledge
Incr
easi
ng c
ompl
exity
of s
kin
dise
ase:
few
er p
atien
ts
Large numbers of cases of straightforward, less complex skin disease
Incr
easi
ng a
mou
nt o
f tra
inin
g
Specialists and supra-specialists diagnosing and managing more
complex skin problems
All patients with skin conditionsAll patients with skin conditions
Appropriate levels of education and training
based on ‘need’ as determined by the
type and amount of disease seen and its
complexity
10 key recommendations
6. Population based teams of health care professionals
7. Accreditation process needed8. Dermatologists: diagnosis, management of
complex skin problems9. Cancer service led by dermatologists10. Patient Reported Outcome Measures
needed
Thank youAcknowledgements
British Association of DermatologyPsoriasis Association
Primary Care Dermatology SocietyProfessor Hywel Williams & Douglas Grindlay
