Skin Care Services - October 2015

In October 2015 we were looking at how we could improve dermatology services in Liverpool.  See below for the background information and final report.

Dermatology report

FAQs (October 2015)

What skin services do we have in Liverpool?

We provide a range of skin (Dermatology) services in Liverpool. These include:-

The suspected Skin Cancer Clinic
This service is provided by the Royal Hospital and provides diagnosis and treatment for suspected skin cancers.

Hospital Dermatology Clinics - Both children and adult clinics are provided.
Adult secondary care skin services in Liverpool are provided by The Royal Liverpool & Broadgreen Hospital and Aintree Hospital.  This includes all skin related conditions and treatments. All children’s dermatology services are provided by Alder Hey.

In addition to treating severe forms of the conditions listed under the ICATs clinic (below), hospital skin services also treat basal cell carcinoma, vulval skin disorders, patch testing, male genital skin disorders and connective tissue disease.

The Community based Dermatology Integrated Clinical Assessment and Treatment Service (ICATs) – This is an adults only service
This is a community service for patients with less complex skin conditions. Conditions treated in the service include:  Mild to moderate eczema, unresponsive to measures tried in primary care-suitable for treatment with topical therapy. Mild to moderate psoriasis, unresponsive for measures tried in primary care-suitable for treatment with topical therapy. Acne or rosacea (not sufficiently severe to require isotretinoin). Chronic or recurrent skin infections (e.g.  fungal infections, folliculitis, recurrent bacterial infections). Acute severe infections such as kerion, extensive herpes or bullous impetigo should be referred to Secondary Care. Infestations including scabies and head lice that are unresponsive to measures tried in primary care. Scalp conditions including alopecia or hair loss that are unresponsive to measures tried in primary care. Seborrhoeic dermatitis and dandruff that is unresponsive to measures tried in primary care. Actinic keratosis. Nail Disorders that are unresponsive to standard measures tried in primary care. Pigmentary Disorders. Mild inflammatory skin disease e.g. lichen simplex, lichen planus (unless diagnosed in the mouth), granuloma annulare.  Treatments offered:  Liquid nitrogen cryotherapy, curettage and cautery, incisional and excisional biopsy.

The Community Skin Team – This is an adults only service
The service provides care for patients with complex skin conditions, such as leg ulcers or wound prevention and management. The patients they see are primarily housebound.

The Minor Surgery Service which is provided by most GPs – This is an adults only service
Minor surgery services are provided at the majority of GP practices across Liverpool and they treat their own patients who present with warts, moles, cysts, or require joint injections. However there are some practices that do not offer this service and those patients requiring minor surgery from these practices can be referred to the Enhanced Minor Surgery service. The enhanced service is available from 12 GP practices across Liverpool.  If a patient has a condition that can be treated by the Minor Surgery service then the referral is sent to the Choice Team who then contact the patient to offer a choice of provider and to arrange an appointment. The Minor Surgery service is only available to adults 16 years or over. 

Which skin services are being reviewed?

Our plans for improving skin services involve reviewing the hospital based skin services (adults & children’s services) and the community dermatology Integrated Clinical Assessment and Treatment Service (ICATs).

The following services form part of the overall provision of skin services in Liverpool and are therefore included in the proposed model but there are no plans to specifically change how the services are delivered.

-  The suspected skin cancer clinic

- The community skin team 

-  Minor surgery service

What new options are being looked at?

In reviewing skin services across Liverpool, four options are open for consideration:-

  1. Do nothing
  2. Develop a new model of care that provides a joined up service for adults only.
  3. Develop a new model of care for a joined up adult and children’s skin service
  4. Include or exclude a triage service to screen referrals into the service.

At this stage the draft model sets out the way we think services could be restructured to improve the care we provide to people with skin conditions. This is option 3, with the inclusion of a triage service.

This is a new way of working and we are keen to understand if the proposed model is responsive to people’s needs. The findings of this engagement will inform the final design of the service.

What does the proposed new model for skin services look like?

The vision for skin services is to provide a model that joins up adults and children’s services across community, primary and secondary care.

Four levels of care are suggested within the model. These are as follows:-

Level 1 - Patient self-management 
People with skin conditions who manage their conditions themselves would be supported with high quality information and input from relevant sources. For example local pharmacies, patient support groups.

Level 2 - GP management / generalist care
People with skin conditions needing general care would be managed initially by their GP and would have access to input from suitably trained nurses and other staff. It is proposed additional input could come from using new technology that can assist with diagnosing and managing skin conditions. For example technology such as Teledermatology which allows GPs to take a photo of a patients skin condition and sent it to a consultant for their opinion, could be used.

Level 3 - Community specialist care 
Consultant Dermatologists would work alongside GPs with specialist interests in skins, Clinical Assistants, GPs, Nurse Specialist, Nursing staff with specific skin training and Pharmacists to offer a one stop service for patients. This would also include access to psychological support.

The service would provide most of the traditional care and treatment currently provided in a hospital setting and would offer a full range of diagnostic procedures. This includes:-

  • Punch biopsy
  • Excision biopsy
  • Incision biopsy
  • Skin scraping
  • Blood tests
  • Swabs

Due to the requirement for large pieces of equipment which can be expensive some treatment which could clinically be provided in a community setting would still need to be provided in hospital.

Community clinics would be available across the city (locations to be determined) and have links to a plastic surgery day case service, which patients may be referred onto. It would also have the ability to book appointments for hospital based procedures if required. This would stop patients having to return to their GPs for another referral.

Level 4 - Specialist hospital care
Specialist hospital care would only be required for patients with complex conditions, or those requiring specialist input. This would include urgent referrals for suspected skin cancers, patients requiring a phototherapy (due to the requirement for large equipment), patch testing (because of the requirement of storage facilities), patients who require a general anaesthetic, level 3 and 4 skin cancer care and patients who need to be seen /treated by a multi-disciplinary team.

Most of the elements of the draft model are already provided. The main differences are in how the services are packaged and aligned based on severity and complexity of need and in the joining up of adults and children’s services. 

These main differences are as follows:-

  • Children’s dermatology services would be available in the community
  • There is no formal structure at present for patient self-management. The suggested model would offer a platform from which more focus could be given to support patients. This may be through patient information leaflets, or upskilling pharmacists to offer patients more advice on the management of most common skin conditions.
  • The proposed model streamlines the dermatology provision and removes duplication of services.
  • It proposed digital innovations are implemented to help with diagnosing and managing skin conditions. For example, GPs could take a photo of a patient’s skin condition and send it to a consultant for their opinion.
  • Dermatology referrals could be triaged to ensure they are directed to the right service, first time. 

How is this different?

Most of the elements of the proposed model are already provided. The main differences are in how the services are packaged and aligned based on severity and complexity and in the integration of adults and children’s services. These main differences are as follows:

  • Children’s dermatology services would be available in the community
  • There is no formal structure at present for patient self-management. The suggested model would offer a platform from which more focus could be given to support patients. This may be through patient information leaflets, or upskilling pharmacists to offer patients more advice on the management of most common skin conditions.
  • The proposed model streamlines the dermatology provision and removes duplication of services.
  • It proposed digital innovations are implemented to help with diagnosing and managing skin conditions. For example, GPs could take a photo of a patient’s skin condition and send it to a consultant for their opinion.
  • Dermatology referrals could be triaged to ensure they are directed to the right service, first time.  

How would the triage system work?

Triage (assessment and direction) of referrals would take place by an appropriate specialist clinician (with the exception of suspected skin cancers). The specialist clinician would review each referral letter to determine if a patient is being sent to the appropriate part of the skin service. Having looked at the referral, the clinician would either:-

  • Progress a patient’s referral through the system and arrange a telephone consultation or an appointment.
  • Contact the person who sent the referral and provide them with advice and guidance on how to manage their patient, removing the need for an appointment with the skin service.
  • If appropriate, contact the patient and provide advice rather than an appointment.
  • Redirect the referral to the appropriate service if it is deemed that the referral is not for the skin service.

This would be a virtual service and the majority of patients would not notice its existence. It is anticipated that if triage is included in the model, referrals would be handles within two working days of them being received.

Why are you looking at changing dermatology services?

Year on year there has been a 10% increase in demand for urgent referrals for suspected skin cancers. This has resulted in lengthy wait times across all services.

One solution to addressing demand would be to recruit additional staff into the service, but the dermatology workforce is limited, both locally and nationally and attracting additional staff is challenging.

Added to this, primary care clinicians sometimes lack experience in dermatology conditions resulting in patients being referred to the urgent clinic for suspected skin cancer rather than risk lengthy waiting times in the general dermatology clinics and this puts extra pressure on services.

The draft model proposes to address these issues by placing a greater focus on increasing knowledge of skin conditions in GPs and Practice Nurses and using digital technology to improve assessment, diagnosis and treatment of skin conditions. It is anticipated that as the confidence of GPs and Practice Nurses increases, less patients will need referring to the urgent clinic for suspected skin cancers and this will alleviate pressure on the service and free up capacity to be used in the community.

How could the proposed changes benefit the people of Liverpool?

  • Introducing digital innovations, such as Teledermatology, would enable GP’s/Nurses to capture photos/videos of skin problems and seek advice and guidance from a Consultant Dermatologist, reducing the need for unnecessary referrals and allowing the GP to manage the patient within primary care.
  • Integrated care pathways that direct patients rapidly to the right person in the right place first time and ensure patients and their carers have a positive experience of care.
  • A model of care that enables people to move readily between the different levels of care as necessary and across Primary Care, Community Care and Secondary Care as appropriate.
  • One service for adults and children, meaning there is no need for transitioning between children’s and adult’s services. This will offer a level of continuity not previously available.
  • Increased choice of service locations for children accessing dermatology services, with specialist paediatric services closer to people’s homes
  • Improved communication between specialists and GP’s – leading to improved care planning.
  • Waiting times for routine dermatology clinics that will reduce to a maximum wait of 28 days within 18-24 months.
  • Facilitation of well supported self-management and improved access to advice and information.
  • Introduction of a triage service will mean patients are less likely to have wasted appointments as they will be seen by the right clinician first time.

 

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