Skin conditions a Health Care Needs Assessment: key messages

1
Skin conditions a Health Care Needs Assessment
key messages

• Julia Schofield
• Special Lecturer University of Nottingham
• Principal Lecturer University of Hertfordshire
• Consultant Dermatologist, Lincoln

2
What I am going to talk about?

• What is need?
• What is a Health Care Needs Assessment?
• Some background to the new document
• What does the updated Dermatology Needs
  Assessment for the UK tell us?
• Recommendations for the future

3
What is need?

• Need is the ability to benefit from care
• Williams HC. J Roy Coll Physicians 199731261-2

The use of the biological agents to treat
psoriasis
The use of isotretinoin to treat acne
4
Demand and supply

• Demand that which is asked for
• Supply that which is provided for
• Williams, HC. J Roy Coll Physicians 199731261-2

Seborrhoeic keratoses demand or need?
5
What is a health care needs assessment (HCNA)?

• 1. The burden of disease
• Prevalence and incidence
• Impact on quality of life
• Economic burden

• 2. Managing the burden
• The services available
• The effectiveness of those services

3. Recommendations for models of care and
delivery of services to manage the need
6
Some background to the project

• 1997
• Dermatology Health Care Needs Assessment
• Hywel Williams
• Radcliffe Medical Press (one of 38 chapters still
  available on the HCNA website)
• 2007
• Needed revision

7
Some background to the project

• BAD sabbatical fellowship April 2007
• Additional funding PCDS, Psoriasis Association,
  CEBD
• March to July 2008
• Peer review process
• Published by CEBD October 2009

8
The team

• Professor Hywel Williams
• Strategic lead for the project
• Author of original Dermatology Health Care Needs
  Assessment
• Dr Douglas Grindlay
• Information Specialist, NHS Evidence skin
  disorders (based at CEBD)
• Information searching, referencing, editing
• Dr Julia Schofield
• Lead researcher and lead author

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Structure of the document chapters

• Introduction
• Burden of skin disease
• NHS reform and its impact
• Services available and their effectiveness
• Models of care and organisation of services
• Specific skin disease areas
• Recommendations
• Lots of references!

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What does the document tell us?
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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

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Prevalence and incidence

• Examined skin disease
• Self reported skin disease
• People with skin disease seeking generalist
  medical care
• People with skin disease seeking specialist
  medical care

13
Examined skin disease in the UK

• Nothing new since the Lambeth study in 1976
• 2180 adults studied
• 55 population had any form of skin disease
• 22.5 had skin disease worthy of medical care
• Tumours and naevi commonest but 90 considered
  trivial
• Prevalence of eczema 9 but 2/3 moderate or
  severe
• Authors concluded
• Skin conditions that may benefit from medical
  care are extremely common
• Most sufferers do not seek medical help

• Rea et al Skin disease in Lambeth a community
  study of prevalence and use of medical care. Brit
  J Prev Soc Med 197630107-14

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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/marketinformat
ion/otcconsumeresearch.htm
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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

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Self reported skin disease PAGB study management
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PAGB study of self reported skin disease
limitations

• Diagnostic information limited, symptom based
• Limited range of conditions included in study
• Respondents not asked about warts, verucca,
  psoriasis, dandruff, hair loss, headlice, boils,
  cradle cap and nappy rash.
• No lumps and bumps, skin lesions
• Under-estimates skin conditions

18
Skin disease seen in Primary Care

• Primary care data from RCGP Research and
  surveillance Unit weekly returns service (WRS)
• Data from 47 practices in England and Wales
  representing about 400,000 people
• Data captured on all patient encounters
• Incidence, prevalence and consultation rate data

http//www.rcgp.org.uk/clinical_and_research/rsc.a
spx
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Data capture and coding issues

• ICD 9 and 10
• Disorders of the Skin and Subcutaneous Tissues
• Does NOT include
• All skin tumours, benign and malignant
• Many common skin infections including viral warts
• Seriously underestimates the amount of skin
  disease

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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

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Skin disease seen in Primary Care
Condition Prevalence Episode incidence Consultation rate
Skin infections 785 656 1131
Eczema 413 274 557
Acne 164 125 251
Psoriasis 69 33 109
Urticaria 53 40 70
Prevalence, episode incidence and consultation
rates for selected skin conditions per 10,000
population 2006. Source RCGP WRS
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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

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Skin disease seen by specialists

• Limited information other than numbers
• About 6.1 of people with skin disease are
  referred to see a specialist
• 35-48 referrals are skin lesions
• Eczema, acne and psoriasis commonly seen
• Patients still admitted

24
Specialists casemix by of new patient activity
Skin lesions
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Services available who sees what and where?
WHY?

• Specialist care
• Skin lesions 45-60

• Primary care
• Skin infections

31-59 are for diagnosis skin lesions even
higher
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Epidemiology summary of key messages
0.75 million people with skin disease referred
for NHS specialist care, 1.5
3752 deaths due to skin disease
24 population, 12.9 million seeking Primary Care
(England and Wales)
Self reported/ self managed skin disease
50 population approx 25 million
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The cost of skin disease in the UK

• Direct and indirect costs
• Over the counter (OTC) sales
• Prescribing costs for skin disease
• Costs to the NHS of delivering services for
  patients with skin disease
• The cost of disability due to skin disease

28
Skin disease
Coughs colds and sore throats
Pain relief
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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

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Economic burden disability living allowance
claims by age
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Burden of skin disease impact on quality of life

• 1990 Psoriasis gt 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.

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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)

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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

34
Services available and their effectiveness

• Self care, expert patient programme
• Internet e-health
• Primary (generalist) care
• Referral management
• Specialist services
• Supra-specialist services

35
Services available and their effectiveness

• Self care, expert patient programme
• Internet e-health
• Primary (generalist) care
• Referral management
• Specialist services
• Supra-specialist services

36
Services available and their effectiveness self
care

• Patient groups important but vulnerable
• Some evidence for social network groups
• No Expert Patient Group Evidence
• High sales OTC skin treatment products but
  limited teaching and training of pharmacists
• No formal evaluation of pharmacists

37
Patient information important points

• The digital divide 70 of over 65s have never
  used the internet
• NHS Direct 4 of all calls skin rashes
• Written information variable quality (Picker
  Institute 2006)
• Patients not involved, clinicians still write the
  material
• Health on the Net Foundation code of
  accreditation, none of common dermatology sites
  accredited

38
Services available and their effectiveness
Primary Care

• Limited evidence
• Evidence that teaching and training inadequate
  (APPGS and others)
• Little formal evaluation
• Some evidence that skin lesion diagnostic skills
  not great
• Not a lot of evidence that up-skilling practice
  nurses helps

39
Services available and their effectiveness
Primary Care

• MISTiC study 2008
• Hospital vs GP skin surgery
• Some concerns about quality of GP surgery
• Malignancies missed
• Hospital more cost-effective
• Patients preferred GP skin surgery

40
Services available and their effectiveness GPwSI
services

• GPwSI services are effective
• Patients like the GPwSI services
• Not particularly cost-effective
• Overall may increase costs
• May not be the most cost effective way of
  increasing overall capacity of specialist
  services (Roland 2005)

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Effectiveness of specialist services

• Little evaluation of effectiveness of doctor
  services
• Nurse services are better evaluated
• Few specialist services measure clinical outcomes

42
Evidence for effectiveness of specialist services

• Good diagnosticians
• Supports role of Inpatient treatment
• Manage skin cancer effectively
• Specialist nurses are effective
• Role in managing cellulitis

43
Models of care and organisation of services

• Consensus documents about models
• Referral management evidence free zone
• Shift specialists in community settings and
  joint working improves access to care and
  maintains quality, no reduction in OP activity
• Digital imaging useful but not implemented

44
Education and training

• Not enough training for Primary Care health care
  professionals
• What there is not needs based, curriculum does
  not match casemix
• Remains optional, undergraduate and postgraduate
  nursing and medicine

45
The HCNA key messages

• 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

46
10 key recommendations

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

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The link between the amount and complexity of
skin disease and current levels of training and
knowledge
Highly trained supra-specialists
Large numbers of patients managed by clinicians
with limited knowledge and training
Knowledge and skill of clinicians small number
of highly trained specialists treating few
patients
Increasing complexity of skin disease fewer
patients
Increasing amount of training
All patients with skin conditions
Large numbers of cases of straightforward, less
complex skin disease
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Optimising the link between the amount and
complexity of skin disease and levels of training
and knowledge
Specialists and supra-specialists diagnosing and
managing more complex skin problems
Appropriate levels of education and training
based on need as determined by the type and
amount of disease seen and its complexity
Increasing complexity of skin disease fewer
patients
Increasing amount of training
All patients with skin conditions
All patients with skin conditions
Large numbers of cases of straightforward, less
complex skin disease
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10 key recommendations

• 6. Population based teams of health care
  professionals
• 7. Accreditation process needed
• 8. Dermatologists diagnosis, management of
  complex skin problems
• 9. Cancer service led by dermatologists
• 10. Patient Reported Outcome Measures needed

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Thank you

• Acknowledgements
• British Association of Dermatology
• Psoriasis Association
• Primary Care Dermatology Society
• Professor Hywel Williams Douglas Grindlay