Skin diseases are disfiguring, distressing and highly symptomatic. One in four of the population are affected by skin disease that would benefit from medical care. Chronic inflammatory skin diseases significantly reduce quality of life and impose a considerable burden on the individual and the community.1 2 3 In the UK skin diseases are among the commonest certified causes of incapacity to work. Skin cancer is the commonest cancer in the UK; some estimate quadrupling in incidence in the past 20 years.
Skin disease accounts for some 15% of primary care consultations, 35% of the disorders under consideration for nurse prescribing, 7% of all referrals to hospital outpatient clinics. It is an increasingly important cause of serious debility in the elderly. Between 1981 and 1991 consultations for skin disease in general practice rose by almost 50%, yet only 6% of GPs have Certificates of Dermatology experience during their training. This reflected an increase in prevalence of common problems such as atopic eczema, venous leg ulcers and skin cancer as well as an increase in availability of effective treatments.4 GPs refer 1-2% of the population to dermatologists each year as new patients.
Dermatologists are hospital based specialists who diagnose and manage significant and complex skin disease in people of all ages. Most dermatologists are skin surgeons as well as physicians. Skin cancer is the commonest cancer in Scotland and is steadily increasing. Cure rates are high providing there is early diagnosis and treatment.
Training of Health Professionals in Skin Disease
Teaching of medical students, postgraduates, family doctors and nurses is an essential part of a dermatologist’s work.5 Although 15% of GP consultations relate to skin disease, only 5% of GP vocational training schemes contain a dermatology component; and the undergraduate curriculum contains on average only six days of dermatology. Newly appointed GPs therefore have little experience of dermatological problems.
Provision of Skin Disease Services
With the new Parliament established in July 1999, it became evident that Scotland was without the equivalent of both the All-Party Parliamentary Group on the Skin and the Action On programme on Dermatology. In short, Scotland has fallen behind England in the structures that exist to ensure the standard of service provided. Stewart Douglas, who has recently stepped down as Chairman, has been working hard and successfully to rectify this situation.
Over the last two years in Scotland, a number of significant developments have taken place. Dermatology has been identified by the National Waiting Times Unit as one of eight specialties requiring focused support to achieve the maximum waiting target for routine patients of 26 weeks by 2005. In addition, the Skin Care Campaign Scotland (SCCS) has been established with a close relationship with the Skin Care Campaign (UK). The SCCS expects to keep a watching brief on key aspects of skin care provision in Scotland. This is important, for a number of crucial issues have to be faced up to, including shortage of dermatology beds, shortage of dermatologist numbers, the need to expand the nursing role and development of nursing education and training programmes. There is no doubt that for the future the increasing amount and sophistication of dermatology care required will need to be provided by multidisciplinary teams. In this respect, the Centre for Change and Innovation (June Andrews) has plans to introduce an "Action On Dermatology" programme,6 which will encourage redesign and development of dermatology services as required at local Health Board level. Additional funding should be seen within the context of dermatology as a low cost speciality. Secondary skin care in Scotland is provided for between £2 and £3 per head of population per year.
A potential problem of health care divergence between England and Scotland relates to Consultant recruitment. It is important that the current contract discussions produce a satisfactory outcome. We already have six vacant Consultant Dermatologist posts in Scotland, representing nearly 15% of the workforce. If the new Consultant contract in England produces a more attractive proposition for Consultant candidates, there may be increased difficulty in recruitment in Scotland. Meanwhile, it seems likely that Scottish dermatology will be looking towards increased access to outpatient therapy centres in the light of reduced bed numbers, increased staff grade and GP with special interest (GPwsi) as well as development of the specialist nurse role. It is unfortunate that there is also a staffing shortage within nursing which undoubtedly will limit potential developments.
On the nursing side, Scottish dermatology nursing training is under active development with NHS Education Scotland (NES).
The key to our understanding of the state of dermatology services is the collection of accurate and relevant data on services within Scotland. It has been recognised that too little information is being routinely collected to get a clear picture of each area service. Moves are afoot to collect this to include key areas such as biopsies, patch testing, phototherapy and other specialist clinics. This, it is hoped, will in the future, be in a standardised format. Such data should provide a current picture of the spectrum of dermatology services and provide clear warning of areas requiring attention.
It is encouraging that the latest version of the SNOMED-CT clinical coding system incorporates the British Association of Dermatologists diagnostic lexicon. Electronic systems based on structured letters, which use these codes have the potential to make quantum improvements in the quality and completeness of dermatological clinical data. Current data collection in the NHS is by crude manual systems which ignore most outpatient and day patient dermatological activity.
Dermatology services in Scotland will, for the near future, be fundamentally provided through the National Health Service. While such services develop in their quality and range, equity of care throughout Scotland should be provided increasingly by teams within specialist outpatient clinics and a wide range of sub-specialty services supported by outpatient therapy centres. Increasing specialisation by nurses, primary health care training, increased consultant numbers with the necessary expansion in consultant trainees (SpRs) are our targets for the future.
- Williams H C. Dermatology: Health Care Needs Assessment. Ed A. Stevens, J. Raftery. Radcliffe Medical Press, 1997 Harlow D, Poyner T, Finlay A Y, Dykes P J. Impaired quality of life of adults with skin disease in primary care. British Journal of Dermatology 2000; 143: :979-982 Williams H C. Increasing demand for dermatological services: how much is needed? Journal of the Royal College of Physicians, London, 1997; 31: 261-262 An Investigation Into The Adequacy Of Service Provision And Treatments For Patients With Skin Diseases In The UK. A Report of the All Party Parliamentary Group on Skin. London, March 1997. Royal College of General Practitioners and British Association of Dermatologists. Dermatology for General Practice Trainees. Royal College of General Practitioners, London, 1998.
- Action on Dermatology: Good Practice Guide, NHS Modernisation Agency, London, 2003.