Dermatology Workforce Service Forecast

Specific service issues

Skin Cancer

As stated above, New Zealand has the highest level of skin cancer in the world. The low level of public dermatology and the increasing numbers of patients presenting with this condition is not sustainable.

The Group supports the development of multi-disciplinary teams for skin cancer in every DHB, led by a Dermatologist, as recommended in the UK NICE guidelines^xxi. Dermatologists are expert diagnosticians of skin lesions, due to their training and wide experience in all aspects of dermatology including benign, premalignant and malignant skin lesions. Appropriate treatment depends on accurate diagnosis. A dermatologist led team would result in a reduction of unnecessary excisions and more appropriate treatment of lesions. Dermatologists are experienced in a wide variety of treatment options including medical (topical and systemic), surgical and other modalities such as cryotherapy and photodynamic therapy.
Multidisciplinary teams should include representatives from plastic surgery, radiation oncology, nursing, General Practice, pathology and general surgery. Teams would be involved in running clinics, reviewing cases, discussing morbidity and developing management plans. Where Mohs surgery is being considered, the case should be discussed in such a multidisciplinary clinic.
National standards of care of patients with suspected skin cancer should be developed de novo or from other sources which already exist, along with clear referral pathways. Standards should also be developed for Mohs surgery.
The Group supports adopting the practice currently used in the UK involving all of those involved in managing skin cancer, including GPs, dermatologists, plastic and general surgeons whether in public or private practice. They are required to be part of a multidisciplinary team, as well as on a register of approved practitioners and are subject to regular review and audit. This will ensure appropriate treatment and outcomes and appropriate standards are maintained.
Correct diagnosis of skin lesions is paramount and can often be made clinically. Biopsy or excision should be performed in cases where there is a definite neoplasm or diagnosis is not certain. GPs require access to more training in the management of skin cancer, funded by DHBs as currently some GPs pay up front for training.
The dermatology component of all medical training needs to be increased. There also needs to be more time for teaching by dermatologists in the basic undergraduate medical course. Currently some medical students in New Zealand have no dermatology training at all, while others receive several half days, which is totally inadequate.
At PHO level, community teams should be available to provide on-going care and rehabilitation when required.
Paediatric Dermatology

There is currently not enough funding for paediatric dermatology in New Zealand. Access to this service is patchy and is often not available. There is a large unmet need.

Nursing involvement in paediatric services, to provide education to patients and their caregivers, has been shown to have very positive results.
Having paediatric dermatology based at all DHBs, in dedicated paediatric facilities, along with outreach clinics as required, will ensure equitable access and quality health care is provided.
Teledermatology

For GPs working in remote areas of New Zealand or as part of the hub and spoke approach, the use of teledermatology could be expanded. Uses could be as a triage tool for skin lesions, as an alternative to a face-to-face consultation or as a combination of these. Live teledermatology clinics allow access to the patient near home, but are difficult to set up and implement. ‘Store and forward’ is a more practical method of getting an opinion from a dermatologist, but it’s limitations must be recognised.

A recent New Zealand seminar showed that there was excellent concordance between face-to-face and teledermatology diagnosis for lesions, while a UK case study showed that teledermatology was effective at reducing unnecessary secondary appointments, reduced time to be seen by a specialist and delivered financial savings.
Further research and development, and national guidelines are needed in New Zealand, to maximise the use of this potentially effective, cost-saving tool.
Contact Dermatitis and occupational dermatology

There is currently an unmet need for this service in every DHB in New Zealand.

Contact dermatitis accounts for 4-7% of all dermatological conditions. Work related dermatitis can result in patients having time off work, the development of chronic disability and in some cases, the inability to work.
Appropriate specialist care and investigation is necessary to distinguish between occupational and non-occupational contact dermatitis, and constitutional eczema, since the management of these conditions is very different. ^xxii
Patients with persistent eczema or dermatitis should be investigated by patch testing, at least to an extended standard series of allergens. Specialist dermatologists working in DHBs should have had training in the investigation and management of contact dermatitis. This service should be provided at either secondary DHB level locally and/or at tertiary regional level in a subspecialty clinic for contact dermatitis and occupational dermatitis. DHBs would hold a series of common allergens with the more specialty allergens held regionally. A regional bank of patch testing chemicals would allow chemicals to be sent to different regions as required. This could be cost effective as the price of patch testing chemicals is high, especially as they have a short shelf life.
At primary care GP clinics and occupational doctors’ and nurses’ clinics, there is a need for an awareness of contact and occupational dermatitis and referral to dermatology specialists. Funding of referrals for consultations, investigations (including patch testing) and reporting, needs to be available and this could include Accident Compensation Corporation (ACC) funding.
Statistics from ACC (Appendix 4) show a decline in the numbers of contact dermatitis claims. It was noted, by the Group, that ACC are reluctant to compensate for the investigation and treatment of occupational dermatitis, despite the fact that much dermatitis seen at a primary and secondary level may be occupational in origin. This situation needs to be changed and would reduce the cost to DHBs.
Phototherapy

Phototherapy is recognised as a safe and effective treatment for moderate to severe psoriasis. New biologic treatments are being produced but they are very costly and can have unwanted side effects.

It is recommended that as a minimum all DHBs should provide nbUVB and some DHBs may wish to provide hand and foot or total body PUVA therapy. These should be available in evenings and weekends to fit with patient’s needs, as multiple visits are required for effective treatment. Childcare provision should also be provided to enable regular treatments. Skilled nurses or technicians can provide phototherapy. This treatment could be one of a suite of treatments offered in day stay units for dermatology that should be provided for the consultant-led teams.
Research overseas has found that providing home UVB phototherapy units for people living too far from a base clinic can be equally successful. Pre-programmed home units can be safe and effective, both clinically and for quality of life and could be loaned by DHBs.
Medical photography

Access to high quality medical photography, including in studio medical photography in all DHBs is necessary. While digital technology is advancing, it is still important to have studio quality pictures. There is also a need for all DHBs to use software that enables photos to be attached to patient records, which can be later reviewed in sequence.

Day stay units

The Group recommends that day stay units be an integral component of DHB dermatology services. These units offer intensive topical therapies to outpatients as well as the provision of effective topical treatments that cannot be safely self-administered. Intensive topical treatments provided by day stay units are recognised to reduce the requirement for expensive systemic medications, therefore offering treatment alternatives with a significantly safer side effect profile. Day stay units are usually staffed by dermatology nurses, who provide education as well as medical and psychological support for dermatology patients. In addition they lead to a reduction in expensive inpatient care.