Dermatology Workforce Service Forecast

Methodology

Three face-to-face meetings of the Group were held, all of them at Greenlane Clinical Centre, Auckland. A part-time project manager was contracted to assist with the process. Email was the main form of correspondence and information sharing between the Group.

At the first meeting of the Group, a background document was tabled, which was a starting point for information gathering about the current dermatology workforce and service delivery model being used in New Zealand. The Group then developed the first iteration of their vision for dermatology and determined the scope of the project. It was decided to define the core dermatology services and how these should be provided, to ensure equity of access and then use a range of patient journeys to describe the current and then the future service delivery model. The Group identified the information that would be useful to inform the project and the need to consider overseas work.
The second meeting included reviewing the information that had already been collected, which included:

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  analysis of prescriptions relating to dermatology to demonstrate the burden of disease
  
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  analysis of the distribution of dermatologists by FTE and DHB and the issues that this raises
  
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  overview of the documentation provided by Group members, particularly the literature from overseas.
  

The Group reviewed and amended the vision, refining the original statement. In addition, they shared their experiences of working overseas under differing models of provision. Group members then tabled their ‘patient journeys’ and discussed how these could be improved in the envisioned future delivery model.

The third meeting involved the Group focussing on the key issues raised, which had been drafted onto an initial report format.

The Group worked on key findings, relevant data sources and recommendations to include in the report to HWNZ, which highlight the current situation of very limited public dermatology provision and the requirements for the envisioned service for 2020.

A three-hour teleconference was held to agree the final version of the report.

Dermatology in New Zealand

What is Dermatology?

Dermatology is the study, research and diagnosis of disorders, diseases, cancers, cosmetic, ageing and physiological conditions of the skin, fat, hair, nails and oral and genital membranes. It includes the management of these by different investigations and therapies, including but not limited to dermatohistopathology, topical and systemic medications, dermatologic surgery, phototherapy, laser therapy, superficial radiotherapy, photodynamic therapy and other therapies that may become available.ⁱ

The burden of disease

New Zealand currently has 4.3 million citizensⁱⁱ and 61 Registered Dermatologistsⁱⁱⁱ. By 2021 the New Zealand population is projected to reach just less than 5 million ⁱⁱ. Mean age will rise to 37.9 years and 17% will be aged over 65, an increase from 13% in 2011. By 2026 it is estimated that 1 million New Zealanders will be aged 65 and over.
An increasingly ageing population increases the chances of developing skin-related disorders such as dermatitis, bullous dermatoses, skin neoplasms and adverse cutaneous drug reactions^iv. Decreased immunity and exposure to a range of external factors, in particular UV light, is likely to lead to an increase in skin cancer. It is predicted that there will be an increased need for dermatologists to meet these projected needs.

Skin cancer

New Zealand’s melanoma incidence is higher than that reported in any other nation. In comparison with Australia, the most recent complete data is from 2009 where the New Zealand cancer registry reported 2212 new melanomas giving a New Zealand incidence of 51.2 melanomas per 100,000 people. For 2009, the Australian government cancer registry published their incidence of 44.8 melanomas per 100,000 people. The United Kingdom melanoma incidence in 2010 was 26.6 per 100,000 people (Cancer research UK statistics). New Zealand’s melanoma rate continues to be the highest in the world and it is rising.
There were 445 deaths from skin cancer in 2009 of which 326 deaths were from Melanoma and 119 from non-melanoma skin cancer (for example, merkel cell carcinoma, squamous cell carcinoma, etc.)^v.
The exact rate of non-melanoma skin cancer is unknown, as currently these skin cancers are not notified. It has been estimated that 67,000 non-melanoma skin cancers are treated each year in New Zealand making both melanoma and non-melanoma skin cancers a significant proportion of all cancers (80%).
While the mortality from non-melanoma skin cancer is low, the large and increasing number causes a significant burden on the health system. The health system cost of all skin cancer in 2006 has been estimated to be $57 million with the additional lost production cost of $66 million^vi. (Source; The costs of skin cancer: report to the Cancer Society of New Zealand 2009 by Des O’Dea)

Health Loss

In 2006, health loss from skin conditions found 17 408 Disability Adjusted Life Years (DALYs) representing 1.8% of the total health loss and 9479 DALYs for eczema and dermatitis (1% of total). In 2009, there were 95 deaths (58 in 2006) in New Zealand due to diseases of the skin and subcutaneous conditions.^vii

Data on Hospital Services

Data on dermatology in New Zealand is hard to access and is not routinely recorded or centrally collected. Many patients seek treatment in the private sector and this information is not centrally held or readily accessed.
Dermatology is predominantly outpatient based and therefore relatively inexpensive on a per capita basis compared to other hospital specialties. However, dermatology inpatients are often seriously ill and require prolonged hospital stays with multiple assessments.  Many medical and surgical patients develop dermatological complications that require the prompt attention of a dermatologist.  The need for inpatient assessments is often not properly factored in to SMO job sizing.  Many DHBs will have difficulty accessing dermatologist care for the seriously ill inpatient. Where there are inpatient services offered, there are a high number of inpatient consultations, for example Middlemore Hospital with 973 beds, and 15-20 in-patient consultations per week.

Data on GP Services

Dermnet, the website of the New Zealand Dermatological Society Incorporated, notes that in New Zealand, one in six (15%) of all visits to the family doctor (GP) involves a skin problem^viii.
The document ‘Skin Conditions in the UK; A Health Care Needs Assessment’ (2009), found

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  Previous studies on unselected populations suggest that around 23-33% have a skin problem that can benefit from medical care at any one time and skin conditions are the most frequent reason for people to consult their general practitioner with a new problem.
  
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  Surveys suggest that around 54% of the UK population experience a skin condition in a given twelve-month period. Most (69%) self-care, with around 14% seeking further medical advice, usually from the doctor or nurse in the community.
  
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  Skin conditions are the most frequent reason for people to consult their general practitioner with a new problem.^ix
  

Given New Zealand’s high level of skin cancers described above, it is likely that the figures for New Zealand are higher than those described in the UK.

Comparative ratios of Dermatologists: Population

Recommended ratios of dermatologists are based on the numbers of referrals and may vary for community based and hospital based clinicians¹.
Table 1

Country	Recommended	Actual
UK	1: 62 500^x	1: 85 124^xi
Canada	1: 50 000	1: 61 734^xii
Australia	1: 50 000	1: 66 506^xiii
USA	1: 25 000 - 30 000	1: 31 250^xiv
New Zealand	(see below)	1: 274 146 (public)

There is no researched recommended figure for New Zealand. The Group’s recommendation is a minimum of 1 FTE: 100 000 of public dermatologists and is a higher ratio than other countries which reflects the amount of private practice in New Zealand.

Academic Dermatology

There is currently no academic department, or Professor of Dermatology in New Zealand.