Dermatology Workforce Service Forecast

Workforce

Dermatology consultants

As seen from Figure 2 (page 12) nowhere in New Zealand does the ratio of public dermatologists to population, reach the proposed figure of a minimum of 1 FTE: 100 000. An increase of 30 dermatologists working in the public sector is required to achieve this target by 2020.

There should be at least three dermatologists in every DHB, who may be part-time. This would allow adequate cover during times of leave, as well as providing collegiality, which would ensure better care of patients.
There must be allowance in their contracts for teaching registrars, GPs and nurses, and other health professionals.
Subspecialties

Establishing national or regional subspecialty tertiary services could enhance the general quality of dermatological care across the country. Having different dermatologists or teams head up subspecialty services would support dermatologists working in isolation and would promote audit and research in different fields. This would provide pathways for dermatologists to send difficult patients to, or to have a virtual consultation for advice for example, from a lymphoma expert, photobiology unit, vulval expert or to send slides to a dermopathology expert. To establish these tertiary services and have them adequately resourced, would require the support of all DHBs and leadership at a national level.

Academic Dermatology

Establishing a dedicated academic unit, the National Centre for Expertise in Dermatology, would allow for advancements in understanding of skin conditions in the New Zealand context and would enhance knowledge and understanding, skill levels and patient outcomes.

As with other specialties, it is important that we undertake high quality research to investigate New Zealand specific dermatological issues. This ultimately leads to improved medical care. In addition our dermatology trainees require some training in research. By 2020 we would hope to have an academic unit in place somewhere in New Zealand with a Professor or Senior Lecturer to head up the dermatological research and supervise more junior researchers.
Dermatology Registrars

As of November 2013, there are five training positions over three sites in New Zealand. There are 14 New Zealand dermatology trainees (one half of whom are currently overseas finishing their training). There is limited opportunity for public dermatology positions when they complete their training and return to New Zealand.

There needs to be career pathways into public hospital provision and increased training placements for dermatology trainees, and at the end of training there must be hospital positions available for them. As at November 2013, there are no advertised vacancies in New Zealand for hospital dermatologists, despite the growing need for more dermatology services in public.
Previously advertised posts have not been filled, as they have been a singlehanded position of 0.5 FTE. This type of post is not appropriate or attractive for a junior consultant, where a collegial, supportive team is the ideal, as would be achieved through adopting the recommendations below.
Because, at present, training for FRACP in Dermatology requires two years to be spent in an overseas post, HWNZ needs to consider funding this overseas training and then bond the workforce to come back to New Zealand as specialists – and needs to ensure that there are posts available.
The development of a New Zealand based Centre of Expertise in Dermatology could provide more opportunities for New Zealand based training and could reduce the need for going overseas to one year. Gaining overseas experiences in sub-specialisms is seen as very valuable, not only to the consultant themselves, but to the dermatology service as a whole.
Dermatologists also need to have clear work plans, that are reflected in their contracts, which are drawn up to allow for outpatient clinics and inpatient and/or outreach clinics where needed. In addition, to run effective consultant-led teams, there needs to be time available for their own professional development, providing collegial support for other dermatologists (particularly those working in isolation) and teaching opportunities for GPS, nurses and other health professionals.
Dermatology nursing

It is recognised that nurses can play a vital role in the delivery of dermatology and should be a part of all consultant-led teams. Dermatology nursing roles can include providing education and health promotion advice, organising clinics and multidisciplinary teams and observing inpatients. Providing better education for specialist nurses, including training to perform minor procedures such as skin biopsies and diathermy, would also help to improve accessibility and reduce waiting times.

Dermatology trained nurses should be employed at all dermatology clinics and in wards in hospitals where dermatology patients are treated. These nurses could act as nurse educators for generalist nurses. Ideally dermatology inpatients should be nursed in a dermatology ward. If this is not possible, then nurses with dermatology training or at least with assistance from dermatology nurse specialists, should care for inpatients.
Skilled dermatology nurses also administer phototherapy, perform skin biopsies, provide a range of treatments for day stay patients, observe inpatients and support patients and their families. Nurse-led clinics for education such as paediatric eczema management or monitoring of systemic medications are also supported. In addition, nurses must be supported by administration staff (see below) to enable them to concentrate on nursing.
There is currently no defined role, standards, definition or qualifications available to nurses who would like to further their career in dermatology in New Zealand. Figure 2 shows that only three DHBs currently have dedicated Dermatology nursing staff. Following the lead of the Dermatology Nurse Education Australia, professional courses could be developed through interaction with the Nursing Council of New Zealand and academic institutions.
Providing a career pathway in dermatology nursing would benefit the whole model, supporting and being trained as part of consultant-led teams and gaining relevant qualifications, responsibilities and skills would help to ensure that each member of the team could perform the tasks that only they are able to perform, thus maximising the resource available. Including dermatology nurses in GP practices is also seen as adding huge value to the service.
In addition, ensuring that the undergraduate-nursing programme for all nurses has a significant dermatology component is essential.
General Practitioners

From the information provided above, it is clear that GPs are seeing, treating and managing a high proportion of the community with skin conditions. Referral pathways to dermatology services are not always clear and, due to the limited provision currently available, are sometimes insufficient to provide timely access to secondary care. Improved communication with specialists (dermatologists and plastic surgeons) would ensure timely outpatient management of skin neoplasms.

Other countries, such as the UK, are supporting the development of GPs with a Special Interest in Dermatology. In the New Zealand context, however, this was not seen as the best way forward. Rather than having a few GPs with a higher skill level, it was felt as more useful if all GPs had an increased level of training in dermatology and in particular, in the management of skin cancer. By linking GPs into consultant-led DHB based teams and by consultants working with GPs in community-based clinics, GPs can have better access to more dermatology clinical time. Improving GPs competency and knowledge of dermatological conditions and treatments, should result in reduced referrals. In addition, it will improve the quality of consultations and advice given to patients.
There is also a need for the development of guidelines and standards for GPs for the management of skin disorders and skin lesions, for example the UK NICE guidelines for psoriasis and childhood eczema, or New Zealand specific guidelines could be prepared. Referral pathways, both for inpatients and outpatients need to be clearly defined, which could be developed at a national level or by individual consultant led teams and involving GPs.
GPs would also benefit from the Centre of Expertise in Dermatology, which could link with the College of GPs to enhance postgraduate training in dermatology and develop continuing professional development modules as required. Providing a GP biopsy service funded by the DHBs would reduce delays in diagnosis of skin lesions and dermatoses.

Other surgical specialities including: Plastic Surgery, General Surgery, Head and Neck surgery and Ophthalmology

While dermatologists and dermatological surgeons play a major role in the diagnosis and management of skin cancer the surgical specialities have an important role particularly in the advanced stages of the disease. Currently each DHB has a different pathway for skin cancer. In some centres, cases are seen first by plastic surgeons in secondary care but in other DHBs dermatologists are the initial service for patients referred by GPs.  

Dermatologists usually excise most lesions but will if necessary refer to plastic surgeons for complicated cases requiring skill and expertise beyond their scope. Examples include:

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  Plastic surgery for complex reconstruction and large flap repairs.
  

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  General surgery for advanced melanoma and sentinel node biopsy
  
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  Ophthalmology for reconstruction of surgical defects around the eye.
  

There needs to be closer relationships between dermatologists and surgical colleagues and clear referral pathways and guidelines for the more complex cases. This can be achieved with regular multidisciplinary clinics, (including plastic surgeons and general surgeons), for discussion of diagnosis, and treatment options in these complex cases with the primary goal of deciding the best outcome for the patient diagnosed with a skin cancer.

Psychological services

Many dermatology patients have psychological distress because of their skin disorders, whether this is a congenital lesion or an acquired lesion or dermatosis. Other patients have skin diseases that are the direct result of stress or indicate a serious underlying psychiatric disorder. Currently there is no direct access to these services within DHBs.

Having psychological support available to the dermatology team would provide the patients with a holistic treatment plan that leads to better outcomes.
Pharmacists

Pharmacists are the first port of call for many common skin conditions. In order to ensure quality health care, the information provided by pharmacists about treatment regimes and prescribed medicines needs to be informed and accurate. Pharmacists should be knowledgeable about when to refer and to whom and these pathways need to be kept current.

Providing pharmacists with continuing professional development in dermatology to increase knowledge was supported and could be part of the consultant-led education programme.
The new role of Clinical Pharmacist Prescriber was not seen as appropriate for dermatology due to the complexity of diagnosis of skin conditions.
Administration

Providing a good level of administrative support for the consultant-led teams, including dermatology nurses, will again increase the amount of time available to the health professionals for seeing patients and providing the support and education identified above. Administrative and clerical staff need to be an integral part of the dermatology team.