Phototherapy
1. 35 yr old male with psoriasis. Phototherapy treatment recommended. Workplace not flexible and early time slots already taken. Delayed treatment, condition worse and systemic treatment offered instead.
2. 45yr old woman in Blenheim, nearest phototherapy service Nelson, therefore 3x per week not feasible. Condition deteriorates and patient approved for expensive biologic treatment instead.
3. 25yr old single mother with 3 children unable to attend 3x per week due to lack of transport and childcare. Continues to use inadequate topical treatment.
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Phototherapy needs to be accessible at convenient times. 3x per week for maximum benefit.
Needs to be accessible, provide childcare, parking and fast turn around time to minimise time from work or childcare.
Limited service provision across S.Island at Dunedin, Christchurch and Nelson.
Relatively cheap and successful treatment not accessible to all patients therefore increasing alternative drug use and reducing outcomes for patients.
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Increasing phototherapy provision – provision at all DHBs.
Extended hours for providing phototherapy treatment to allow treatment early and late.
Provision of childcare facilities.
More trained nurses to provide the service.
In remote areas, provision of portable lamps for the duration of treatment.
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Patients can access treatment at times to suit their lives and maximise treatment programmes.
Phototherapy is a safe treatment but currently requires medical specialist to be available.
Could be part of day stay unit and combined with other treatments.
Nurses/technicians trained to deliver phototherapy, therefore freeing up Dermatologists to provide other services.
Costs involved would be offset by reduced use of conventional systemic drugs and biologic agents (drug costs, side-effects, repeated visits to health professionals).
Home phototherapy can increase delivery for patients in remote areas.
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2. Elderly patient (96yrs) with skin cancer.
Referred 4 times over a year. Communication problems led to patient declining surgery as thought treatment was as inpatient.
Delays in getting first appointment.
Could not afford to have surgery done privately.
Funding of GPs not adequate to deliver excision of lesions.
GPs unsure of referral pathways to Dermatology or Plastic Surgery for skin lesions.
Is Dermatology providing surgical expertise as well as diagnosis and management?
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Lack of communication to allow patient to make informed choice.
Lack of clear referral pathway.
Options for inpatient treatment while patient in hospital with another condition not explored.
Delays caused by inaccessibility
Currently faster response time if GP refers to Plastic Surgery (Counties Manukau) rather than Dermatology in Auckland.
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More Dermatology FTE to improve access to clinics.
Provision of virtual clinics (teledermatology) and outreach clinics to improve access.
Integrated approach to respond to GP referral based on what is best for the patient.
Better communication between multidisciplinary teams.
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Patient seen and treated in a timely way.
Patient able to make informed decisions based on detailed discussion of options.
Access to services increased through use of technology and outreach clinics.
Publicly funded Dermatology provision matches community needs.
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3. Skin Cancer cases
a) High risk skin cancer patient – 65 yrs – with history of ischaemic cardiac disease. 3 previous BCC excisions. Lesion on cheek. Requires careful assessment on the correct management and reconstruction.
b) 35yr old with history of melanoma. Mother died of melanoma at 55. Presenting with irregular mole.
Requires Dermatological assessment and excision and on-going surveillance and skin care education.
c) 85yr old man with rapidly enlarging lesion on leg. Needs help with daily living in rest home. Has range of co-morbidities. Requires consideration of pre-morbid state and available treatment options. Increased risks of skin breakdown and poor healing.
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Need to have a Dermatologist review the lesion – limited access due to low numbers in public sector.
Lack of standards for treatment – Melanoma Guidelines due out shortly but not for NMSC.
Lack of multidisciplinary teams.
Lack of audit and review of cases, treatment and outcomes.
Lack of training for GPs both during pre-registration training and on-going professional development.
Lack of community based follow up post surgery.
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Multidisciplinary team, including Dermatologist, in every DHB for skin cancer with national standards applied.
Community teams to provide on-going care and rehabilitation when required, supported by PHOs.
Hospital based skin cancer clinics held with multidisciplinary team diagnosing and developing management plan.
Record all tumours and outcomes.
Hold morbidity meetings.
Provide more training for GPs – include 3 month session as dermatology registrar in training.
More time for teaching for Dermatologists
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Patients are seen early and have multidisciplinary approach to treatment.
GPs better trained and involved at team level.
Standards of care are provided and audited across New Zealand.
Records of all cases are available for review and audit, including photographs.
Patients have access to range of options to ensure best outcomes.
Multidisciplinary teams provide collegial support, training and educational opportunities.
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4. Paediatric patient
7yr old with extensive psoriasis. Topical treatment not successful Being teased and afraid of going swimming. 6 month wait for specialist appointment at paediatric service. Ended up at adult clinic where found that condition had deteriorated and spread. Advice from GP led to insufficient topical treatment and no diagnosis of secondary infection.
Change of medication and appropriate advice led to significant improvement in psoriasis and also in quality of life.
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Insufficient funding for paediatric Dermatology leading to long waiting times.
Right treatment provided by GP but inadequate and incorrect advice on how to use it.
Length of consultation time with GP very short compared to time with Dermatologist.
Very rare to have nursing input at GP practice to provide education.
Education of patients/caregivers vital to successful management of conditions.
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Faster referral time to see specialist in correct clinic (ie Paediatric).
Better information provided by nurses at clinics.
Longer time spent with health professionals as administrative tasks are carried out by other staff.
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Nurses able to spend longer with patients explaining how to use treatments for maximum benefit.
Longer appointment times lead to more informed patients.
Better education for GPs and nurses and clear referral pathways lead to better provision of services.
Increased training for pharmacists will enhance the management of a range of skin conditions.
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5. Patch testing
Young female hairdresser with hand dermatitis. Lots of time off work due to severe eczema.
Dermatologist recommended comprehensive patch testing but access to this is limited. Costs of this could be covered by ACC.
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Limited access to patch testing in New Zealand.
Patch testing is resource intensive.
Guidelines for patch testing exist in other countries, e.g. UK, but not currently in NEW ZEALAND.
Lack of data recorded on incidence and outcomes and no audits carried out.
Access to Contact Dermatology and Occupational Dermatology very limited in New Zealand.
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Patch testing available in timely way for identification of allergens and appropriate treatment and plan developed.
Reduced time off work.
Better informed to make decisions.
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Patient can be diagnosed accurately and continue in employment.
Data on patch testing will be available for audit and review, leading to better understanding.
Bank of allergens can be centrally held and distributed to regions as required.
Standards of care maintained through Dermatologist led service, regular training and review processes.
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