Dermatology Workforce Service Forecast

The vision for Dermatology in 2020

The Group’s vision for dermatology in New Zealand in 2020

‘is that patients will have equitable access to an integrated, consultant-led dermatology service that delivers high-quality health care’.
The proposed model of service delivery is based on providing the right treatment, by the right person, at the right time and in the right place.
Given the current numbers of dermatologists, the predicted increase in demand for services, not only for skin cancer diagnosis and treatment but also for other skin conditions, it is unrealistic to expect that the current workforce and model will meet this demand.
Developing consultant-led teams, who work collaboratively to offer diagnosis and treatment, utilising the skills of other health professionals, including nursing staff and GPs will be vital to being able to meet demands in a timely way.
An integrated, consultant-led service would be DHB based and centred on an outpatient service, but with inpatient consults. There would be specialised inpatient treatment for patients requiring this, for example, very severe eczema, psoriasis or blistering disorders. Registrars would be part of this service in larger centres. Dermatology nurses would be an integral part of the team, together with pharmacists, psychologists and other allied health professionals.

Model showing core services provided at each level
The proposed model of service delivery in 2020



*Regional: 5 regions – Northland/Auckland, Mid-Central, Wellington Region, Northern and Southern South Island

National Centre for Dermatology Expertise

In addition to the service model described above, there is a need for a tertiary level national Centre for Dermatology Expertise in New Zealand. This would provide opportunities for academic leadership, training, research and education. In addition, the Centre could provide opportunities for a tertiary referral service for paediatrics and hard to manage conditions.

Discussion

Based on the personal experiences and research knowledge of the Group, internet and literature searches were carried out to provide information on current dermatology workforce and service provision in New Zealand and overseas. These can be found at Appendix 2.

All the dermatologists on the Group have experience of working in the UK and it was acknowledged that a significant amount of work has been done there in relation to dermatology service provision, the development of standards and guidelines and in nursing training and practice.
This literature was discussed and analysed to help formulate the best model of care for dermatology in New Zealand in 2020.
In addition, the Group tabled a number of patient journeys that describe current experience and illustrate issues with service provision and the solutions that the proposed service model would provide as illustrated in Appendix 3.

Dermatology service in New Zealand

It is clear that currently, public dermatology in New Zealand is very under-resourced not only in terms of the workforce, but also in the range of services and treatment options available to the people of New Zealand. The service needs to expand to address current unmet need, long waiting lists and predicted increased demand, as well as providing equity of access and service across the country.

It is acknowledged that private dermatology services are available in most centres and have a role in reducing the pressure on the public system. However, these can only be accessed by those who are insured or who can afford to pay for the services. It is also not suited to managing complex conditions.
With numbers of patients with skin cancers already at the highest rate in the world and increasing, combined with an ageing population and Ministry of Health outcomes of better, sooner, more convenient health care, the need for accessible, quality dermatology is only going to increase. There is an increase in medical dermatology and complex cases, for example an increase in organ transplantation and immunosuppression and the use of biologic agents.
By constructing the pyramid model described above, an efficient, accessible service will be provided, adequately resourced to deliver quality health care in appropriate settings.

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  High cost treatment options for complex and rare conditions will be provided at a national level.
  
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  Regional services will provide the next tier of treatment options, reducing travel for patients and maximising the skills of those in regional centres.
  
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  Consultant-led teams within DHBs will provide a wide range of treatments, working closely with the PHO/GP tier to provide an integrated service for patients, while supporting and developing skills.
  
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  Underpinning the model is the proposed Centre of Expertise in Dermatology, which will provide New Zealand focussed training, research and academic excellence to enhance the current workforce.
  

Providing adequately resourced, dermatologist-led, integrated teams in all DHBs will ensure a solid foundation for the dermatology workforce and service in 2020. Adequate resourcing will allow dermatologists not only to run outpatient clinics but also to provide inpatient services as required. In addition, dermatologists will be able to provide education for trainees, GPs, nurses, pharmacists and other health professionals to support outreach and teledermatology services if required. Multidisciplinary teams (linking primary and secondary) provide collegial support, opportunities for collaborative patient management and treatment plans, education and training and a holistic health care approach for patients.

Developing a ‘hub and spoke’ approach to delivery, not only in rural areas, but also in Auckland, is seen as good model for an accessible and effective multi-disciplinary approach. The Counties Manukau ‘Localities’ programme is seen as a good model for this.
There is a lack of an academic unit in New Zealand. Unlike most other medical and surgical specialties, dermatology is lacking the research opportunities and leadership that this would provide. Currently there is a 2/10^th paid position for academic dermatology research and teaching in Auckland and two honorary posts at Auckland University. The University of Otago in Christchurch also has 3/10^th paid teaching positions for senior lecturers.
New Zealand lags behind other countries in the development of standards, guidelines and pathways for dermatology. The Ministry of Health Tumour Standards currently being developed, and which include melanoma, are a starting point, but the high levels of non-melanoma skin cancers are not included in this. There is a place for developing national standards and guidelines for non-melanoma skin cancer and other common dermatoses. Existing guidelines, such as those produced by the British Association of Dermatologists could be a useful starting point.