Dermatology Workforce Service Forecast
Yüklə 271,59 Kb.
|
- Bu səhifədəki naviqasiya:
- Appendix 2 Examples from literature (New Zealand and overseas)
RecommendationsTo achieve the vision for dermatology in New Zealand in 2020 ‘that patients will have equitable access to an integrated, consultant-led dermatology service that delivers high-quality health care’, the Group proposes the following recommendations:
Appendix 1: Dermatology Workforce Service Forecast GroupDarion Rowan (Dermatologist, Counties Manukau DHB, Chair) Steven Lamb (Dermatologist, Auckland DHB) Deborah Greig (Dermatologist, Auckland DHB) Martin Keefe (Dermatologist, Nelson & Christchurch) Weng Chyn Chan (Dermatologist, Middlemore Hospital) Wee-ling Koo (GP, Cornwall Medical Centre, Auckland) Karen Agnew (Dermatologist, Auckland DHB) Ann Giles (Dermatology Staff Nurse, Greenlane Clinical Centre, Auckland) Barbara Graves (Project Manager) Appendix 2 Examples from literature (New Zealand and overseas)Workforce Dermatology (General) Several studies in the UK have identified issues similar to those currently being seen in New Zealand. In 2007, the Dermatology Workforce Groupxxiii noted that too many patients are attending hospital-based services and that any future model of care should concentrate on service delivery governed by three broad statements:
It was also noted that service models should be patient oriented and that correct diagnosis is the starting point for quality care. It was identified that primary care should take responsibility for straightforward management of long-term skin diseases and facilitate patient self-management. The educational role of secondary care should be acknowledged and developed and appropriate educational modules should be developed, to ensure knowledge and expertise of those in primary care. Multi-disciplinary teams to deliver Dermatology care were identified as central. In 2008, the Workforce Review Team reported on ‘Workforce Planning for Dermatology in the National Health Service’ xxiv(NHS, UK). Key points included the need for networked specialist teams to provide care delivery in hospital and community settings. The report also noted the aging Dermatology workforce and that little work on researching and planning for the Dermatology service has been carried out. Changes to delivery, including the increasing requirements for care in the community and changing GP practice, have led to the service being fragmented.
The 2009 ‘Health Care Needs Assessment of Skin Conditions in the UK’ xxviiprovides information on the burden of disease, quality of life data and direct economic costs. The range of available services is discussed along with the evidence of effectiveness of services. The Needs Assessment makes several recommendations including:
Early in 2013, the specialised services national definition of Specialised Dermatology Specialistsxxviii was commissioned. Specialised services are provided in the UK to serve populations of more than one million people and the definitions help with service reviews, planning and commissioning. This definition outlines the roles, workload, service delivery models and standards required to deliver high quality dermatology and again, emphasises the need for the correct diagnosis, adequate training and staff, multidisciplinary teams, services provided in the right place and at the right time, the need for standards and audits and the need for good communication across professional boundaries. Consultant Dermatologists As has been found in New Zealand, the UK has concerns over the future Dermatology workforce. The Royal College of Physicians Census on Dermatology – 2010xxix found that for the first time, female dermatologists outnumbered males, a trend likely to continue. It also found that dermatology has twice the proportion of consultants working less-than-whole-time (35.3%) than the mean value for all medical specialties. It was also noted that although vacancies still exist, numbers of consultant Dermatologists are rising and that Dermatologists work 50% over their contracted time for academic work. The lack of cohesive planning for the workforce was also highlighted. The revised 5th edition of ‘Consultant physicians working with patients’ in 2013xxx notes that Dermatology care is carried out most efficiently in the UK using a hospital-based team led by a consultant dermatologist, with Staff grade and Associate Specialist (SAS) doctors, GPs and nurses in secondary and integrated intermediate care. Multi-disciplinary teams in skin cancer clinics involve dermatologists, surgeons, histopathologists, oncologists, radiotherapists, nurses, and psychiatrists and psychologists. Combined clinics between dermatologists and hospital specialists exist for complex problems, e.g. involving rheumatology, plastic surgery, HIV, genital/oral diseases, psychiatry, paediatrics, genetics, stomas, eyes, vascular surgery and allergy. Dermatology Nursing The definition and scope of Dermatology nursing is not consistent, or even evident, in many countries. Through contact with the Dermatology Nursing Education Australia and the British Dermatological Nursing Group, it was found that both organisations are currently working on this. The UK has recently developed general competencies for nurses working in Dermatologyxxxi and is currently working on developing standards. They also carried out a workforce survey, which identified three key issues.
The Dermatology Nurses Association (USA) has a defined ‘Scope of practice’ and ‘Standards of Clinical Practice’. The scope of practice uses the framework of core, dimensions, boundaries and intersections to inform practitioners, educators, researchers and administrators as well as other health professionals and the public. The Standards of Clinical Practice are to provide definitive direction for the provision of care and professional role activities of dermatology nurses, through assessment, measurable outcomes and nursing interventions customized to meet the needs of the individual. Several UK reports highlight the importance of nursing in dermatology care delivery and the currently unmet potential of nurses to provide education to patients and other health professionals, to take on increased roles, to administer therapeutic regimes and to coordinate care. A solution to the lack of dermatologists worldwide was seen as providing effective delivery by nurses as part of multidisciplinary teams, community outreach and management and self-management of skin conditionsxxxii. Another report highlighted the integral role that nurse-led care provides to dermatological services and noted that nurses are currently providing treatment in a broad range of settings. Where nurses were involved, patients reported faster access to treatment, reduced referrals to GPs and increased knowledge of their condition. Again, the lack of educational opportunities for nurses was cited.xxxiii A questionnaire-based study of ‘The expanding role of nurses in surgery and prescribing in British Departments of dermatology’ xxxivfound an anticipated increase in nurse-run clinics and a wide variation in nurses prescribing and administering treatments. Obstacles to extending nursing roles were seen as opposition from administration or nursing hierarchies, funding and uncertainties from the nurse themselves. Dermatologists supported the development of increased roles, as long as they were provided with adequate training protocols and staff support. Advanced nursing roles, where nurses take on a range of procedures more commonly provided by other health professionals are outlined in several studies. The article ‘Biological Nurse Specialist: goodwill to good practice’xxxv notes that with additional training, the specialist nurse may take responsibility for a number of tasks in the patient pathway including screening, treatment administration, patient education, prescription coordination, patient monitoring and data collection. The report also notes that nurses trained to deliver increasingly widely used biologic therapies are of great benefit to patients and central to the operation of multi-disciplinary teams. However it is also noted that they need to have in-depth nursing knowledge built on a foundation of biologic therapy and disease activity. Two American papersxxxvi,xxxvii which considered the role of nurse practitioners in the assessment and referral of skin cancers, again highlighted a lack of measurement of barriers. A lack of time was cited as the most common barrier. Recognition and referral of skin lesions was inconsistent, but improved over time. There are few skin cancer training programmes available for Advanced Practice Nurses, but these need to be put in place to increase the skills needed and to enhance the role that nurses can take on in the assessment and management of skin cancers. General Practice In 2011, the Department of Health in the UK revised the NICE (National Institute for Health and Care Excellence) ‘Guidance and Competencies for the provision of services using GPs with Special Interests (GPwSIs): Dermatology and skin surgery’. xxxviiiThis framework was developed by a multi-disciplinary team including specialists, GPs and patients. It is designed to help dermatology GPwSIs understand and develop the extended knowledge and skills they require to provide services beyond the scope of their generalist roles. The Royal College of General Practitioners has developed accreditation based on this framework. The key points of these guidelines are that the training and development of GPwSIs will require the on-going support from Dermatology specialists. Improving diagnostic skills is essential, but the core activities of the GPwSis will depend on the resources and skills of the GP. The service would be required to be supported by suitable trained dermatology nursing, necessary facilities and equipment, links with dermatology and histopathology departments, administrative support and good record keeping, including photographs.
‘Implementing care closer to home: Convenient quality care for patients Part 3: The accreditation of GPs and Pharmacists with Special Interests Supporting Q&A (2007) and providing care for people with skin conditions: guidance and resources for commissioners’ (NHS Primary Care Commissioning 2008) In New Zealand, several regions are working on developing GPs with a special interest in skin lesions and/or developing skin lesion pathways. The skin lesion GP service in Otago has been running for approximately four years, and has seven trained GP practitioners. The service receives referrals from primary care, mostly for suspected skin cancers, and is contracted by Southern DHB to perform 350 procedures each year. Under this service, patients can still be referred to secondary care clinicians when required; however, because of referrer knowledge of the service, and the level of expertise and experience GPwSIs have developed, 99 percent of referrals are managed by the trained GPs. The service was reviewed in 2012.xxxix The benefits of the scheme are:
Key learnings are noted as:
In Christchurch the Canterbury Initiative have been running a programme for the last few years in which GPs are trained in skin surgery techniques by the plastic surgeons. Once accredited, they receive a subsidy to excise skin cancers from public patients who would not otherwise be able to afford treatment in primary care. Accredited GPs can take referrals from colleagues. The programme is carefully audited to make sure that most of the lesions excised are indeed skin cancers and that excisions are done satisfactorily. The scheme has proved popular and effective. A recent report released in the UK notes that, in the UK, ‘GPs with a special interest (GPwSI) in dermatology can provide effective intermediate care for individuals with chronic mild/moderate inflammatory diseases, skin infections, sun damage and certain skin cancers as part of an integrated consultant dermatologist-led team. There is no good evidence that these services reduce secondary care referrals or save money; they may ‘de-skill’ GP colleagues. There are detailed Department of Health safety, governance and training guidelines for the accreditation of GPwSIs, which some primary care trusts (PCTs) ignore, risking patient safety’.xl Pharmacists In many countries, including New Zealand, pharmacists can undertake continuing professional education on a range of subjects related to Dermatology. In 2013, in New Zealand, the Medicines (Designated Pharmacist Prescriber) Regulations 2013 was introduced in July 2013. This enabled the introduction of a scope of practice for pharmacist prescribers.
Under the Health Practitioners Competence Assurance Act 2003 the Pharmacy Council (the Council) must publish a description of the contents of the profession in terms of one or more scopes of practice. The Council has developed the competence and registration requirements for the Pharmacist Prescriber scope of practice. In this scope suitably qualified and trained pharmacists who are already working in a collaborative health team environment will be able to prescribe medicines. Dermatology is not currently listing as an area of practice.
In 2012, The British Association of Dermatologists and British Society for Paediatric Dermatology produced the ‘Working Party report on minimum standards for Paediatric Services’xli. The aim of this report was to provide a consensus statement for the provision of paediatric dermatology. Again, multidisciplinary teams were recommended, based in appropriate child-friendly facilities with high levels of information and choice for parents. In addition, basing the service on the needs of the child, rather than the child fitting in with the existing services was highlighted. Detailed information provided includes descriptions of services, pathways, referral management, staffing requirements and training, facilities, education, procedures, administration, prescribing and governance. Two New Zealand studies looked at children with specific dermatological conditionsxlii A longitudinal study of the prevalence of childhood eczema showed that it remains a significant problem, particularly for young Māori and Pacific New Zealanders in whom less recognition of eczema and poorer access to effective, sustained eczema management may be contributing factors. A study of serious skin conditions in the Tairawhiti region found that serious skin infections are an increasing problem for all New Zealand children, but incidence rates in the Tairawhiti region are consistently greater than average national trends, with significantly larger ethnic disparities. Teledermatology In the UK, ‘Quality Standards for Teledermatology’ xliiihave been produced. This document compares teledermatology to face-to-face consultations. Three levels of teledermatology are described – as a triage tool, as ‘full teledermatology’ where it is offered as an alternative to a face-to-face consultation and intermediate teledermatology – which combines both of these approaches. A case study in the UK in 2012xliv described a service that used teledermatology to avoid unnecessary referrals and improve the quality of care for patients usually seen in primary care settings. The study showed that the service was effective in preventing avoidable attendances at secondary care, delivered financial savings, reduced the time for patients to receive specialist opinion and was popular among GPs. The British Teledermatology Society describes teledermatology in the UK, shares best practice and provides educational opportunities and information on setting up services. In New Zealand, a Clinical Research Seminar with the title ‘Improving access and grading evaluations using in-depth teledermatology: image it trial’ found that:
Contact Dermatitis and Patch Testing In 2009, the British Association of Dermatologists produced an update to the ‘Guidelines for the management of Contact Dermatitis.’ xlv The recommendations in these guidelines are:
Minimum standards include; a lead dermatologist for the unit, who attends regular training, best practice guidelines being followed, electronic gathering of information with audits and up to date reference material. Skin Cancer A report to The Cancer Society of New Zealand in 2009 “The Costs of Skin Cancer to New Zealand’ notes that
Skin cancers fall into two types, Melanoma and Non Melanoma Skin Cancer (NMSC). In New Zealand, The Ministry of Health are about to launch Melanoma Tumour Standards as part of a wider tumour standards initiative, designed to:
Several regions of New Zealand are working to develop skin lesion pathways (Hawke’s Bay) and the Wellington Sub-region has an established Melanoma Multidisciplinary Team based at Hutt Hospital, with an established protocol for management of melanoma. In 2006, the NICE guidance ‘Improving Outcomes for People with Skin Tumours including Melanoma ‘(UK)xlvi on skin cancer services, outlines how healthcare services for people with skin tumours should be organised. The key recommendations include:
These guidelines were reviewed in 2010 when NICE published a partial update of this guidance. Recommendations and text relating to the management of low-risk basal cell carcinoma (BCCs) in the community have been removed from the 2006 guidance and replaced by 'Improving outcomes for people with skin tumours including melanoma (update): the management of low-risk basal cell carcinomas in the community'. An analysis of the potential economic impact of the guidelines was also produced in 2006, to illustrate the costs to service commissioners of providing the recommended services as per the guidelines. The ‘Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand’ xlviiproduced by the Cancer Council Australia, Australian Cancer Network and the Ministry of Health, New Zealand in 2008 recommends that:
Home Phototherapy Two articles in the British Medical Journal support the delivery of home-based phototherapy as a treatment option. An editorial in the British Medical Journal (BMJ)xlviii ‘Home UVB phototherapy for psoriasis’ refers to a pragmatic study that compares home UVB with outpatient UVB as part of normal clinical practice. The study highlights an important gap in the provision of treatment for patients with psoriasis. With new potent, but costly, biological treatments now widely available for moderate to severe psoriasis, it is timely to reassess conventional treatments such as UVB. It would be inappropriate for patients to receive these new and expensive treatments when the infrastructure to deliver well established cheaper treatments, such as UVB, is lacking. Dermatologists should reflect on the shortcomings of current phototherapy services, where many patients are excluded because they live too far from their local unit. The case for home provision of UVB phototherapy for psoriasis is most persuasive in sparsely populated areas. Experience in Germany, the US, the Netherlands, and Scotland confirms that it would be feasible and practical to implement home based UVB phototherapy. The study referred to in the editorial, Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study)xlix, found that Ultraviolet B phototherapy administered at home is equally safe and equally effective, both clinically and for quality of life, as ultraviolet B phototherapy administered in an outpatient setting. Furthermore, ultraviolet B phototherapy at home resulted in a lower burden of treatment and led to greater patient satisfaction. In the USA, the National Psoriasis Foundationl note that home phototherapy is an economical and convenient choice for many people. Like phototherapy in a clinic, it requires a consistent treatment schedule. Individuals are treated initially at a medical facility and then begin using a light unit at home. Yüklə 271,59 Kb. Dostları ilə paylaş:
|