Consultant physicians working with patients - Royal College of ...

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2 Specialties Dermatology run monitoring clinics for isotretinoin andbiologic/systemic treatments for inflammatory skindiseases.Tertiary care servicesThe UK has many national and international experts indermatology who provide services for complex cases.As of January 2011, national commissioned groupservices in England exist for: xeroderma pigmentosum,epidermolysis bullosa, Ehlers–Danlos syndrome,neurofibromatosis types 1 and 2, Fabry disease andcryopyrin diseases. The National Commissioning BoardDermatology Clinical Reference Group is developing, in2013, nationally commissioned networks of specialisedservices in over 20 areas of dermatology, which may becommissioned from April 2013 onwards. Proposals forthis service include virtual MDTs with referralsdelivered through a portal hosted by the BAD.Psychological servicesPeople with skin disorders often benefit frompsychological intervention, but services are oftenlimited by NHS financial restraints. The NICEguidelines for skin cancer care require psychologicalservices to be available for those with skin cancer.Community careCommunity pharmacists can reinforceself-care/self-help messages at the point of dispensingfor patients. People spent £413 million (18% ofover-the-counter (OTC) sales) on skin treatments in theUK in 2007. 1Camouflage services may be an integral part of care.Complementary servicesAlternative therapies lack evidence of efficacy and safetyand some (eg eastern herbal treatments) may containpotent corticosteroids or liver toxins.3 Working with patients: patient-centredcareEnsuring that the patient is at the centre of carePatient involvement and choiceInvolving patients in choice and decision-making abouttheir care has been improved by increasing consultationtimes with doctors and nurses and by providing qualityinformation such as BAD patient information leaflets(PILS) (available at www.bad.org.uk).Patient choice would be enhanced were information forpatients available, at the point of choice, about thequalifications, experience and accreditation of doctorsproviding services.Patient support groups and access to informationThe BAD recognises and supports 55 patient supportgroups (PSGs), providing links to their websites fromwww.bad.org.uk, where over 130 PILS on over 120conditions are available.Education and promoting self-care for acute andchronic skin diseasesInformation provided by PSGs is invaluable. The BADprovides ongoing support, including financial grants, tothe PSGs.Role of the expert patientThe Dermatology Councils for England, Scotland andWales represent multiple stakeholders including thePSGs. Patient and public involvement groups (PPIs)are active in many dermatology departments.4 Interspecialty and interdisciplinary liaisonDermatology care is carried out most efficiently in theUK using a hospital-based team led by a consultantdermatologist, with SAS doctors, GPs and nurses insecondary and integrated intermediate care.Multidisciplinary teams in skin cancer clinics involvedermatologists, surgeons, histopathologists,oncologists, radiotherapists, nurses, and psychiatristsand psychologists (see BAD and PsychodermatologyUK working party report on psycho-dermatology). 13Combined clinics between dermatologists and hospitalspecialists exist for complex problems, eg involvingrheumatology, plastic surgery, HIV, genital/oraldiseases, psychiatry, paediatrics, genetics, stomas, eyes,vascular surgery and allergy.5 Delivering a high-quality dermatologyserviceWhat is a high-quality service?A dermatology service should provide patient-centredcare focusing on outcomes that meet national standards.To achieve this, all staff must be correctly trained andaccredited and the local service structure should provideC○ Royal College of Physicians 2013 83
Consultant physicians working with patientsfacilities that enable safe and effective investigation andtreatment. A multi-stakeholder document, theproduction of which was supported by the DH Qualitystandards for dermatology, provides commissioners withguidance in commissioning high-quality dermatologyservices. 14 A high-quality service should follow andaudit compliance with national guidelines provided byNICE and the BAD, and should participate inBAD-facilitated and -hosted national audits.StaffingConsultant dermatologists should be on the specialistregister of the General Medical Council (GMC). Theyshould not work alone and must have appropriatesupport staff including specialist dermatology nursesand trained secretarial staff.Local facilities needed for dermatology patients 15The following local facilities are needed: dedicated outpatient units with rooms for patienteducation, breaking bad news and counselling areas for contact allergy testing with storage areas forallergens meeting national published standards surgical facilities meeting national standards forspace, cleanliness and equipment, with storage forliquid nitrogen laser-safe areas where required facilities for Mohs’ micrographic surgery whererequired, meeting national standards day-care centres staffed by dedicated dermatologynurses phototherapy units for adults and children staffed bytrained dermatology nurses who can also provideskin care (unlike physiotherapists), meeting nationalstandards for equipment and safety. Medicalphysicists should monitor ultraviolet (UV) output.A named consultant dermatologist should beresponsible for the service hospital beds staffed by trained specialistdermatology nurses with 24-hour medical care.Dermatology patients require a specialiseddermatology nurse to apply treatments and provideeducation, with adequate bathing and treatmentrooms. Inpatients should be geographically close tooutpatient units for maximal efficiency laboratory support including chemical pathology,haematology, radiology, microbiology, mycology,histopathology and immunopathology information technology (IT) hardware and softwarethat is robust, modern, reliable, fast, in the rightplace and immediately available medical photography services (eg for mole mappingand monitoring) comprehensive pharmacy services appropriate accommodation for paediatricdermatology clinics and inpatient care.Maintaining and improving quality of careDermatologists lead the team delivering clinicalservices, driving service developments/innovations toimprove patient outcomes.Education and trainingEducation and training of medical students, specialtyregistrars (StRs), GPs and nurses improve care forpatients with skin disease. Twenty per cent of GPconsultations relate to skin disease but only 20% of GPtraining schemes include dermatology. Medicalstudents, on average, receive approximately 6 days onlyof dermatology education. The BAD campaigns formore and better undergraduate and GP training indermatology. Consultants conduct assessments (such asmini-clinical evaluation exercise (mini-CEX), directobservationofproceduralskills(DOPs))fortraineedermatologists, SAS, and foundation year 1 and 2 (FY1and FY2) doctors and medical students. Entry todermatology training requires proficiency in coreinternal medical training, including passing the MRCPqualification. Trainee dermatologists follow a 4-yearcurriculum, overseen by the specialist advisorycommittee (SAC), encompassing all aspects ofdermatology.Mentoring and appraisal of medical and otherprofessional staffThe UK leads the world in development of specialistdermatology nurses.Continuing professional developmentDermatologists spend more than 50 hours per year oncontinuing professional development (CPD).Clinical governanceClinical governance meetings discussing outcomes andreviewing departmental data, audit, complaints, newguidelines, etc should be included in the workprogramme. Protected time should be allowed for local,regional and national audit.Research – clinical studies and basic scienceClinical and basic science research is essential to driveinnovation and improve outcomes. The UK84 C○ Royal College of Physicians 2013
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AcknowledgementsWe would like to th
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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1 Physicians in the NHS todaycan be
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