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2 Specialties DermatologyDermatology Clinical Trials Network has over 600members. Academic dermatologists contribute to NHSwork by setting up tertiary services, and leading UKdermatology education and research. The second largestcharity for dermatology research, the British SkinFoundation, is funded and supported by the BAD,which has also set up, in 2012, a network fortranslational dermatology research. The NIHRDermatology Specialty Group is being reorganised in2013 and supports delivery of clinical dermatologyresearch studies on the NICE research portfolio.Local management rolesDermatologists have multiple roles, leading clinicalareas such as paediatric dermatology or patch testingand being responsible for registrar training orundergraduate teaching, audit and clinical governance.They also may be MDT chair or clinical service lead.Regional and national workMedical representation is essential on local, regionaland national committees, and for national, professionalor governmental bodies such as the DH, GMC, SAC, theRCP and the British Medical Association (BMA). TheBAD has elected officers and committees that contributesubstantially to national policy. Appropriate timeshould be allocated in the work programme for theseimportant roles if the NHS is to function efficiently.The British Journal of Dermatology and Clinical andExperimental Dermatology, essential for servicedevelopment and CPD, are run by the BAD, witheditorial work and paper reviews undertaken by UKdermatologists.National guidelinesNational guidelines are produced by dermatologists andlisted on www.bad.org.uk,badgedbyNHSEvidence.Dermatologists contribute to NICE appraisals andguidelines and NHS ‘Clinical knowledge summaries’.Audits, quality tools and frameworksAll dermatologists participate in local, regional andnational audit programmes, and many help developquality tools and service frameworks.6 Clinical work of consultants indermatologyInpatient workIn many hospitals, dermatology care is moving from afixed ward base to multidisciplinary involvement withdermatology patients on multiple wards. This must bereflected in job plans, with inpatients also receivingexpert, dedicated dermatological nursing care. Ward rounds, leading and training a team includingregistrars, specialist nurses and students, usuallyoccur for dermatology inpatients twice weekly. Referral work. Urgent requests for dermatologicalopinions on acute admissions require review onward rounds. These frequently reduce length of stayin hospital.Outpatient and day-case workOutpatient and day-case work is the core work of mostdermatologists. The nature of these clinics and specialistprocedures varies considerably. General dermatology clinics: the ratio of new tofollow-up patients and time allocated varydepending on the type/complexity of the cases seen.On average 12–16 patients may be seen in a clinic. Inclinics teaching undergraduates, training registrars,or supervising doctors and nurses, numbers must bereduced accordingly. Skin cancer/‘see-and-treat’ clinics: variousmodelsareused. In screening clinics dermatologists see largernumbers of patients. See-and-treat clinics providesurgery on the first visit, reducing the numbers seen. Specialised clinics within dermatology includepaediatrics, skin allergy, photodermatology andgenital clinics. Complex case clinics: regions and large departmentshold multidisciplinary clinics weekly or monthly forcomplex cases. Surgery lists may include biopsies (often done bynurses), day-case skin surgery lists including Mohs’micrographic surgery and laser lists (requiring alaser-safe area and general anaesthetic facilities forchildren). Skin surgery will usually take 20 minutesfor a skin biopsy, 30 minutes for a simple excisionand 60–90 minutes for more complex flaps and graftrepairs. Micrographic surgery can take 90 minutes toseveral hours. These times do not include‘turnaround’ time between cases, which depends ontrained nursing support and efficiency.Specialist on callDermatology trainees require training in acute ‘on-call’dermatology. Patients with severe skin disease or skinfailure should have access to expert dermatologyadvice.C○ Royal College of Physicians 2013 85
Consultant physicians working with patientsOther specialist activitiesOther specialist activities include weekly 1–2 hour MDTcancer meetings reviewing cancer cases according to theNICE guidelines, cancer networks, case conferences andnationally commissioned specialist services.Clinically related administrationClinically related administration includes screening andprioritising referral letters, reviewing and acting uponlaboratory results and communicating with and aboutpatients with colleagues in writing, by telephone oremail. The time ratio between direct patient contactand clinical administration for dermatologistsis 1:0.4.TeledermatologyTeledermatology may be a useful triage tool forgeographically remote areas only as part of an integratedconsultant-led team subject to full clinical governance;there is no evidence that it can safely reduce referralsoutside this setting. 11 Quality standards forteledermatology have been produced in 2012–13 by amultistakeholder group, supported by the DH, to guidecommissioners. These standards should be available onthe Primary Care Commissioning website and onwww.bad.org.uk in 2013 (personal communication, JanMcLelland, honorary secretary, BAD).7 Opportunities for integrated care andcontinuityConsultant dermatologists are the most efficientproviders of skin care. Due to consultant shortages inthe UK, dermatology services work most efficiently asinterdisciplinary, consultant dermatologist-led teamsincluding SAS doctors, GPs and nurses (in secondaryand intermediate care). GPwSIs must comply with DHrules on training and governance. 168 Workforce requirements for the specialtyBased on government statistics for new patient referralsin 2009–10, a population of 250,000 generates 4,000new patients. 5 With a ratio of 1 new to 1.6 follow-uppatients achievable for general dermatology clinics (notcounting patients attending for patch testing,phototherapy, surgery and other specialist treatmentsthat should be separated and removed from thisstatistic), 17 6,400 follow-up patients would give 10,400patients per year in total.The recorded new to follow-up ratio in 2009–10 fordermatology in England was 1:2.1. 5 Commissionersusing current recording methods should expect thesefigures.Activities related to direct clinical care generateapproximately 0.4 PA (programmed activity) for eachclinic (Table 1). A 10-PA consultant should work 5 PAsin the clinic, operating theatre, seeing ward patients, etc,with 2 PAs of patient administration and 0.5 PA forMDT. A newly appointed consultant on 8.5 DCC and1.5 SPA (ie with no teaching, research and traineesupervision or department management) may do anextra 0.7 PA in clinic or operating (with an extra0.3 patient admin) initially pending job planningreview.A consultant with no travel to other centres, noinpatients, ward rounds or on call, no specialist clinics,no clinic teaching and no junior supervisory role shouldundertake2new,2follow-up(orequivalentmixedclinics) and 1 skin surgery clinic per 10-PA week. With12 new patients (20 minutes per consultation), 16follow-up cases (15 minutes per consultation) or up to 7surgical cases per clinic, 24 new patients, 32 follow-uppatients and 7 surgical procedures are seen per week.These are maximum numbers; actual numbers andnew:follow-up ratios vary according to casetype/complexity, with a ratio of 1:1.6 reported forpsoriasis. 18 People attending phototherapy, day care,treatment visits, surgery or investigations should notcount or be coded as follow-up cases. Intermediateservices take simple cases, resulting in more complexcases in secondary care adversely affecting new tofollow-up ratios.In an average 42-week year, a consultant will see 1,008new and 1,344 follow-up patients and perform 280operations. A population of 250,000, therefore, requires4 whole-time equivalent (WTE) consultants (ie oneconsultant per 62,500 based on DH 2009–10 figures).This does not allow for specialist clinics, teachingstudents, supervising or training any grade of staff, wardreferrals, inpatient care, on-call work, travel or MDTs.There were 655 (557 WTE) consultant dermatologists,213 WTE specialty registrars (equivalent to 44 WTEconsultants) and 157.3 WTE SAS doctors (equivalent to125 WTE consultants) in the 2012 UK BAD workforcesurvey, totalling approximately 726 WTE consultants.For the population of 61,800,000 6 the UK workforcerequirement for a consultant-led service is a minimum86 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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