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Improving dermatology services in primary care

Polly Buchanan
RGN BSc(Hons) RM ONC DipN
Consultant Nurse
Department of Dermatology
Salisbury Health Care NHS Trust
E:polly.buchanan@salisbury.nhs.uk

The government recognises that specialist dermatology services are not currently meeting the needs of our patients.(2) This has been reflected in the waiting list data, availability of services and provision of services.(3) The waiting times for a patient to see a consultant dermatologist are in excess of national standards. There also appears to be great disparity in the availability and provision of dermatology services throughout the UK.(4)
To address these issues, the Department of Health's Modernisation Agency implemented an "Action-On" programme for dermatology.(5) This initiative has been specifically aimed at improving dermatology services in primary and secondary care. Capital money has been made available to healthcare trusts to improve existing facilities and services. Pilot projects have been established to evaluate the most appropriate and effective strategy to deliver dermatology services in primary care.

Models of dermatology care provision
Models of provision include nurse-led primary care clinics for atopic eczema and other chronic inflammatory skin conditions, GPs with a special interest in dermatology (GPSI) clinics, and consultant dermatologist outreach clinics in primary care. The main aim of these initiatives is to provide specialist dermatology services for the local community and meet government targets.(6) The anticipated results are: effective and appropriate treatment at first consultation; new and improved services; improved access to services for patients; more appropriate referral to secondary care services; and reduction in waiting times to see a consultant dermatologist.

Dermatology nursing perspectives in primary care
There is no doubt that the emphasis on managing atopic eczema effectively lies in improving dermatology services in primary care.(7) This has major ramifications for all primary care nurses, as specialist education and training will be required to develop the knowledge and skills to care for patients with atopic eczema.(8)
One strategy already employed is the development of the primary care dermatology nurse. This model of provision has proved the most successful to date and is adaptable to the local needs of the community and healthcare providers through liaison roles, expert practitioner roles, nurse specialist roles and consultant nurse roles.
The philosophy underpinning the model is one of prevention and holism. The specialist knowledge and skills directly benefit patients through a nursing approach that aims to empower patients and carers to make decisions about management in partnership with professionals. This is fundamental to health promotion or disease prevention for chronic relapsing skin conditions such as eczema. This approach enables the carers (both formal and informal) to be proactive in management, thereby reducing the severity and frequency of acute exacerbations of the disease.
Another key component of the role is dissemination of knowledge and skills to primary care colleagues. The long-term strategy is for primary care nurses to work autonomously in dermatology nurse-led clinics. This requires support and education and can be provided through liaison with secondary care services, mentorship programmes and academic study. Planning improvements in primary care services requires a multidisciplinary approach across all trusts and a shared vision that will ensure the most appropriate care is provided by the most appropriate person in the most appropriate place.

Demonstrating health outcomes

Appropriately trained primary care nurses can positively influence the health outcomes for patients with atopic
eczema. This can be achieved in two main ways:

A pragmatic approach to care
Managing atopic eczema requires patience, skill and understanding. A family-centred approach is essential, and
long-term commitment to the family must be openly discussed.
Demonstration of techniques represents the single most effective means of teaching carers how to apply topical medications. Attempts at describing how to apply topical medications are futile and will result in confusion, frustration and disillusionment. Demonstration of techniques such as application of emollients, application of treatment creams and application of dressings/bandages takes time. It is estimated that the appropriate allocated time dedicated to a demonstration session should be one hour. This represents one hour of nursing time for clarifying, demonstrating and educating carers how to manage the physical aspects of the condition. This strategy of demonstration is strongly recommended and is essential if health outcomes are to improve.
The benefits of implementing a nurse-led clinic that facilitates demonstration of techniques are:

  • An increased and more effective use of emollients
  • Carers demonstrate a greater understanding of different types of emollients and their application.
  • Carers demonstrate a deeper understanding of the anti-inflammatory agents (topical corticosteroids and topical immunomodulators) used to treat eczema.
  • Carers demonstrate a confidence in application of anti-inflammatory agents on the skin.
  • Carers demonstrate a greater understanding of complications associated with atopic eczema and recognise the early signs of infection.
  • Carers demonstrate a clear understanding of how to manage complications such as infected eczema.

The health outcomes will be:

  • Fewer, less severe acute exacerbations of eczema with severe itch and scratch.
  • Fewer episodes of infected eczema.
  • Better-controlled skin condition through emollient maintenance programmes.

The impact on pharmacy costs will also be positive. The development of nurse prescribing will facilitate greater flexibility for patients.(9) The most appropriate topical medications will be effective following the initial consultation, thus reducing long-term pharmacy costs. Also, a well-supported emollient therapy programme is steroid sparing for the patient and prescriber, which can further reduce pharmacy costs.

A supportive-educative approach to care
The main carer of the child with atopic eczema (usually the mother) needs support and understanding in dealing with the emotional aspects of the condition. Atopic eczema affects every aspect of the child's life, including the physical, emotional, psychological and social aspects.(10) Family members are all touched by the consequences of this disease and relationships are affected within the family between all members. Psychological morbidity associated with atopic eczema is rare but can be profound for the mother of a child with atopic eczema.(11) This is often manifest as stress, relationship problems, anxiety and depression. The constant itch and scratch associated with atopic eczema can cause sleep deprivation for both child and mother (or parents). Loss of sleep over a few days is manageable; however, some patients and carers living with atopic eczema suffer sleep deprivation for many months or years. The distress of being unable to stop the scratch-itch cycle can be overwhelming at times for the mother, leading to exhaustion, irritability and depression. The child may exhibit the stresses of living with eczema as irritability, behavioural disturbances and hyperactivity. All in all, life with atopic eczema is not easy or simple for carers. The chronicity of the condition, which is interspaced with acute exacerbations in the early years, makes it difficult for mothers to see any long-term improvement. Undoubtedly, the primary care nurse skilled in dealing with such cases can provide the support and guidance required. Knowledge of support agencies and health professionals who can help in times of need is vital.
A deep understanding of how the carer feels and knowledge of specific strategies to help alleviate feelings of helplessness that are expressed by mothers are essential. This requires counselling skills. Recognising that the mother is caring for the child to the best of her ability is frequently forgotten but is so important for the mother to hear. This type of reassurance provides the mother with the confidence required to care for a child with eczema.
The nature of the disease, especially the unrelenting itch, compounds problems for patients and carers. If itch is present, scratch cannot be avoided and is recognised as a normal physiological response.(12) Itch associated with eczema is often described as deep, generalised and unrelenting. Normal scratching behaviour does not adequately relieve the itch, so the scratching becomes aggressive and intense, causing trauma to the skin. This results in widespread excoriations, which act as portals of entry for pathogenic organisms, which colonise the skin in larger numbers.(13)
Support, education and demonstration of behaviour modification techniques have proved useful in the management of scratching behaviour.(14) Alternative behaviours, such as rubbing and patting, can be taught to help relieve itch without damaging the skin through scratch. Behaviour modification programmes are a valuable adjunct to orthodox management and within the realms of primary care dermatology clinics. Dedicated atopic eczema clinics in the community that provide physical care, support and education for carers can be further complemented by cognitive-behavioural therapies.
The health outcomes from these types of nursing interventions are: increased self-efficacy for carers due to increased knowledge, understanding, confidence and control; improved sleep patterns for child and parents; greater use of active positive coping strategies; greater satisfaction and quality of life; and perceived partnership in care between parents and health professionals.
It is clear that the dermatology nursing service in primary care would benefit patients and families with atopic eczema. These benefits can be measured in terms of disease severity, associated morbidity, availability of services, and accessibility to specialist nursing care.

Clinical governance agenda
Benefits are also perceived for healthcare providers and policymakers as we strive to reach government targets through clinical governance agendas. Implementing a primary care dermatology nursing service will assist in meeting these agendas by: improving nursing standards of care in the community; ensuring appropriately trained nurses deliver the most appropriate care in the most appropriate facilities; ensuring more appropriate referral to, and use of, secondary care services; facilitating audit of dermatology services; ensuring the most appropriate and cost-effective topical treatment regimens.
 
Conclusion
To establish nurse-led primary care atopic eczema clinics a combined approach to policy and practice development is required that will include integrated care pathways across trusts with increased liaison and nurse prescribing. There still remains one area of uncertainty - that of funding service developments. Despite increasing evidence to support nurse-led atopic eczema clinics in the community, only a few Primary Care Trusts actively support such initiatives.15,16 Without dedicated and continued funding from PCTs, the clinical governance agenda for dermatology services will not be achievable. More published evidence demonstrating efficacy is required to support these initiatives and convince PCTs of their value in the community.

References

  1. Williams HC. Dermatology: health care needs assessment: the ­epidemiologically-based health need assessment reviews. 2nd series. Oxford: Radcliffe Medical Press; 1997. p. 26-7.
  2. DoH. The NHS plan. London: The Stationary Office; 2000.
  3. Associate Parliamentary Group on Skin. Report on the enquiry into primary care ­dermatology services. London: APGS; 2002.
  4. All Party Parliamentary Group on Skin. An investigation into the adequacy of service provision and treatment for patients with skin diseases in the UK. London: APPGS; 1997.
  5. Evans N. Br J Dermatol Nurs 2001;5(2):6.
  6. Dermatological Care Working Group. Assessment of best practice for dermatology services in primary care. London: Ash Communications Healthcare; 2001.
  7. Lawton S. Dermatol Pract 2000;7(6):12-13.
  8. Smoker AL. Br J Dermatol Nurs 1999;3(2):5-7.
  9. Courtenay M. Nursing Times (NTPlus supplement) 2002;98(30):53-4.
  10. Armstrong-Brown S. The eczema solution. London: Vermilion; 2002.
  11. Titman P. Br J Dermatol Nurs 2001;5(4):7-9.
  12. Atherton D. Eczema in childhood: the facts. Oxford: Oxford University Press; 1994. p. 20-3.
  13. Williams REA. Bacterial adherence. In: Lever R, Levy J, editors. The bacteriology of eczema. London: RSM Press;1995. p. 13-5.
  14. Bridget C, Noren P, Staughton R. Atopic skin disease: a manual for ­practitioners. Petersfield: Wrightson Biomedical Publishing Ltd; 1996.
  15. Mateos M. Dermatol Nurs 2002;1(4):6-8.
  16. BAD/BDNG Annual Conference. Conference proceedings. Edinburgh; July 2002.

Resources
National Eczema Society
Hill House
London N19 5NA
T:020 7281 3553
F:020 7281 6395
Eczema Information Line:
0870 2413604
W:www.eczema.org

National Health Service Modernisation Agency
W:www.modernnhs.nhs.uk

Primary Care Dermatology Society
PO Box 6
Princes Risborough
Bucks HP27 9XD
T:01844 276271

Further reading

Atherton D. Eczema in ­childhood: the facts. Oxford: Oxford University Press; 1994
Bridget C, Noren P, Staughton R. Atopic skin disease: a manual for practitioners. Petersfield: Wrightson Biomedical
Publishing Ltd; 1996
Hughes E, Van Onsalen J. Dermatology nursing. London: Churchill Livingstone; 2001