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Quality standards for dermatology: why do we need them?

Janet McLelland BSc MD FRCP
Consultant Dermatologist
Royal Victoria Infirmary
Newcastle upon Tyne

A multi-stakeholder group has produced a set of quality standards for dermatology: ‘Providing the right care for people with skin conditions'. But why do we need dermatology standards and how should we use them?

Studies suggest that over half of the UK population experiences a skin condition in any given year.¹ Most people self-care and many buy skin treatments over the counter, sometimes with the advice of the pharmacist. A total of £414m was spent on skin treatments in 2007 and this amount has been increasing steadily over time.

However, some people need to seek further medical advice, usually from the doctor or nurse in the community. Each year, 24% of the population presents to a GP with a skin problem, and skin disease is the most common disease in children, with one in five babies having eczema. Practice and district nurses spend a lot of their time managing patients with leg ulcers, skin infections and other skin diseases.

Skin problems are important
Skin diseases not only cause great discomfort but, because they are often visible, they can also affect people socially and psychologically. Quality of life of people with skin diseases such as psoriasis, atopic eczema and acne can be significantly impaired, and at times worse than that experienced by people with life-threatening conditions such as cancers. Skin conditions, particularly hand dermatitis, cause disability and loss of earnings, and some diseases can be serious. There were nearly 4,000 deaths due to skin disease in 2005, of which 1,817 were due to malignant melanoma.

A changing NHS
As we all know there has been a lot of NHS reform over the last few years, mostly focused on process and targets; but the 2010 NHS white paper, Equity and Excellence: Liberating the NHS, highlighted the importance of quality standards and measurable clinical outcomes in optimising patient care.²

As dermatology services do not usually need to use expensive equipment they are likely to attract competition. An increasing number of providers deliver dermatology services, particularly private companies, some employing groups of GPs with a special interest. It is important to ensure that those services that are cheap and easier to provide are not cherry-picked leaving more complex patients less well provided for. It is also important to ensure that all these services are providing good quality care to our patients.

We are also moving into a different era with GP commissioning groups due to start choosing services. It is important that those professionals who are commissioning services, whoever they may be, have information on what constitutes high-quality care based on the best available evidence.

Setting standards
Over the last year, the British Association of Dermatologists (BAD) has led a project to develop standards of care, describing the key elements of best practice that people with skin conditions are entitled to expect. This should apply whether the person with the skin condition is self-caring, seeking advice from primary care or referred for specialist treatment and applies to all situations whoever sees the patient, whether in the public or private sector.

Who came up with the standards?
A working group was set up in 2010 with nurses, patients, dermatologists, paediatric dermatologists, GPs, primary care dermatologists, pharmacists and commissioners and input from the Department of Health. A medical writer was employed and the first draft was sent out widely for consultation and feedback incorporated into the final version. The document entitled Dermatology Quality Standards: Providing the Right Care for People with Skin Conditions was produced in July 2011 and is available on the Primary Care Commissioning and BAD websites (see Resources).

The document is supported by the British Dermatological Nursing Group, the Royal College of General Practitioners, the British Association of Dermatologists, The Primary Care Commis- sioners, the British Society for Paediatric Dermatology, the Primary Care Dermatology Society, the Psoriasis Association, Skin Care Campaign, and the Eczema Society.

Dermatology Quality Standards (from the Executive Summary of the document)

Standard 1: Principles of dermatology care
This covers the overarching principles that should underpin the provision of care for people with skin conditions. These principles are absolutely crucial to the delivery of good-quality care and should be viewed as non-negotiable.

  • Every local health economy must provide for full and fair patient access to the full range of high-quality dermatology services at all levels of care - to this end, models of care should be developed using stakeholder commissioning groups.
  • Consistent, nationwide high-quality care that meets independent quality standards, such as those developed by NICE, is a cornerstone of NHS for the 21st century - it can only be achieved if there is clear local support for independent quality standards.
  • People with skin conditions should have their care managed at a level appropriate to the severity and complexity of their condition, acknowledging that this may vary over time.
  • All services should have access to a range of supportive services that can help meet the holistic needs of people with skin conditions - these could include psychological support, access to medical social workers, camouflage services and occupational therapy.

Standard 2: Patient and public involvement

  • The best way to design and develop user-centred dermatology services that meet the needs of people with skin conditions is to involve potential and current service users in their design, development and ongoing governance.
  • Commissioners should develop and support a stakeholder commissioning group that includes patient representation, as outlined in the Primary Care Contracting document Providing Care for Patients with Skin Conditions: Guidance and Resources for Commissioners.
  • Each dermatology service, whether integrated or stand alone, should have a patient panel that is involved in its development and governance.

Standard 3: Appropriately trained staff

  • Individual competencies will depend on job role and should be relevant to services being commissioned; ie, they should match patient need.
  • Healthcare professionals are responsible for maintaining their competence, but this must be supported by commissioners and providers working together within the context of a local governance framework that is commissioned and regularly monitored.
  • Specialist dermatology services should play a key role in supporting the delivery of education and training across a range of providers.
  • Standardisation of educational provision (across professional disciplines and educational providers) is important, and lack of standardisation represents a risk.

Standard 4: Clinical assessment and management

  • Patients should be seen by the right person in the right place with suitable facilities; those with special or particular needs, such as children, should be seen by appropriate staff in facilities that meet their specific needs.
  • Patients should be fully informed about their diagnosis and management and be involved in decisions about their care.
  • Patients should have access as needed to all treatments approved by national agencies, eg, NICE, and treatment should be carried out in a safe, competent and timely manner according to national and local standards.
  • Those with long-term conditions should be offered appropriate ongoing care and access and re-access to services as needed.

Standard 5: Models of care and links to other services

  • Models of care for people with skin conditions should be developed by stakeholder commissioning groups using consensus guidance to ensure they reflect the needs of the health community.
  • All services for people with skin conditions should be integrated to ensure patients can move between levels of care as necessary (this requires established links between generalist, specialist and supra-specialist services to facilitate advice, support and onward referral, irrespective of provider).
  • All health communities should establish clinical care pathways with other clinical services - these should be clear, agreed and used by all service providers to ensure equity of access for all patients. (For patients with skin cancer the specific national guidance on care pathways should be followed).
  • Triage and referral management, where used, should be performed by experienced, suitably trained clinicians with the sole aim of ensuring that patients are seen in a timely fashion by appropriately trained healthcare professionals.

Standard 6: Diagnostic investigations

  • Dermatological investigations should be requested, carried out and reported by appropriately trained staff in accordance with local and national guidelines.
  • Specimens should be transported in a safe manner.
  • Results should be available and reported to the patient in an appropriate time frame.

Standard 7: Clinical governance

  • It is essential that clinical governance arrangements are embedded in clinical practice to enable services to constantly review and measure themselves in terms of effectiveness, safety and patient experience.
  • Commissioners should ensure that requirements for clinical governance are explicit in all contracts with providers of dermatology services and should monitor services against the agreed standards.
  • Specialist services must be able to show the results of regular audit against national and local guidance - this will support compliance with Care Quality Commission requirements.
  • Strong clinical leadership is required for clinical governance to work well, and specialist services should provide this within local health communities.

Standard 8: Information governance

  • Data (including digital images) should be obtained, recorded, held, altered, retrieved, transferred, destroyed or disclosed in accordance with the Common Law Duty of Confidentiality, Caldicott Guidance, the Data Protection Act 1998 and other national and professional guidelines.

Conclusion
People with skin disease should have their care managed at a level appropriate to the severity and complexity of their condition, which may vary over time. People who manage their conditions themselves should be supported with high-quality patient information and input from suitably trained nurses, patient support groups and community pharmacists.

Patients who need generalist care should be able to access input from suitably trained nurses and self-refer to their practice nurse or GP. Any patient who cannot be managed by a generalist will need to be referred for specialist care and patients should have choice about the providers of dermatology care available.

Whatever care is provided, and at whatever level, people with skin conditions should have equitable access to the best available evidence and consensus views that determine what constitutes a good-quality service. These standards should act as a reference guide so that those of us who are already seeing people with skin conditions can benchmark ourselves and see when we can perhaps improve. Commissioners can use these standards to compare competitive providers. We hope that if services are delivered to these standards then outcomes for people with skin conditions will improve. We suggest that you:

  • Read the standards and see how you perform.
  • See where you can improve your care of people with skin problems.
  • See how services that you work with perform against the standards.
  • Point out where they should improve.

References
1.    Schofield J, Grindlay D, Williams H. Skin Conditions in the UK: A Health Care Needs Assessment. Nottingham: Centre of Evidence Based Dermatology, University of Nottingham; 2009.
2.    Department of Health (DH). Equity and Excellence: Liberating the NHS. London: The Stationery Office; 2010.

Resources
Primary Care Commissioning
www.pcc.nhs.uk/quality-standards-for-dermatology
British Association of Dermatologists www.bad.org.uk