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Setting up a dermatology service in primary care

Nicola Ball
Dermatology Nurse Specialist
Bristol Community Health

What is your nursing background?
My nursing career started in 1987 when I joined the Queen Alexandra's Royal Naval Nursing service. I completed my RGN training with the Navy and then every 18 months would receive a draft order informing me where my next place of work would be. In 1992 I was drafted to work in the dermatology outpatient department at the military Haslar Hospital in Hampshire. I very quickly realised that dermatology nursing enables you to deliver holistic care that includes improving quality of life. Many people live with visible chronic skin conditions and nursing intervention and support can make a huge difference to all areas of a person's life.

In 1995, after completing my dermatology course, I took up the post of dermatology nurse at Stoke Mandeville Hospital and developed a nurse outpatient service, which included performing minor surgery and delivering psoralen combined with ultraviolet A (PUVA) and ultraviolet B (UVB) treatments.
I moved to Bristol in 1997 to take up the position of dermatology outpatient manager at the Bristol Royal Infirmary and helped design and move the service to a purpose-built department. During this time, I assisted in setting up the role of dermatology specialist nurse in primary care. After a few years working in the primary care setting as a community nurse I took up the post of primary care dermatology nurse specialist and was challenged to offer a trust wide service to a population of 480,000 serviced by 72 GP practices.

What led you to set up the service?
There had been two specialist nurses working in different parts of Bristol offering excellent dermatology nursing care to patients from some Bristol GP practices. Dermatology problems account for 24% of visits to the GP and with the Darzi Report in 2008 there was a need to provide a city-wide service that would offer equal access to all.1,2

Bristol has a huge multicultural population and so it was important to provide the service from a variety of bases that people could access easily and that suited their needs. For example, we have a clinic in Barton Hill, an area which has a high Somalian population and many Somalian children have eczema (there is some evidence that eczema may be slightly more common in people from African-Caribbean backgrounds).3

What challenges did you face initially? How were these overcome?
Initially I was the only nurse to deliver the trust-wide service and I worked part time! Once we had recruited another band 7 nurse and had won a successful bid to the commissioners we were able to recruit a team. This was easier said than done as experienced dermatology nurses are few and far between.
We decided to advertise two band 6 training roles hoping to attract experienced primary care nurses with a range of knowledge and skills but who had an interest in dermatology. We ended up with two fantastic and enthusiastic nurses who after initial training can now work autonomously but they still have protected training time to enhance their dermatology knowledge and skills.

We also had to find bases to work out of that served north, inner and east and south Bristol. With support of an excellent manager we were able to secure three great primary care bases and our own admin base. The service is only able to run so effectively because we have excellent administrative support and a computer system database that we can access from all bases.

How does the service work? Who are the members of the team?
The team is made up of two GPs with a special interest (GPwSI) who work two sessions each. The nursing team is made up of two band 7 nurse specialists, two band 6 nurses in training posts, one full-time clinical support worker and two admin staff who work a total of 49 hours a week. This administrative support is vital. We are able to receive referrals via Choose and Book from any trained member of Bristol Community Health staff. Referrals for clinical diagnosis will be booked into see the GPwSI and for management, support, education and treatment planning to see a nurse.

We link very closely with secondary care and their support is invaluable. Once a week each band 7 will have a clinic in hospital alongside a consultant dermatologist. This gives us the opportunity to receive clinical supervision and support with patients whose disease is proving tricky to manage.
One of the band 6 nurses works with the paediatric dermatology consultant once a week and the paediatric dermatology nurse works alongside her in a clinic once a week. As the service can see a range of age groups, this paediatric support is imperative and reflects guidance outlined in the Royal College of Nursing (RCN) document published in 2009, An Education and Training Framework for Paediatric Dermatological Nursing.4 Our other band 6 nurse also links closely with the tissue viability team.

What is a typical day like for you?
We are a performance-led service and have a target of seeing 93 new patients a month, with 185 follow-ups. This means life is busy. Every day there will be a nurse-led clinic running in each of the three bases and a GPwSI clinic three days a week. We spend one hour with a new patient and half an hour with a follow-up. Management plans are drawn up and treatment regimens worked out.

Joint visits with community nurses and practice nurses are arranged if deemed necessary and our clinical support worker will provide regular home visits to check patients are managing their treatments. We also visit families at home if we feel this will provide us with valuable information that will help with treatment planning, and link with health visitors and school nurses in child-in-need cases.

What do you like most and least about your work?
Working with this wonderful new team is the best part of the job. It has been fantastic to have a vision for a trust-wide primary care service and then see it come to fruition. Dermatology patients are amazing and I love supporting people with chronic skin disease, planning treatment, considering their views and then seeing them manage their disease so effectively and the positive impact this has on their lives.

On the other hand, sometimes it seems like there are too many balls in the air to juggle - but I suppose that comes with any expanding service. There have been a few management changes recently and it is sometimes hard to sell the vision. However, Bristol Community Health is generally supportive of the service.

Is there anything particularly challenging about your work?
Sometimes our patients have been so poorly managed for many years by people with little dermatology experience that they are negative about many of the treatments we offer. However, because of the time we have to see a new patient, we are able to show how effective treatments can be when people know how to use them correctly. We complete a Dermatology Life Quality Index (DLQI) on each patient, classify severity of eczema and Psoriasis Area and Severity Index (PASI) every person with psoriasis so we are able to see the difference education and encouragement can make.5

How do you think other nurses could learn from your service?
Even with the changes set out in the Department of Health's Liberating the NHS, new services can be set up that deliver excellent quality of care to patients closer to home.6 If nurses feel there is a need to improve concordance with treatments, particularly with patients with eczema and psoriasis, they should look at ways of offering this within primary care.
Nurses might need to ‘think outside the box' and set up services with support from secondary care. We have proved it can be done and targets can be met while delivering a high-quality, patient-focused service.

What does the future hold for the service? Are there any plans for expansion?
From 1 April 2011, Bristol Community Health became a Social Enterprise and I am sure with GP commissioning there will be many changes. We are looking at bidding for a low-risk skin cancer clinic and in the future I think there will be plans for expansion outside the Bristol area.

There is always room to improve dermatology care but I think delivering an equitable, accessible service led by competent practitioners in primary care is the way forward for many dermatology patients.

Advice for nurses

  • Join the British Dermatological Nursing Group (BDNG) and try to attend the annual conference as this is a great place to network
  • Link up with your closest dermatology nurse and arrange to spend some time with them
  • Target one area in which you think you could make a difference, ie, eczema patients and see whether you could run a joint education sessions with a dermatology nurse.

References

  1. Schofield J. Updated Dermatology Health Care Needs Assessment. Dermatology Nursing 2009;8(2):20-5.
  2. Lord Darzi. High Quality Care for All: NHS Next Stage Review final report. London: DH; 2008.
  3. Myers T, Higgins E. Skin disease in black patients. Clinical Pulse 1998;78:
  4. 81-2.
  5. Royal College of Nursing (RCN). An Education and Training Framework for Paediatric Dermatological Nursing. London: RCN; 2009.
  6. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI). A simple practical measure for routine clinical use. Clin Exp Dermatol 1994 19(3):210-6.
  7. Department of Health (DH). Equity and Excellence: Liberating the NHS. London: DH; 2010.