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All Party Parliamentary Group on Skin
Parliamentary Meeting
Monday 11th March 2013
House of Commons, Committee Room 14

Speakers:

Prof. Christopher Bunker, President of the British Association of Dermatologists (BAD) - CB
Parliamentary Members Present:
Sir Paul Beresford MP (Chair)
Baroness Masham of Ilton (Vice-Chair)
Baroness Gardner of Parkes
Rt Hon Cheryl Gillan MP
Minutes

The Chair welcomed everyone to the meeting and introduced the speakers.
1. Introduction,
!
CB!began!by!setting!out!the!main!topics!of!his!presentation:!
Crisis!in!Dermatology!and!for!People!with!Skin!Disease!
!
•!Demographics!and!Demand!
•!Workforce!
•!Configuration!
•!Research!
•!Influence!
,
2. Demographics,and,Demand
!
!CB!set!out!the!three!main!chal enges!of!demographics!and!demand.!An!ageing!population!was!one.!As!people!were!living!longer,!demand!on!dermatology!services!was!steadily!rising.! The!increased!rate!of!skin!cancers!diagnosed!in!the!UK!combined!with!the!complications!of!longHterm!chronic!diseases!and!their!treatments,!meant!that!demand!on!healthcare!was!rising!at!an!alarming!rate.! !CB!reminded!the!audience!of!the!work!of!a!skin!specialist.!This!included!managing!up!to!2000!different!diseases!of!the!skin,!hair!and!nails!in!adults!and!children.!Each!year!54%!of!the!population!was!affected!by!skin! disease,!and!23–33%!at!any!one!time!had!a!disease!that!would!benefit!from!medical!care.!Approximately!4,000!deaths!occured!in!the!UK!on!an!annual!basis!due!to!skin!disease,!most!often!from!malignant!melanoma.!Skin!diseases!represented!34%!of!al !diseases!in!children!(atopic!eczema!affected!20%!of!infants).!Skin!cancer!was!the!most!common!cancer!and!the!second!most!common!cancer!causing!death!in!young!adults.! Basal!cel ! carcinoma!(BCC)!numbers!equaled!al !other!cancers!combined,!and!increased!by!133%!between!1980!and!
2000.!
!
Dermatologists!also!manage!the!psychological!burden!carried!by!patients!with!a!skin!disease,!which!could!be!
very!severe.!
!
3.,Workforce!
!CB!said!that!there!were!approximately!830!posts!available!in!the!NHS!for!Consultant!Dermatologists!but!with!the!actual!number!of!dermatologists!in!the!UK!around!650,!this!left!a!deficit!of!almost!200!vacancies.!!Despite!the!demand!for!Dermatology!services,!Dermatology!is!unevenly!and!inadequately!taught!at!Medical!School!and!rarely!if!ever!considered!a!core!module.!!This!walked!handHinHhand!with!poor!training!and!uneven!training!for!GPs,!who!often!referred!patients! unnecessarily!to!secondary!care!for!a!second!opinion.!Were!GP!education!better,!patient!management!in!the!primary!care!setting!would!be!improved!and!the!number!of!unnecessary!referrals!could!be!significantly!reduced,!as!could!the!potential!for!litigation!on!the!other!end!of!the!scale.!9!out!of!10!claims!over!delayed!diagnosis!of!melanoma!involved!GPs.!!More!general y!the!morale!of!medical!and!nursing!staff!was!waning!considerably!and!the!relative!unimportance!attached!to!Dermatology!by!policy!makers!was!not!helping.! !
4.,Configuration!
!
Dermatology!services!had!traditional y!revolved!around!the!secondary!care!hospital!base!because!that!has!
been!perceived!to!be!the!most!efficient!way! to!deliver!care!i.e.!by!a!team!of!specialists!pooled!together!in!one!
integrated!setting.!The!shift!away!from!this!to!the!community,!despite!superficial!benefits,!fragments!
integrated!services!(and!teaching,!training!and!research!synergies)!built!up!over!decades!and!leaves!the!
hospital!itself!devoid!of!readily!accessible!Dermatological!input!and!nowhere!to!look!after!the!sick!Dermatological!patient.!These!things!are!further!jeopardised!by!the!Any!Qualified!Provider!scheme!H!disintegration!of!services!and!the!redistribution!of!profit!away!from!the!NHS!and!into!private!pockets.!!There!is!also!much!unneeded!bureaucracy!in!the!system!that!could!be!reduced.!For!example!MultiHDisciplinary!Team!working!for!the!treatment!of!skin!cancer!patients!was!not!necessary!for!the!majority!of!cases:!most!patients!with!skin!cancer!could!be!dealt!with!rapidly,!effectively!and!safely!by!an!accredited!Dermatologist!without!the!need!for!additional!input.!Unnecessary!referrals!from!GPs!under!the!two!week!wait!rule!were!also! wasting!resources!that!could!be!better!spent!assessing!and!treating!those!who!actual y!need!the!skin!cancer!service.!!Isotretinoin!for!the!treatment!of!severe!acne!was!another!example!of!over!zealous!micromanagement.!The!drug!was!unnecessarily!difficult!to!prescribe!and!females!were!needlessly!being!subjected!to!recal !to!clinic!monthly!for!a!pregnancy!test!and!repeat!prescription.!!The!hospital!setting!would!always!be!needed!for!Dermatology,!yet!this!was!slowly!being!eroded!through!the!loss!of!beds,!on!call!expertise!and!the!outsourcing!of!outpatient!activity!–!away!from!the!geographic!location!of!the!hospital.!Links!with!other!disciplines!such!as!paediatrics!and!the!essential!provision!of!services!such!as!phototherapy!and!patch!testing!were!also!being!affected!! In!Nottingham,!Consultants!have!little!choice!now!but!to!become!actual!employees!of!Circle,!an!independent!provider!that!has!recently!won!the!tender!for!a!Treatment!Centre!that!includes!the!Dermatology!service,!removed!from!the!NHS!hospital!base.!The!problem!is!that!many!of!these!Dermatologists!also!work!in!other!areas!such!as!paediatrics!and!as!a!result!wil !elect!to!retain!their!NHS!employment!at!the!hospital!and!so!wil ! not!be!available!for!general!Dermatology!duties!at!the!Treatment!Centre,!a!significant!schism!geographically!and!professionally,!deleterious!to!integrated!patient!care.! This!is!just!one!example!of!the!disintegration!that!is!happening!up!and!down!the!country.!!CB!explained!that!Dermatology!had!been!placed!in!Domain!2!(Long!term!Conditions)!under!the!NHS!Commissioning!Board.!This!concerns!him!greatly!as!Dermatology!fails!to!fit!into!any!of!the!areas!covered!by!the!Clinical!Directorships!being!appointed!in!Domain!2!(listed!below).! This!leaves!the!13!mil ion!patients!with! skin!disease,!that!present!annual y!to!their!GPs,!without!anyone!specifical y!coordinating!commissioning!policy!for!them.!!Domain!2:!Long!Term!Conditions!•!Dementia!!•!Integration!and!Frail!Elderly!•!End!of!Life!Care!•!Mental!Health! •!Chronic!Disability!and!Neurological!Conditions!•!Musculoskeletal!Disorders!•!Spinal!Disorders!•!Renal!Disease!!The!expansion!of!soHcal ed!‘alternative!providers’!is!a!cause!for!concern!as!there!is!no!real!alternative!to!the!experienced,!trained!and!accredited!dermatological!staff!and!services!already!in!place.! Community!clinics! have!some!superficial!attractions!and!properly!configured!could!complement!other!services,!but!require!
intelligent!integration!to!provide!continuity!of!care.!However,!commissioners!and!independent!providers!may!
be!too!readily!influenced!by!cost!rather!than!quality!issues.!Revisions!to!the!recent!secondary!legislation!on!
competition!suggest!that!policy!makers!are!being!forced!to!act!by!expediency.!More!ad!hoc!secondary!
legislation!is!likely.!!Furthermore,!few!of!the!decisions!being!made!around!service!redesign!seem!to!take!into!
account!the!unheard!of!voice!of!patients.!
!
5.,Research!
!
Moving!on!to!research!CB!said!that!the!NHS!often!has!trouble!translating!what!was!already!known!from!recent!
clinical!research.!For!example!there!is!no!evidence!that!sentinel!node!biopsy!for!melanoma!improves!survival!
yet!it!is!widely!practiced.!It!is!very!expensive!to!the!NHS!and!there!are!side!effects.!It!is!not!advocated!by!any!
Guidelines!or!NICE.!Securing!funding!for!dermatological!research!is!immensely!chal enging!as!is!recruiting,!
training!and!retaining!the!research!workforce!(considerably!threatened!by!changes!in!medical!training!and!
recruitment).!Funding!is!badly!needed!for!research!into!the!most!urgent!areas!of!dermatological!need.!
!
6.,Influence.!
!
CB!bewailed!the!lack!of!influence!that!skin!medicine!commanded,!pointing!to!the!unheard!voice!of!patients,!
the!unheard!voices!of!specialist!doctors!in!primary!and!secondary!care!and!nurses.!'People!do!not!understand!
what!we!do'!he!said.!There!is!a!poor!comprehension!of!Dermatology.!
!
7.,Solutions!
!
The!BAD!is!a!charity!whose!objects!are!to!promote!for!the!public!good!the!teaching,!training,!research!and!
practice!of!Dermatology.!Its!income!comes!from!member!subscriptions,!journals!and!conferences!and!surplus!
is!spent!on!the!above!or!on!research!through!the!British!Skin!Foundation.!These!things!legitimise!the!airing!of!
the!above!concerns!and!its!active!engagement!in!proposing!and!promulgating!solutions.!
!
Demographics,and,Demand!
!
In!the!absence!of!any!significant!NHS!initiatives!to!date,!!the!BAD!is!developing!registries!and!audits!to!
quantify!some!important!areas!where!data!are!scarce!eg!non!melanoma!skin!cancer!(estimated!at!over!
120,000!case!pa)!and!especial y!to!provide!qualitative!statistics!about!performance!and!outcomes.! Patients!
deserve!these!and!Commissioners!need!them!to!make!the!right!decisions!about!where!and!by!whom!such!
work!should!be!done.! Specifically!the!BAD!is!funding!the!development!of!Patient!Reported!Outcomes!
Measures!(PROMs).!
!
Workforce!
!
The!BAD!is!deliberating!with!the!RCGP,!RCPCH,!RCP,!PCDS,!BDNG,!RCS!and!BAAPS!to!campaign!at!Heath!
Education!England,! the!DH!and!through!the!GMC!and!Shape!of!Training!to!improve!the!teaching!of!
Dermatology!to!Medical!Students!and!Nurses,!to!bolster!the!training!of!GPs,!and!to!regulate!the!accreditation!
of!GPwSIs!and!the!practice!of!cosmetic!procedures,!in!order!to!protect!and!enhance!the!training!and!
accreditation!of!Dermatologists.!
!
Configuration!
!
Already!the!BAD!has!issued!or!contributed!to!important!documents!that!help!define!dermatological!health!
needs,!explain!and!assist!in!the!commissioning!process!and!delineate!quality!standards!(Teledermatology!and!
Psychodermatology).!This!multidisciplinary!work!continues.!The!BAD!has!been!vociferous!in!the!ongoing!
Future!Hospital!Commission!undertaken!by!the!RCP!arguing!for!the!hospital!base!for!Dermatology!and!the!
dermatological!needs!of!sick!inpatients.!The!BAD!actively!chal enges!egregious!commissioning!and!outcomes.!
CB!emphasised!the!fact!that!a!number!of!problems!had!arisen!in!the!last!two!years!due!to!the!reconfiguration!of!services,!unacceptable!commissioning!practice!and!outcomes.!There!are!vital!lessons!to!be!learned.!The!BAD!and!the!RCP!are!working!on!a!‘Lessons!to!be!Learnt’!document!to!be!published!later!in!the!Spring,!from!which!al !would!benefit,!not!just!patients!with!skin!disease.! The!BAD!has!earmarked!a!significant!sum!for!researching!alternative!models!of!service!delivery!given!the!constraints!detailed!above!and!hopes!to!announce!a!partnership!with!the!Kings!Fund!to!take!this!forward!in!the!very!near!future.! The!best!interests!of!patients!and!taxpayers!are!served!by!continuity!of!care!and!integration.!Academic!Health!Science!Centres!and! Networks!provide!the!best!vehicle!for!these!aspirations!in!Dermatology.!The!DH!is!keen!on!Strategic!Clinical!
Networks!and!the!BAD!wil !argue!that!this!is!a!suitable!approach!for!skin!disease.!
!
A!key!issue!is!that!the!perceived!profitability!of!Dermatology!should!be!'repatriated'!for! service!(and!teaching!
training!and!research)!and!that!public!money!derived!from!the!tax!take!for!health!should!not!disappear!into!
either!excessive!unnecessary!management!costs!in!the!NHS!or!the!pockets!of!private!investors,!but!be!
repatriated!for!the!good!of!patients!and!the!specialty.!
!
Research!
!
See!above.!Disintegration!threatens!research.!British!Dermatology!punches!above!its!weight!in!the!research!
arena!but!the!future!needs!securing,!especially!concerning!the!recruitment!and!training!of!the!research!
leaders!of!tomorrow.!The!BAD!spends!directly!on!research!and!facilitates!other!activities.!British!Dermatology!
has!been!a!lauded!player!in!the!NIHR!Clinical!Research!Network!environment!and!we!have!our!own!highly!
successful!Dermatology!Clinical!Trials!Network.!The!national!biologics!registry!(BADBIR)!is!envied!around!the!
world!and!the!data!for!research!(about!efficacy!and!safety)!that!it!is!capable!of!generating!is!just!beginning!to!be!tapped.!The!BAD!wil !similarly!facilitate!other!multipartite!Registry!projects!(eg!around!skin!cancer!especially!nonHmelanoma!skin!cancer!and!genetic!skin!disease).!UKTREND!wil !bring!together!leading!researchers,!funding!bodies!and!industry!to!integrate!research!activity:!it!has!been!funded!and!wil !be!hosted!by!the!BAD.!Charitable!activity!directly!and!indirectly!can!be!bolstered.!The!BSF!has!reviewed!its!strategy!both! around!increased!fundraising!and!the!type!of!research!it!supports.!Fol owing!CBs!approaches!Skin!Disease!has!been!offered!a!meeting!to!set!out!its!stal !in!a!meeting!with!Dame!Sal y!Davies!the!Chief!Medical!Officer!and!Chief!Scientific!Adviser!to!the!DH!in!July,!an!opportunity!so!far!accorded!only!to!HIV,!Obesity,!Physical!Activity!and!AlcoholHa!real!coup!and!a!real!opportunity.!As!above,!a!fundamental!principal!must!be!that!any!inherent! 'profitability'!in!Dermatology!should!be!shared!with!the!patients!from!whom!it!is!derived!in!research!(and!
teaching!and!training!and!service!improvement!as!above).!
!
!
Influence,!
!
CB!is!committed!with!the!BAD!in!trying!to!get!heard,!for!the!benefit!of!the!nations!dermatological y!sick!and!
disadvantaged.!We!have!the!legitimacy!and!credibility!of!our!charitable!objects!and!our!professional!positions.!'We!are!the!trained,!experienced,!accredited!vocationalists'.! The!APPGs!should!be!pivotal!in!influence!at!Westminster!and!al !BAD!Members!wil !be!Advisory!Members!in!the!near!future.!Patients!Support!Groups!and!the!Dermatology!Councils!of!England,!Wales!and!Scotland!are!becoming!more!vocal!and!persuasive.!The!BAD!has!a!practised!communications!team,!the!better!to!engage!with!the!media.!But!the!key!thing!is!to!meld!coalitions!of!multipartite!(eg!BAD,!PCDS,!BDNG,!RCP,!RCPCH,!RCGP,!BAAPS)!to!try!to!shape!the!future!to!provide!a!better!deal!for!patients!with!skin!disease!H!remember!~13!mil ion!a!year!consulting!a!doctor.!!!

Source: http://www.appgs.co.uk/wp-content/uploads/2013/03/APPGS_Minutes_11-03-2013.pdf

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