The crisis in dermatology
Authors: David Eedy
Publication date: 09 Jun 2015
David Eedy considers the current state of dermatology services
It was no surprise that the NHS was a major focus of all parties during the general election campaign, with much argument around its future. But, if the new Conservative majority government wishes to avoid the mistakes of the past, it would do well to use the specialty of dermatology as a case study. Dermatology is a prime example of the ill considered incentives of commissioning in the current NHS, and its issues are likely to resonate with similar specialties.
The current crisis in dermatology stems from two key areas: a major shortfall in the number of dermatologists, with a refusal by the relevant powers to address this critical need; and government experiments in service restructuring, which lead to poor commissioning decisions and a failure to rescue the decimated departments and their patients when the experiments fail. The consequences of such failures have to then be borne by the taxpayer.
Our patient population is extensive: each year, 54% of the population is affected by skin disease, and 23-33% of the population at any time has a skin disease that would benefit from medical care.
Unfortunately, despite a deficit of more than 200 consultant dermatologists across the UK there has been no allocation of further training posts for dermatology. Health Education England has commissioned 177 specialty training places in dermatology in 2014/15, a reduction from the previous 178 posts. We do not have enough trainees coming up through the ranks to replace retiring staff. Although there is no quick fix for the current crisis, the fact that training numbers are not increasing suggests that the problem will plague us for many years. A reduction in training posts may have stemmed from the belief that primary care physicians would take on some of the hospital work, but the continuing annual increase in referrals to secondary care dermatology does not bear this out.
In 2010, the Centre for Workforce Intelligence recommended an increase of between five and seven posts nationally, with the geographic allocation of these posts being dependent on training capacity, funding, and distribution of the existing workforce. Eight trusts with adequate training capacity made bids for posts, but the required funding was only available for four. In addition, two deaneries reduced their number of dermatology training places by one each, resulting in a net increase of only two posts.
The latest annual workforce census data, published by the Health and Social Care Information Centre (HSCIC), show there were 486 directly employed consultant dermatologists working in the NHS in England as at 30 September 2013.
In 2012 the British Association of Dermatologists said that there were 813 dermatology specialists in the UK (consultants, trainees, associates, and associate trainees, not all full time) and a total of 729 consultant posts, 75 of which were vacant and 98 of which were occupied by locums. The Royal College of Physicians recommends one full-time equivalent consultant dermatologist per 62 500 population. This scales up to 1.6 consultants for 100 000—even London, with the highest number of consultants (1.15 per 100 000 population), is still below this figure.
For a population of 61.8 million, the level of consultants recommended by the royal college would result in 989 full time equivalent dermatologists, suggesting a shortfall in the region of 250 consultants at present. No region in England has sufficient dermatology consultants. We know that in the long term locums have been employed in certain locations to try to mitigate the consultant workforce crisis, but we also know that not all of these consultants have training equivalent to the UK certificate of completion of training.
Between 2007-08 and 2012-13, there was a 15.5% increase in general practitioner referrals for dermatology. The growing rates of skin cancer, which account for 40-50% of specialist activity, have undoubtedly fuelled this increase. Skin cancer is the most common cancer— basal cell carcinoma numbers equal all other malignancies combined, and increased by 81% between 1999 and 2010. Reported melanoma incidence increased by over 400% over 35 years. Additionally, referrals to dermatology services have risen as a consequence of an increasing and ageing population, as well as an increase in frequency of diseases such as leg ulcers and eczema, improved treatments, and changing expectations to skin conditions. The workforce and training to deal with this “epidemic” have not increased accordingly.
GP training posts versus consultant training posts
For some time it has been Department of Health policy to increase GP training numbers in England to 3250 per year, a number supported by the Centre for Workforce Intelligence’s GP In-depth Review 2014. The Health Education England Mandate (2013) set the target of 50% of medical students becoming GPs by 2015.
A GP taskforce report commissioned by the Department of Health in 2014 recommends that GP training numbers are increased alongside a “concomitant reduction in hospital specialty places” and suggests 2025 hospital training places could be decommissioned to achieve this aim. This all ties in with the government’s agenda to move as much care as possible into the community.
General practitioner recruitment, however, is falling well below this target. Applications for postgraduate GP specialty training dropped by 15% in 2014 compared with 2013. Figures for 2015 show a 6% reduction in applications for training posts compared with 2014.
While GPs are feeling the strain of an ageing population and increased demand there is limited enthusiasm among medical students for becoming GPs. Increasing the number of training posts is not working, and other solutions to make the role of the GP more appealing should be identified.
Reducing the strain on GPs by increasing the support available from secondary care clinicians can only be beneficial. We know of hospitals that have had to return non-urgent dermatology referrals to GPs, owing to waiting lists. Given that 20-25% of GP workload involves skin disease, the added pressure on GPs will not be alleviated by further cutting the number of consultant dermatologists who help them with some of their most common and time consuming cases.
Furthermore, it is widely acknowledged that there is a lack of knowledge about skin disease in general practice as a result of poor undergraduate and postgraduate teaching. This means that more patients are referred to consultants.
Restructuring where care is delivered
The introduction of the Care Closer to Home agenda in 2007 exemplifies the problems of translating policy into practice. On the face of it, moving medical facilities closer to where patients live and work is a sensible proposal. However, in practice, the policy led many commissioners to mistakenly believe that dermatology could be delivered largely by GPs with a special interest, with little understanding of the multidisciplinary nature of the care pathways, staffing, and facilities required to treat acutely unwell patients with inflammatory skin conditions and skin cancer.
General practitioners with a special interest can provide effective intermediate care for certain patients but only as part of an integrated consultant dermatologist led team. Furthermore, research shows that, where there are GPs with an interest in dermatology, there is an increase in referrals to secondary care of 67%, and, in the majority of cases, the cost of care per head of patients remains the same as the hospital service.
Poorly designed community services can also lead to the decommissioning of dermatology hospital services. A key concern is the practice of “cherry-picking” by private healthcare providers who are more likely to take on relatively easy, high volume, lucrative work. The local NHS hospital department is left to pick up the more difficult and expensive work while saddled with increased financial pressures.
We need better and more transparent service planning from the outset. Clinical commissioning groups are expected to ensure that commissioning decisions are not made in isolation from the patients and the public, from local authorities, or from other health and care professionals. Unfortunately, we see too many cases where this has gone awry. Successful commissioning can be achieved only with GPs and secondary and tertiary care clinicians working together.
In many areas, the issues outlined above have led to the decline or even total collapse of services. One example is in Nottingham, which cut back adult dermatology services earlier this year. Nottingham University Hospital was once regarded as one of the best research centres for dermatology in the UK, but, due to poor commissioning decisions over recent years, it has been reduced to working with fragmented pathways, has limited on call, transfers sick patients to Leicester, has lost all dermatology trainees and medical students, has faced reduction in research activity and reduced service facilities, and has ceased to provide acute adult dermatology services.
Transferring doctors to the private provider Circle, without satisfactory consultation, has resulted in an exodus of staff and the fragmentation of care pathways for patients across acute and tertiary services. The loss of key staff from the trust makes it difficult for those remaining to deliver patient care, as clinical responsibilities become overwhelming. Vital services, such as on-call care for patients outside normal hours, have limited cover. In these situations the private provider often has to pay higher salaries than NHS trusts to attract locum consultants. This money would be much better spent on the local service and workforce.
The rationale behind these decisions, which appear to have given a monopoly to a private provider and reduce choice, is questionable given the warnings raised in 2013 by BAD.
Our concerns have been echoed by a report from the King’s Fund released this month, which states: “Dermatology represents an important part of NHS provision . . . and yet this important area is poorly understood and has received comparatively little attention. Commissioning has often been poor. Inadequate planning has left gaps in the workforce. The 40 000 GPs managing this workload have received little training in dermatology and there are only 650 consultants to advise them and provide the more specialist care.”
Warning to other specialties
The problems I have described should serve as a warning to other specialties, which are also faced with poor commissioning and workforce decisions. As the new Conservative health team settles into political office I hope they take note of what has happened in dermatology.
I have read and understood BMJ’s policy on declaration of interests and declare that I have no competing interests.
thebmj.com News: Transfer of services from NHS to private provider was “unmitigated disaster,” report says ( [Link] )
- Centre for Workforce Intelligence. Dermatology—medical specialty workforce summary sheet. Aug 2011.
- King’s Fund. How can dermatology services meet current and future patient needs, while ensuring quality of care is not compromised and access is equitable across the UK? May 2015. [Link] .
- Department of Health. Delivering high quality, effective, compassionate care: developing the right people with the right skills and the right values. 2013. [Link] [Link]
- Matthews-King A. Over 2000 hospital training posts should be axed to fund GP expansion, recommends DH review. Pulse 22 Jul 2014. [Link] [Link]
- Matthews-King A. Revealed: 6% drop in GP training applications this year. Pulse 13 Feb 2015. [Link] [Link]
- Levell NJ, Penart-Lanau AM, Garioch JJ. Introduction of intermediate care dermatology services in Norfolk, England was followed by a 67% increase in referrals to the local secondary care dermatology department. Br J Dermatol 2012;167:443-5.
David Eedy president, British Association of Dermatologists, London W1T 5HQ