Dermatology Good Practice Framework - Social care
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Good Practice Framework Dermatology
Greater Manchester Health and Social Care Partnership
1
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Overview of Dermatology Interventions . . . . . . . . . . . . . 4
Descriptions of the Dermatology Interventions . . . . . . . . 6
Further Information per Intervention . . . . . . . . . . . . . . . 10
Supporting Case Studies . . . . . . . . . . . . . . . . . . . . . . . 15
Good Practice Framework Dermatology2
Introduction
This Good Practice Framework outlines elective care
interventions for Dermatology that Localities should consider
implementing locally in collaboration (commissioners and
providers and other organisations) to effectively manage the
increased demand for elective care services. Interventions
outlined in this document should inform the Locality planning
and prioritisation process for 2019/2020.
The document forms part of the following suite of inter-related documents, but also
can be used as standalone document:
1. Overview and Introduction to the Elective Care
Good Practice Frameworks and Interventions
2. GM Elective Care System Wide Interventions (non-specialty specific)
3. Implementation Considerations – A Stepped Approach
4. Evidence Document – from national/local information, good practice and impact
data emerging from NHS England Specialty Based Transformation pilots from
across England, and/or actual integrated service offers in place in GM
Further information pertaining to our vision for Elective Care in Greater Manchester,
our GM Elective Care Outcomes and Standards, and our approach to the
development of Good Practice Frameworks can be found in the Overview and
Introduction document.
Further information regarding approaches to implementation is detailed in the
Implementation considerations document.
This Good Practice Framework for Dermatology covers:
●● Overview of Dermatology Interventions and alignment with GM Elective Care
Standards
●● Dermatology Interventions – details on what is required to be implemented
●● Further Information – Supporting examples, benefits, resources
●● Supporting Case Studies -– from Localities across GM and from National elective
care pilot sites 100 Day Challenge Teams
Greater Manchester Health and Social Care Partnership3
Introduction continued
The interventions broadly fall into three main areas:
Supported Self Management & Shared Decision Making
Rethinking Referrals
Transforming Out-Patients
We have also included public health interventions, which are consistent with the
GM Population Health Plan and gives a ‘whole system approach’ to commissioning
Dermatology elective care services. Interventions regarding workforce/education
and training for dermatology are featured in the GM Elective Care System wide
interventions.
Good Practice Framework Dermatology4
Overview of Dermatology Interventions and
Overview of Dermatology Elective Care Intervention
Community/web based readily accessible patient information
Public Health
Social prescribing
Readily Available Community Pharmacy advice
Self
Management
& Shared Information to support medication adherence
Decision
Making High quality patient education technology to support self-manageme
GM Dermatology Referral Guidelines
Rethinking Community Champions
Referrals
GM Standards for clinical education
Teledermatology
Community rapid access hot clinics
Transforming GP run community dermatology clinics - ‘routine’ specialist care and
Outpatients
Virtual reporting and follow up (default position)
Greater Manchester Health and Social Care Partnership5
Alignment with GM Elective Care Standards
ns How they Align with Elective Care Standards
The public should have access to well-publicised resources
which enable self care at all stages of the elective care
pathway
People should be able to obtain advice through a variety of
mechanisms including self referral, social prescribing and
community options
Patients should be involved in shared decision making
ent throughout the elective care pathway and feel in control of
their care
Mechanisms should be in place to support clinicians to
make the right referral decision
Referring clinicians should have access to specialist advice
without the need for the patient to visit a hospital setting
All referrals should be triaged to ensure patients arrive in the
right place with the right information
d follow up
Wherever possible follow up should be virtual and
undertaken by the most appropriate member of staff
Good Practice Framework Dermatology6
Dermatology Interventions
Intervention Descriptor
Public Health
Community/web Readily accessible information should be made
based readily available to support prevention, support early detection
accessible patient and treatment of Dermatological conditions, and
information - supporting patients to be medication compliant.
prevention, SDM This should be made available in a range of formats
and EUR including the use of online portals.
Social prescribing Social prescribing should be embedded within
all dermatology pathways - approaches include
incorporation of community networks and ‘expert
patient’ support into dermatology pathways.
Self-Management & Shared Decision Making
Community Pharmacy expertise should be made available to
Pharmacy Advice provide local support for the patient to self-manage for
minor conditions, as well as to provide advice on more
specialist medications to help improve adherence.
Information Patients should be offered a range of information,
to support and support to ensure adherence to medication. This
medication includes information on what may happen and when,
adherence and when to seek further advice and who that may
come from.
Pt education to Patients should be offered a range of educational
support patients materials (in a range of formats such as video/other
to self-manage tech) to support the patient to self manage and provide
information on treatment options.
‘Mechanisms should be put in place to ’follow up’
patients who are self-managing, to encourage and
support the adoption of self management techniques.
Greater Manchester Health and Social Care Partnership7
Dermatology Interventions continued
Intervention Descriptor
Rethinking Referrals
GM Dermatology Commissioners and providers should work jointly
Referral together to ensure the implementation of the GM
Guidelines Dermatology Referral Guidelines and that they are
embedded within existing pathways and on eRS. An
implementation plan should be developed for doing this
with a phased action plan. This should be supported
by a rolling education programme with referrers and
embedded within patient information (as they may be
seen by a specialist nurse, not a consultant).
Community A network of community champions (including GPs)
Champions should be in place to provide support, advice, and
training in supporting the patient getting a diagnosis.
GM standards for Commissioners, providers and GPs should work jointly
clinical education to implement standardised education across GM
that demonstrates change in practice and improved
population outcomes through effective decision making.
An implementation plan with a phased action plan
should be developed to enable this.
Teledermatology Advice and guidance should be introduced as an
(Teledermatology integral step, pre-referral in elective care dermatology
enables GPs to pathways. e-RS/telederm should be used as the
share an image of
the affected skin platform for doing this. The referrers should be
area securely with a educated about the referral criteria and clinical
specialist clinician for
assessment findings that should prompt onward referral
advice and review.)
of patients for diagnosis and treatment. This includes
the inclusion of a feedback loop so that common
request for A&G are used to identify education needs/
guidelines and thus reduce the need to seek advice and
guidance for that issue in the longer term.
Good Practice Framework Dermatology8
Dermatology Interventions continued
Intervention Descriptor
Transforming Out-patients
(Note new service models should work across the entire pathway)
Community rapid Community rapid access dermatology hot clinics
access hot clinics should be in place for assessment, diagnosis, and
treatment including cognitive behavioural therapy and
(Hot clinics - patient
comes back when biopsychosocial model.
they need to – they
are discharged with A population health approach of segmentation and
an open self-referral standardisation should be taken focusing on high
appointment which
means that only the volume patients with less complex needs.
patients that need to
be seen are seen. ) Mechanisms should be in place to enable patients with
chronic skin conditions to re-access specialist advice
and treatment directly, rather than having to wait for a
GP referral.
GP run community GP run community dermatology clinics should be
dermatology in place as an intermediary service to support and
clinics - ‘routine’ improve the diagnosis and treatment of skin conditions.
specialist care and The service should embed timely feedback and
follow up communication to GPs, including about the patient’s
management plan, to facilitate knowledge transfer and
engage GPs in dermatological conditions.
Virtual reporting Virtual reporting and remote/virtual follow up should
and follow up be made the default position with face to face
(default position) appointments offered only when clinically needed or
supported with when it is deemed not appropriate for the patient to
online support receive follow up virtually. Patient information should
materials be made available to advise that follow up will by the
most appropriate clinician who may not necessarily be
the consultant.
Greater Manchester Health and Social Care Partnership9
Dermatology Interventions continued
In addition to the dermatology interventions listed we recognise that there is a need to
improve the quality of dermatology knowledge in primary care through a programme
of continued education and training (inclusive at the undergraduate level), as well as
look at new models of care and redesigning whole system pathways. Segmenting
the overall workload and deploying staff such as GPwER (GP with extended
roles), specialist nurses and specialty doctors offer opportunities to improve the
flow of patients and to create new and more effective models. This could include
segmentation by treatment type as well as thinking about how referral, diagnosis,
treatment and follow up should be managed. For example, there is evidence that
a significant proportion of the workload is follow-up care, which can be managed
differently to referral and diagnosis, where there is a need for more specialist
expertise.
Work is underway in the GM North West Sector to develop a set of proposals for
redesigning pathways and models of care for managing dermatological demand and
capacity. It is intended to revisit this approach along with the workforce strategy that
is being developed as this work unfolds.
The interventions in this document, along with the system wide mandated
interventions will support the development of experts in larger practices; along
with improved education and training, including targeted continuing professional
development, could help address this deficit.
Good Practice Framework Dermatology10
Further Information
Examples, Benefits, Resources
Public Health
Examples Benefits References
Community Web-based Information
Online tools are freely ●● Supports a population GM Population
available such as clinically level focus Health Plan
approved websites and
●● Increases quality and
webinars, workshops to upskill
amount of information
patients and enable a better
available to patients
understanding of their condition.
●● Increases patient
Good consistent (trusted/ understanding of their
approved) information made condition
available in ‘regular’ places
●● Increases patients ability
e.g.media/hairdressers/barbers/
to self manage
schools/nursery
The use of Community health
ambassadors have been
effective in GM cancer and
Vanguards
Social Prescribing
The VCSE should be part of ●● Supports a population
the pathway and service offer level focus
to support self management
education; peer support; health
coaching; group activities and
supporting wider asset based
approaches
Greater Manchester Health and Social Care Partnership11
Further Information continued
Examples, Benefits, Resources
Self Management and Shared Decision Making
Examples Benefits References
Pharmacy Advice
Supports patients to self
manage and medication
adherence (reduced
adherence to dermatological
treatment occurs in 34-
45% of patients)
Information to support medication adherence
Patient education videos on Supports patients to self
common skin conditions, to manage and medication
support patients after diagnosis adherence.
– focusing on application of the
common treatments.
Patient Education
Patient education delivered by: The majority of people
Ladders, Web, pharmacy, health with dermatological
professionals, Mapmypsoriasis conditions self-care: some
(Health innovation Manchester) estimates put this as high
as 86%. Health education
Patient Passports help to
videos play an important
educate and empower patients
role in getting patients
to self-manage their condition. If
engaged and activated in
taken to appointments, patient
their care.
passports can provide a written
record of the steps patients are When patients are engaged,
already taking to self-manage they become more actively
their condition and have the involved in their own
potential to support shared healthcare, leading to lower
decision making about their costs and better outcomes.
care.
Good Practice Framework Dermatology12
Further Information continued
Examples, Benefits, Resources
Rethinking Referrals
Examples Benefits References
GM Dermatology Referral Guidelines
Implementing GM dermatology ●● Provides a consistent GM Pathways
education pathways – acne, and standardised
psoriasis, eczema, actinic guidance for patient
keratosis, warts. referral management.
Community Champions
Practices or groups of practices ●● Over time this contribute
would benefit from having a GP to supporting a
with further training and links to continued programme of
the consultant service to help education and training
them keep up to date provide
advice and training. This could
be a networked arrangement or
on a wider sector level footing.
In addition to champions peer
review and audit are effective in
improving diagnosis and referral.
Dermatoscopes
Roll out in Stockport ●● Education and Rightcare DoH
communication to
primary care – to
improve the knowledge
of GPs and support
patients being managed
appropriately within
primary care
Greater Manchester Health and Social Care Partnership13
Further Information continued
Examples, Benefits, Resources
Telederm
Tele-dermatology should be ●● Tele-dermatology to The Kings Fund
supplementary to a specialist support primary care
service, but there are areas education, improve the
where a robust teledermatology triage of referrals and to
service could enable limited provide better access to
consultant resources to go specialist opinion in rural
further. and remote areas
Clinician-to-clinician support ●● Supports triage and
(either by email or real time referral management
communication) is valuable. – to facilitate patients
being streamed into the
right service
Transforming Out-patients
Examples Benefits References
Community Rapid Access Hot Clinics
Face to face appointments with ●● Improves the accuracy GM Pathways
hospital specialists should be of referral destination.
reserved for those patients who
●● Clinical triage can be
will benefit from this encounter,
successful in diverting
either because there is a need for
referrals to alternative
delivery of significant diagnoses
out-of-hospital services.
/ management discussions that
would not be appropriate to be ●● Avoids inappropriate
discussed by other means or referrals
because there are procedures/ ●● Improves the quality of
diagnostics which need to be referrals and ensures
undertaken. that patients are
directed to the right
One-stop clinics, where patients
setting first time.
may receive tests, diagnostics
and in some cases treatment
within a single appointment in
one location, reducing the total
number of appointments required
Good Practice Framework Dermatology14
Further Information continued
Examples, Benefits, Resources
Transforming Out-patients
Examples Benefits References
GP community dermatology clinics
Virtual Reporting and follow up
Alternatives to traditional face- ●● Strengthens
to-face clinics include: dermatology
●● virtual clinics –over email, assessment and care in
skype or telephone; primary care
●● group consultations–more ●● Virtual interactions
than one patient or clinician; have the potential to
●● nurse or other healthcare free up clinician time
professional led and appointment slots,
consultations by reducing the time
and space required for
The range of consultation patient interactions and
types will be most effective reducing DNA rates
at managing demand and
improving experience, when
combined with mechanisms to
allow patients to choose when
and how they will receive care
Greater Manchester Health and Social Care Partnership15
Supporting Case Studies
Stockport – 100 Day Challenge Team
(Source – NHSE Dermatology Elective Care Handbook)
Telederm
What was the idea?
To expand the use of a tele-dermatology app from five to 10 GP practices in
Stockport.
Why here, and why now?
Under the wider Stockport Together programme there is an ambition to reduce
outpatient attendances by 55 to 65% over the next three years. As part of the
dermatology team’s work towards this, they aimed to redesign the traditional
dermatology GP to hospital pathway of care, where patients can wait 16 weeks to be
seen at the hospital. With five GP practices already using teledermatology, it was felt
that the 100 Day Challenge was an ideal opportunity to roll this platform out further.
Headlines achievements/impact
From the five practices piloted:
●● 68 referrals to consultants for advice and guidance were made during 100 days.
●● Of these, 71% were deflected back to primary care with appropriate advice and
guidance given.
●● Nearly all (99%) of referrals to consultants for advice and guidance were
responded to in the same day (compared to a three or four month waiting list for
a face-to-face outpatient appointment).
●● GPs supplied good-quality images – only 12% of referrals were rejected due to
inadequate images.
●● Three skin cancer patients were identified via teledermatology.
How did you do it?
●● Software used was integrated with NHS IT systems already in place and
relationships built with the technology provider team.
●● Demonstrations given at the GP practices by the software provider MDSAS who
ran a short training and Q+A session for the pilot practices.
●● Communicated updates with the team, such as when GP practices have ‘gone
live’ with teledermatology so dermatologists expected additional referrals.
●● Filmed and shared an information video for local practitioners explaining
teledermatology through working with the CCG communication lead, including
filming a person with lived experience who had used the service.
●● Tested and adapted the referral process in response to feedback from clinicians.
Good Practice Framework Dermatology16
Supporting Case Studies continued
Lincolnshire – 100 Day Challenge Team
(Source – NHSE Dermatology Elective Care Handbook)
One-stop Clinic
What was the idea?
To trial consultant-led triage (spot clinics) in the community that GPs can refer to
directly for those patients where the GP believes the issue is not cancerous but is
unsure of the diagnosis.
Why here, and why now?
Since 2005/06, outpatient appointments in Lincolnshire have doubled. Two week
wait referrals have increased 57% in the last five years and now account for a
third of referral activity. This leads to significant delays in the standard pathway.
A significant part of the workload in dermatology includes skin tumours (benign,
precancerous and malignant lesions) many of which can be addressed in a spot
clinic. The spot clinic model is being used as a basis to develop a one stop clinic
and a self-referral clinic. It is hoped that as the clinics develop, GPs will be able to
join the consultations for education purposes.
Headlines achievements/impact
●● 73 patients were seen at four spot clinics, held over a four-week period.
●● 43% of cases were diverted away from secondary care (either requiring no
further treatment or treatment from GP only). A further 9% of people were
referred directly for surgery in the community.
●● Patient satisfaction scores were very high on every area: 100% of patients rated
the clinic as good or excellent Cost saving of £4,688 was recorded across the
four weeks. This figure was calculated by subtracting the cost of running the
clinic from the money saved through avoided referrals.
How did you do it?
●● The weekly clinics involve short consultations enabling consultants to see and
triage around 24 patients in two hours.
●● Triage is consultant-led in the spot clinic.
●● Patient pathway was developed, staff trained in the process, and GPs engaged
with.
●● Worked with the ‘Choose and Book’ team to agree a process for referrals to be
made directly into the spot clinics by GPs.
●● Patients have clear next steps if an onward referral was required. If no further
appointments were necessary, it was ensured patients understood this.
Greater Manchester Health and Social Care Partnership17
Supporting Case Studies continued
Stockport – 100 Day Challenge Team
One Stop Clinic for 2 week referrals
What was the idea?
To offer patients being seen in an outpatient clinic the opportunity to have their
procedure done on the same day as their clinic appointment.
Why here, and why now?
Under the wider Stockport Together programme, there is an ambition to reduce
outpatient attendances by 55 to 65% over the next three years. The dermatology
team also wanted to focus on addressing the current long waiting times. Stepping
Hill Hospital has high demand for dermatology theatre appointments in the two week
wait service (approximately 15 days) and as a result, patients can experience delays
in this pathway. By offering two week wait patients a same-day procedure, the aim
was to reduce their overall pathway length by up to 14 days.
Headlines achievements/impact
Over a 6 week period:
●● Of 100 patients listed for a procedure, 68 had their procedure done on the same
day as their clinic appointment.
●● Average theatre waiting time for two week wait patients fell by 13 days from 15
days to two days (15 patients audited in March 2017 compared to 15 in March
2018).
●● Positive response from patients, clinicians, nurses, administration and
management teams: 90% of one stop patients surveyed said they preferred
having the procedure done on the same day compared to coming back another
time
How did you do it?
●● The team employed a whole-system approach including input from consultants,
nurses, a service manager, commissioners, a representative from the British
Association of Dermatologists and administrative staff.
●● Letters including specifically designed clinic information sent to the patient in
advance.
●● A one stop rota for a trial month, designated theatres that could be used as part
of one stop clinics.
●● Encouraged live feedback from clinicians to management team and made
changes for next clinics throughout 100 days.
●● Completed a qualitative telephone survey with 10 patients attending a one stop
clinic to get their feedback.
Good Practice Framework Dermatology18
Supporting Case Studies continued
Wigan
Community Rapid Access/Hot Clinic
What was the idea?
A Community rapid access/hot clinics.
Why here, and why now?
Headlines achievements/impact
●● Only the patients that need to be seen are seen.
●● Supports early and quick diagnosis
How did you do it?
●● Joint clinics (consultant/GPSI/nurse/psychologist) offering a holistic, including
psychosocial aspects.
●● Patients are discharged with an open appointment and so can self-refer when
they need to. They will then be seen within two weeks
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