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Make a gpsi dermatology service work for patients and gps

Dr George Moncrieff explains how PBC can be used to run a community dermatology service with the potential to make big savings

Dr George Moncrieff explains how PBC can be used to run a community dermatology service with the potential to make big savings

Skin problems account for 15% of consultations in primary care, yet undergraduate training has been minimal and formal postgraduate experience the exception. Consequently, many GPs feel insecure about managing skin diseases.

There are fewer dermatologists per capita in the UK than other EU countries and secondary care struggles to meet demand, complaining that many referrals are ‘inappropriate'. It is therefore easy to make the case for a dermatology service between primary and secondary care.

Necessary GPSI qualifications

It is essential that the lead GP has credibility. Experience in hospital dermatology,

a recognised postgraduate diploma (such as the Cardiff Diploma in Practical Dermatology) and ideally membership of the Royal College of Physicians should demonstrate sufficient core knowledge.

The RCP has also recently agreed that GPSIs working in appropriate specialties can become affiliated, once vetted by the GP steering group.

In April the Department of Health produced national guidelines for GPSI accreditation, with recommendations on core competencies and implementing care closer to home. See the document at: www.primarycarecontracting.nhs.uk and go to the section PwSI.

My clinic

I have run the North East Oxon dermatology service for our PCT since March 2000. My aim is to provide a high quality primary care opinion with advice on diagnosis and management, ideally in one appointment.

A consultant dermatologist joins me once a month to review selected cases. Roughly 20% of all patients referred to me are seen in this joint clinic, which also provides personal teaching. An experienced dermatology nurse practitioner offers practical advice to appropriate cases in a monthly clinic.

I felt it was essential to start small and build the service gradually, initially limiting access to only a few practices. One of the most valuable advantages I have to offer is rapid access and the volume of referrals could otherwise easily have overwhelmed the clinic's limited capacity.

I consider how I would manage each patient if I were their GP. I specifically discourage complicated patch testing scenarios or suspected cancer which should be referred through the two-week rule. However, I do get requests to look at potentially worrying lesions and consider if referral to secondary care is appropriate.

Patients who might need hospital treatment (such as ultraviolet light) are only referred if they are prepared to travel the 35 miles to the hospital.

My new to follow-up ratio is 1:1.4 including monthly monitoring of Roaccutane and the consultant clinic.

A recent white paper recommended a ratio of 1:1.53 which dermatologists have described as difficult to achieve, though secondary care is responsible for more complex cases.

In 2006 I received 430 new referrals from a population of 56,500 (7.6 per 1,000). The white paper, Our Health, Our Care, Our Say, recommended a target referral rate of only 2.9 per 1,000 population. However, a recent survey of 57 hospital dermatology departments revealed rates between 10 and 22 per 1,000.

Further savings under pbc

The cost for the clinic was negotiated on the basis of one weekly GP session. Additional on-costs and sessional rates for the consultant and nurse practitioner clinics provided a total annual cost to the PCT for the service of £24,000 (see table, left).

Last summer, we formed a PBC group with the same footprint as the previous local PCT, responsible for a total population of about 73,000. The group wanted open access to this clinic for all practices, but two large practices, looking after more than 16,000 patients, were excluded.

My experience has developed and each year fewer patients need to see the consultant. Furthermore, since March last year I have initiated treatment with Roaccutane, rather than bringing all such cases to the consultant. As a result the consultant clinic was becoming underused, yet still ideally available every month. An increased referral base would address that and provide an equitable arrangement across our PBC group (see table, below).

The cost per new referral in 2006 was £56 which is roughly half the secondary care tariff. Using this figure, and analysing the historical referral data of these two additional referring surgeries, I negotiated a straightforward contract to receive their 126 referrals annually from September 2006. This guaranteed a saving of more than £7,000 for the PBC group.

Benefits

For the referring GP, communication is clear and rapid. The correspondence is the only record I keep, usually dictated with the patient present, posted within 24 hours and comprehensively outlining my recommendations and follow-up.

For the patient, access is fast and convenient. It is rare to wait a month for an appointment and ‘urgent' cases are seen immediately. Parking is free and convenient and appointments take into account local issues such as school hours. If appropriate,

I sometimes see patients in their own home.

My experience of general practice and consequently more holistic approach has tremendous advantages. I have developed a dermatology formulary which has been discussed and agreed by all the local GPs, ensuring effective cross-practice management. The consultant enjoys the sessions as the cases are interesting, often challenging, and have been worked up appropriately. For me, it is rewarding to receive requests for advice from respected colleagues. Meeting that investment of trust is challenging and provides a dimension beyond routine general practice.

I keep a record of all referrals from each GP. Providing this service has forged close links with colleagues in neighbouring practices, at the same time as identifying and assisting with any dermatological learning needs. Every year I send a postal questionnaire to a random selection of patients and all the GPs who refer into the service. So far I have been rewarded with very positive comments and gratitude.

A threat to secondary care?

It is important to appreciate that secondary care is threatened by these initiatives that risk taking resources away from units struggling to maintain a service.

Managing straightforward problems with a dramatically lower cost-per-case in primary care is not difficult and obviously makes sense. However, it is unrealistic to assume that secondary care can manage

the more complicated, resource-intensive conditions at the standard tariff. Such ‘cherry-picking' threatens the fragile relationship between primary and secondary care physicians and requires intelligent dialogue. Commissioning must enable a streamlined service that provides both value for money and a competent opinion, rapidly and conveniently.

Problems

So what are the problems? Well, I'm single-handed, so holidays, illness and sabbaticals present a problem. I feel fully supported by the consultant, but without their confidence the service would be vulnerable. My colleagues sometimes expect me to provide an opinion at the limits of my knowledge and it is crucial to appreciate that boundary and not hesitate to admit insecurity and insist on re-direction when appropriate.

I regularly emphasise that I am not a dermatologist, but a GPSI.

Inevitably, the occasional patient fails to keep an appointment only to request another. This puts a huge strain on a service that is already stretched beyond full capacity and is very frustrating.

Each year I have agreed with the PCT that I would manage all referrals as a block contract. In reality, the number of patients referred has exceeded the capacity of the clinic and I have seen extra patients either at the end of the clinic or in normal surgery appointments. It is obviously in my interest to ensure all referrals are ‘appropriate', but as I have very close links with all the referring doctors, this has never been an issue, and my colleagues are happy to accept phone or email advice or an informal opinion.

There are a number of ‘costs' that are not itemised in the contract. My time spent on administration (audits, chasing results, correspondence) is seriously underestimated. I need to keep up to date and the Department of Health recommendation is for a minimum of two days' (15 hours) CPD annually. Superannuation is not included, which is possibly reasonable within the new contract.

Some patients are still referred direct to secondary care, and hospital treatments (such as light therapy or inpatient episodes) are separately accounted. Costs for Roaccutane are compensated by longer-term savings in alternative acne treatments.

The future

Effective management of skin conditions can make a dramatic difference to patients' lives and delivering a first-rate primary care service is achievable and cost-effective. Ensuring secondary care is used appropriately is essential. Perhaps the Government recommendation of only 2.9 referrals per 1,000 population is realistic? Competent clinicians and managers with vision are essential for a successful outcome.

Dr George Moncrieff is a GPSI in Bicester, Oxon


60 second summary


Initiative GPSI service screens all GP dermatological referrals from a population of 56,500 to give advice on diagnosis and management. Letter posted to patient's GP within 24 hours of patient being seen outlining recommendations and follow-up.

Policy links Implementing Care Closer to Home, Department of Health guidance (April 2007).

Staffing Weekly GPSI clinic supported by a monthly dermatology nurse practitioner clinic. A consultant dermatologist also visits once a month to review selected cases.

Cases managed All dermatology cases are seen with the exception of suspected cancer and patch tests. About 20 per cent of patients are treated at the clinic including initiation and monitoring of Roaccutane.

Running costs £24,000 for one year seeing 430 new referrals

Savings Cost per new referral is £56 – roughly half the secondary care tariff bringing savings of £26,230 in 2006. Additional £7,686 savings expected this year across expanded population of 73,000.

Patient benefits • Fast and convenient access for patients with home visiting available when necessary. • Urgent cases seen immediately, routine wait is less than one month.

Contact georgemoncrieff@hotmail.com


pbc business case for including two additional practices

Existing cost of secondary care for ‘additional practices':

126/year @ £117 unit cost (initial appointment only) £14,742

Cost of managing these patients in GPSI clinic:

126/year @ £56 per referral (total cost including follow-up) £7,056

Anticipated saving £7,686

the cost per new referral to the clinic in 2006 was £56 – which is roughly half the secondary care tariff the cost per new referral to the clinic in 2006 was £56 – which is roughly half the secondary care tariff access is fast and convenient for patients and I see some at their home access is fast and convenient for patients and I see some at their home

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