Setting up a community psoriasis clinic sponsored by a pharmaceutical company improved patient care and led to a model framework for collaborating with industry, says Dr Iain Gilmour, chair of Sunderland Commissioning Network, and Eric Harrison, joint management lead.
Psoriasis is a distressing condition and there's a lot of related depression. There is also strong evidence that patients are unhappy with the standard treatments. Failure to collect prescriptions is quite common.
At Sunderland Commissioning Network, we were interested in reducing outpatient referrals and managing more patients in the community. There are 23 practices in our PBC group. We aren't based on localities – we cover practices across Sunderland that shared the same vision, with the aim of seizing the opportunity to develop better services and patient pathways.
We were looking for quick wins in the early days of PBC to demonstrate that it was viable, and identified dermatology as one area where there was scope to do more in the community. A group of GPs sat down with local consultant dermatologists to talk about conditions commonly seen in secondary care. A key mover was Dr Keith Freeman, the first consultant in the country to hold a combined post with the community dermatology service and local hospitals. His role was designed to promote patient-centred services across the primary and secondary care sectors.
The consultants felt often patients were referred at a very early stage where GPs could have done more initial management. We started work on drawing up guidelines to distinguish between patients who should be referred quickly and those with common and mild presentations of psoriasis. (A copy of the guidelines is on the related articles section of this page)
The discussions were very positive – everyone was keen to bring down unnecessary outpatient appointments and offer a better service. The guideline, ‘Psoriasis Therapies Summary Report for Sunderland Commissioning Network', was circulated to practices in November 2008. But we had to find a way to embed that in day-to-day primary care. It's no good just sending guidelines out to sit on a shelf.
We aimed to encourage use of an effective topical agent. The recommended treatments vary according to the type of disease. Dovobet (betamethasone dipropionate and calcipotriol hydrate) is first line for chronic plaque psoriasis, used for a maximum of 3 months when moisturisers alone are ineffective and re-starting when the condition recurs. Other products are suggested for flexural, scalp and facial psoriasis. Patients who do not respond to first-line treatment are prescribed a second topical agent by their GP. If that doesn't work, they are referred to secondary care.
At that stage of PBC we really didn't have the sort of detailed information we have now. It was impossible to say precisely how many dermatology outpatient appointments could be avoided – we were putting a finger in the air. But we worked out that there were just under 1,500 patients prescribed topical treatments for psoriasis every year out of a total patient population of 125,000. We also found 841 patients where these had failed but who remained in primary care. We estimated that switching to more effective treatments could improve outcomes and reduce referrals.
Developing the guideline was a lengthy process. There was a lack of much evidence base for many of the treatments we were prescribing – it's not an area NICE has tackled. So the team of GPs and consultants had to do the groundwork, looking at what is effective, safe and convenient for patients.
We built a consensus, looking carefully at the cost and effectiveness of treatments such as shampoos, ointments and anti-fungals. The guideline had a very positive reception but we had to find a way of making sure it was applied in everyday practice. So we looked at introducing a new service to get the guideline up and running.
Relationship with the PCT
Back in 2008 we didn't have the PBC savings to fund new activity and there was no pump priming available from Sunderland Teaching PCT. In those early days we felt they were paying lip service to PBC. It was a new way of commissioning and they were wary of its long-term viability.
For instance, our proposals for a musculoskeletal Community Assessment and Treatment Service engaged clinicians from both acute and primary care across a range of disciplines from consultant orthopaedic surgeons, consultant rheumatologists, private providers of physiotherapy services, GPs and GPSIs. But towards the end of the project the plans were not accepted by the PCT.
That approach has changed as the policy has developed over three years.
Getting up and running
Even though PCT funding was not available at the time, we realised there was another potential source of support. We had informal contact with Leo Pharma which was aware of our work as their product, Dovobet, was one of those we had independently listed in our psoriasis guideline. We didn't go to any other companies at the time, as Leo was ready, willing and able. But we had to ensure there was a patient-centred approach.
Leo funded two posts, a healthcare specialist who could trawl the records for psoriasis sufferers, and a nurse advisor experienced in reviewing patients. They were both independent, contracted to the service rather than drug company employees. We were never informed about the cost of providing this support. The nurse and specialist went to each practice in the network in turn. The service was run as a contract between the drug company and individual practices. In my own, out of a population of 14,500, we found 549 patients, which was fairly typical.
The specialist sent out a questionnaire, ( to see a copy of the questionnaire go to the related article section of this page) with approval from the patient's GP, to find out how many were satisfied or dissatisfied with their treatment. The nurse advisor collated the responses and prepared a summary sheet for each patient. That information enabled the GP involved to make an informed decision about the appropriate intervention, using the guidelines. So the GPs were in control at each stage.
The nurse ran clinics at each surgery, where patients were assessed in line with our guidance and given information leaflets we had developed to help them manage their condition. Where there was any uncertainty, the nurse would have a conversation with the GP. The patient would be referred back to their GP if necessary for onward referral to secondary care.
There were initial concerns about a potential increase in workload, so we set up a system where one GP in each practice would deal with any patients who needed more attention. In fact, there were only one or two patients per GP in this category. The project ran for a year so all practices had the chance to take part.
Our aim wasn't primarily financial, but about improving patient care. We now know who the patients are and how we can manage them for the best outcomes. Patient feedback demonstrated that they were much more satisfied with their treatment, and we could see there was a more consistent approach to psoriasis management – our prescribing team reported an increase in the use of recommended products. We have had no negative feedback.
Unfortunately, we have not been able to measure any reduction in referrals due to the limitations of our IT system and poor PBC support at that time. It is impossible to identify acne and psoriasis patients in outpatient PBR tariffs.
The project broke down the barriers between primary and secondary care and we built up a much better relationship with our consultant colleagues. They were reaching out into the community, using their skills to support primary care and better management of patients.
This was one of the very first projects to demonstrate that Dr Freeman's model worked – that dermatology isn't primarily a hospital-based specialty and most patients can be managed in the community. There are discussions at regional level about the potential for working groups bringing GPs and dermatologists together, and moving to a national level in line with the Darzi strategy.
I'm sure Leo Pharma will have had a few extra prescriptions but the main attraction for them was establishing some credibility with GPs. They showed that they were interested in improving patient care and supporting the development of services. There was no branding on the patient questionnaires or leaflets – as far as patients were concerned, this was about a better service through their GP practice. It's vital to do the groundwork. You need to get GPs and consultants together to build a consensus about the management of patients, so any clinical decisions are made before any pharmaceutical companies become involved.
We took advice from the PCT's legal team and adopted policies that were in line with their industry collaboration framework. We've since developed our own framework for working with pharma. (To see a copy go to the related article section on this page). It sets out that projects should involve more than one sponsor – all potentially interested parties should be approached. There are now drug companies involved in other projects for diabetes and COPD services.
Our psoriasis guidelines are due for review in February, so we are looking at any new products on the market and talking to our consultant colleagues about developments in psoriasis management. With services in other areas such as COPD, we are working more closely with the other six PBC groups in South Tyne and Wear, so we aren't all climbing the same learning curve separately. We expect that business plans that look at similar areas will integrate to form one pathway.
The World Class Commissioning competencies have encouraged PCTs to be much more supportive. And the success of this and similar projects has helped the PCT to understand how PBC can be used to not only meet DH initiatives or targets but also ensure that patient pathways are designed to ensure that a full consultation is taken and benefits to the patient are realised. The PCT is much more supportive, and has developed a PBC team to help the three local clusters develop. Now the MSK CATS model we designed, with alterations from the PCT, has undergone a tender process and will launch on the 1st April. . We have a greater degree of earned autonomy as they see PBC can deliver and meet their strategic objectives. We make sure any projects we are working on fit within the PCT vision so we can access funding much more readily. The PCT has been quite innovative here. They have created a system for pump priming where a PBC cluster can take a plan to the ‘Directors' Den'. Within an hour or so, a group can secure funding of up to £15,000. Detailed plans can be submitted via the normal business planning process.
Dr Iain Gilmour, Chair, Sunderland Commissioning Network, email – Iain.Gilmour@GP-A89001.NHS.UK. Eric Harrison, joint management lead, email – firstname.lastname@example.org
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