Bringing it all together: new guidance for commissioners

1
Bringing it all together new guidance for
commissioners

• Julia Schofield
• Principal Lecturer
• Postgraduate Medical School
• University of Hertfordshire
• Consultant Dermatologist
• United Lincolnshire Hospitals

2
(No Transcript)
3
2006 Our Health Our Care Our Say

• White Paper Jan 2006
• Our Health Our Care Our Say
• Chapter 6 Care Closer to home
• No compromise on quality of care
• Speciality subgroups to advise on implementation
• Dermatology one of the groups

4
Shifting care report 2007

• NHS reform provides real challenges to providing
  seamless care
• Cost per case is a disincentive to refer
  patients
• Need for health communities, both commissioners
  and providers of care to work together
• Guidance needed for commissioners

5
2008 Guidance for those commissioning services
for people with skin conditions
Stakeholder Steering Group, Chair Robin Graham
Brown Skin Care Campaign, BAD, PCDS, RCGP,
BDNG Pharmacy, Management
Project Team Input of PCT commissioners
Published early July 2008 NHS Primary care
Contracting Launch event Feb12th 2009
6
2008 Guidance for commissioners

• Uses the commissioning cycle
• Links to other documents
• Importance of people and patients in shaping
  services
• Considers all skin disease not just dermatology
• Incorporates recommendations from Shifting Care
  report

7
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
8
First step develop a local stakeholder group

• Patients and public
• Facilitated by commissioners
• Local providers in primary and secondary care
• Network Skin Cancer Tumour Site Specific Group
  lead
• Public health doctors
• Information analyst/data analyst
• ..and any other local stakeholders

9
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
10
What is need?

• Need is the ability to benefit from care
• Williams HC. J Roy Coll Physicians 199731261-2

The use of the biological agents to treat
psoriasis
The use of isotretinoin to treat acne
11
What is a needs assessment?

• 1. The burden of disease
• Prevalence and incidence
• Impact on quality of life
• Economic burden

• 2. Managing the burden
• The services available
• The effectiveness of those services

3. Recommendations for models of care and
delivery of services to manage the need
12
The updated UK dermatology HCNA

• 1997
• Dermatology Health Care Needs Assessment
• Hywel Williams, Radcliffe Medical Publishing
• 2009
• JK Schofield, D Grindlay H Williams
• Centre of Evidenced Based Dermatology, Nottingham

What does it tell us?
13
UK Prevalence and incidence
Deaths
3752
Referred for NHS specialist care
0.75 million
21 persons consulting 10.7 million
Primary Care
50 population approx 25 million
Self reported/ self managed skin disease
14
UK Prevalence and incidence
Deaths
3752
Referred for NHS specialist care
0.75 million
21 persons consulting 10.7 million
Primary Care
Self reported/ self managed skin disease
50 population approx 25 million
15
Assess needs who sees what and where?

• Primary care
• Skin infections

16
Assess needs what conditions are common?

• Acne (5 of15-24yr olds)
• Atopic eczema (20 under 5s)
• Psoriasis (I.5)

17
Needs assessment who sees what and where?

• Specialist care
• Skin lesions 45-60

• Primary care
• Skin infections

31-59 are for diagnosis skin lesions even
higher
18
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
19
Dermatology commissioning cycle review current
service provision

• Define current pathways
• Process map patient journey
• Identify bottlenecks
• Scoping exercises where data is missing
• Data and knowledge must influence service
  provision
• What works well, what works badly?

20
Skin disease the diagnostic bottleneck
Treatment Surgery
Specialist opinion, diagnostic service
CORRECT DIAGNOSIS CORRECT MANAGEMENT
Patients with skin disease requiring diagnosis
and management
21
Dermatology commissioning cycle review current
service provision

• Casemix information primary care (remember nurse
  practitioners)
• Referral rates for different diagnoses
• Specialist services casemix
• New to follow up ratios with diagnostic
  information

22
Dermatology commissioning cycle review current
service provision

• Accurate data primary and secondary care
• Activity related to skin disease in all settings
• Include community leg ulcer services and wound
  care
• Activity performed by ALL skin surgery service
  providers

23
CURRENT SERVICE skin surgery

• Baseline audit of surgery performed in Primary
  Care
• PCT enhanced services records
• Diagnoses and indications for surgery
• Audit Primary Care cancer excisions
• Identify practices performing regular skin
  surgery

24
PATIENT with skin disease seen by GP
CURRENT SERVICE care pathway
Consultant Dermatologist clinical triage
50 SKIN LESIONS FOR DIAGNOSIS AND TREATMENT OF
SKIN CANCER
50 RASHES FOR DIAGNOSIS AND TREATMENT
URGENT Within 2 weeks
ROUTINE 5 weeks
ROUTINE 5 weeks
DERMATOLOGY SPECIALIST SECONDARY CARE SERVICE
25
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
26
The commissioning cycle decide priorities

• While local commissioning is bound to make best
  use of the skills and resources available,
  national standards should be set as to what and
  what is not eligible for NHS treatment as a
  safeguard against the postcode lottery effect.

27
Dermatology commissioning cycle decide priorities

• MUST dos
• NICE IOG skin cancer and biologics for psoriasis
• DH access targets 31/62 days for cancer
• 18 week patient journey
• Choose and Book
• Care Closer to Home recommendations

28
Dermatology commissioning cycle decide priorities

• Review local low priority frameworks that relate
  to skin disease
• Skin surgery
• Lymphoedema services
• Fungal nail infection treatment
• Botulinum toxin services
• Health promotion skin cancer
• One pot spent well

29
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
30
Dermatology commissioning cycle design the
service

• Review national guidance about models of care
• Care Closer To Home
• Dermatology Workforce group
• NICE skin cancer IOG model
• Rapid access to diagnosis
• Right place, right person, first time
• Consider local resources people, facilities

31
Care Closer to Home 2007 Figure 2 Dermatology
patient journey (source modified from Model of
Integrated Service Delivery. Skin Care Campaign
2007)
The Patient
Patient support groups
Drop-in Centre
Discharge
Pharmacist
The facility to refer directly to secondary care
services is essential
GP
Diagnosis and treatment
2 week wait cancer pathway
Referral management
GPwSI/PwSI (where appointed)
Diagnosis and specialist treatment
Secondary care
Where referral management schemes are in place
it is essential that these are led by experienced
specialist clinical triage performed daily to
reduce delays
Tertiary (supra-specialist care)
32
Dermatology commissioning cycle design the
service

• Primary Care dermatology services
• Community services
• Local specialist services (allergy, vulva,
  transplant clinic)
• Links to regional and national specialist
  services
• Services for sick patients in hospital
• Day treatment OP phototherapy services

33
COMMUNITY SKIN CANCER SERVICES
PCT accreditation, PCT performers list PCT
governance framework
Acute Trust/Secondary care provider governance
frameworks
Outreach service from local dermatology department
Dermatology GPwSI
Local Skin Cancer MDT
Diagnosis management plan Consultant outreach
or NCCG
Diagnosis and management of low risk BCCs
Surgery by NCCG or other medical practitioner
Surgery by specialist nurse
SS Cancer MDT
34
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
35
The commissioning cycle Shape the structure of
supply
NHS staff providing specialist care Nurses,
AHPs, Medical/Consultant staff
Accredited Practitioners with a Specialist
Interest (PwSI) GPwSI, PhwSI
Specialist care
Practice nurses, community nurses, pharmacists
General Practitioner
Generalist care
Self management
Self care, patients their organisations
relatives and friends
Pharmacists, school nurses, teachers
36
Dermatology commissioning cycle shape the supply

• Important principles
• Joined up services integrated models
• Local resources local solutions
• Quality same wherever and whoever provides the
  service (OHOCOS 2006)
• Robust standards of accreditation
• Competency based assessments supervised practice

37

Dermatology commissioning cycle Shaping the
supply
Specialised services in community settings can be
delivered by a range of clinicians
38
Dermatology commissioning cycle shape the supply

• Clear quality standards for
• GPs and other primary care health professionals
• Consultants,
• GPwSIs
• Non Consultant Career Grade doctors
• Specialist nurses
• Pharmacists
• Expert patients

39
Shaping the structure of supply

• Use national guidance
• Consider facilities, record keeping, data
  collection
• Competency based on formal assessment and
  supervision
• Mandatory framework for PwSIs

40
IMPORTANT NOTE FOR COMMISSIONERS IN RESPECT OF
SKIN SURGERY SERVICES

• For patients having skin surgery, they should
  ensure that
• The procedure was necessary
• Appropriate to have the procedure performed
• The appropriate procedure was performed
• That the clinician was suitably trained
• That the facilities were to the appropriate
  standard
• To reduce unnecessary and inappropriate skin
  surgery being performed good diagnostic skills
  are essential and all clinicians performing skin
  surgery should be strongly encouraged to improve
  their diagnostic skills.

41
GPs performing skin surgery only (Groups SS1 and
SS2)
SERVICES PROVIDED
ASSESSMENT
Clinical assessment (modified mini-CEX) x 2
relating to benign and malignant skin
lesions DOPS1
Group SS1 Providing basic skin surgery
Group SS1 Providing basic and more advanced skin
surgery
Clinical assessment (modified mini-CEX) x 2
relating to benign and malignant skin
lesions DOPS1 and DOPS2
42
2008 Guidance for commissioners uses the
commissioning cycle
From Health reform in England update and
commissioning framework annex DH 2006
43
The commissioning cycle manage quality
performance and outcomes

• Patient experience process measures
• Clinical outcome measures NICE
• Specific quality of life (QoL) measures
• Atopic eczema
• Psoriasis
• Acne
• Patient related outcome measures (PROMs)
• Quality demonstration of competencies of staff

44
2008 What should patients expect?

• To be invited to be involved in discussions about
  designing the service
• To see the right person, right place FIRST time
• Care closer to home but not at expense of quality
• Services that are patient centred
• Referral to starting treatment of less than 18
  weeks
• We hope the new guidance will make this happen

45
Commissioning dermatology services key messages

• Include all stakeholders
• Patient centred care
• Integrated services
• Must dos
• QUALITY
• Access
• Financial flows come later (!)

46
Right person, right place, first time
Thank you