Journal of Integrated Care Pathways > Volume 12, Number 2 > Pp. 67-73

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Opinion

Collaboration across primary and secondary care dermatology services

Simon Hargreaves 

Mill Street Medical Centre, St Helens, UK

Email: simonandkate2000{at}yahoo.co.uk

	ABSTRACT

Top ABSTRACT INTRODUCTION BACKGROUND DEVELOPMENTS IN 2007 ANALYSIS ALTERNATIVE ANALYSES/MODELS OF... SUMMARY APPENDIX 1 APPENDIX 2 References

 
Purpose: The paper demonstrates the complexities of leadership in a local health-care community across primary and secondary care interface, using the example of a general practitioner (GP) with a special interest role (GPwSI) in dermatology. It focuses on how the service will develop and how it could be achieved. Design: Various models and theories about change management were consulted focusing particularly on the goals of the local health-care economy, resources available and environment/contextual surroundings. Practical implications: Primary care trusts (PCTs), acute trusts and clinicians need to work collaboratively to achieve an integrated, flexible care pathway, so that patients and the PCTs can be assured of an efficient and good quality service. Conflicts between primary and secondary care dermatology services are not sustainable for a long period. Originality: The Government's agenda is a shift of care closer to people's homes, so PCTs do need to be aware of what they wish to commission, and consider moving traditional hospital-based facilities into community settings, such as walk-in centres, polyclinics and large health centres, associated with improved GP and patient education on skin problems.

	INTRODUCTION

Top ABSTRACT INTRODUCTION BACKGROUND DEVELOPMENTS IN 2007 ANALYSIS ALTERNATIVE ANALYSES/MODELS OF... SUMMARY APPENDIX 1 APPENDIX 2 References

 
This paper will demonstrate the complexities of leadership in a local health-care community across the primary and secondary care interface using the example of development of a general practitioner (GP) with a special interest role (GPwSI) in dermatology. It will focus on how the service initially started and provide some ideas on how the service could be developed. GpwSIs were first proposed in the NHS Plan 2000 (Box 1).¹

Box 1 Definition of a general practitioner with special interest (GPwSI) General practitioners (GPs) with special interests can supplement their important generalist role by delivering a high quality, improved access service to meet the needs of a single primary care trust (PCT) or group of PCTs. They may deliver a clinical service beyond the normal scope of general practice, undertake advanced procedures or develop services. They will work as partners in a managed service not under direct supervision, keeping within their competencies. They do not offer a full consultant service and will not replace consultants or interfere with access to consultants by local GPs. Their roles will be circumscribed but within their role definition they should offer a high-quality service.'

 

The creation of GPwSI posts followed the realization in 2001 that nationally patients were waiting for more than 13 weeks to see a dermatologist, a rise from 23% to 30%, between 1995–1996 and 2001–2002.¹ The Department of Health, in 2007, published more guidelines on the appointment of GPwSIs.²

Re-designing of the dermatology service locally is an example of ‘allocative efficiency’,^3,4 where, by using different inputs and combining them in new ways, better results and/or greater efficiencies can be made. This compares with ‘technical efficiency, the same thing is done the same way but more efficiently’.

	BACKGROUND

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National

There is some national evidence of fewer follow-up rates in GPwSI clinics compared with hospital outpatient departments.^5,6 Some 15% were referred to minor surgery or for a consultant opinion. The numbers failing to attend were very low (approximately 2%). Another role of the GPwSI is peer education.

Local

St Helens is an industrial town located between Liverpool and Manchester with a population of 190,000. In 2004, the two hospital consultants and primary care trust (PCT) were enthusiastic for a GPwSI service. Secondary care dermatology services had been seeing a steady rise in demand for dermatology opinions. Efforts to reduce waiting times were historically short-term measures, e.g. waiting list initiatives, rather than a long-term review of the structure of dermatology services to meet patient needs. There was an ongoing debate as to whether there was capacity for a third consultant dermatologist in the trust. At the tripartite meetings (i.e. hospital, PCT and myself, as clinician with an interest in primary care dermatology) it was agreed that there were problems in delivering the service, which could be addressed by re-designing the service. The main problem was a diagnostic bottleneck – patients were waiting too long to see a specialist for an initial diagnosis before management could be initiated. We believed that this could be addressed in part by changing the skill mix, in particular, developing a GPwSI role and ensuring that consultants did those things, which only they could do. In doing so, it was hoped that we could balance the needs of the patients with the practicalities of the service. It was agreed that a long-term review of the structure of the dermatology services was required.

It was paramount to involve all clinicians including consultant dermatologists, GPs and nurse clinicians in the decision-making process. This was fairly easy in the early stages because waiting lists were high and the development of a primary care dermatology service met the needs of the trust and the PCT to reduce waiting lists in accordance with Government directives.

Personal profile

In 2004, I completed a 12-month distance-learning diploma in practical dermatology. Prior to this, I had spent several years as a clinical assistant in the speciality, one morning a week. I was now ready, with my experience and my newly extended knowledge to develop a role of GPwSI in dermatology. To that end I entered into discussions with the commissioning department of the PCT and the consultants in dermatology at the local hospital trust.

I was appointed GPwSI in Dermatology in 2006. A dermatology nurse specialist works alongside me with his own caseload. My aim is to try to discharge as many patients as possible back into the care of their own GPs with detailed management plans. GPs would be able to refer directly to GPwSI or to a consultant. Guidelines were issued to GPs about what to and what not to refer to GPwSI (Appendices 1 and 2).

	DEVELOPMENTS IN 2007

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However, in early 2007, a third consultant dermatologist was appointed by the acute trust. A new national system of payment for secondary care services was introduced. Traditionally, the acute trust had block contracts for treating dermatology patients; now a ‘payment by results’ system (PbR),⁷ where money follows the patient into secondary care, has been established. Simultaneously, there also appeared to be a fall in the number of referrals to the dermatology department.

The resulting financial problem has recently led to a more aggressive marketing strategy by the acute trust, which has included letters to GPs advertising their services and educational events for GPs and patients. The last business meeting, in January 2007, between the dermatology unit and the PCT was cancelled with no new date fixed – it is now over 12 months since a meeting was held.

The challenge that lies ahead is how to negotiate on the different priorities of the acute trust and those of the PCT and primary care. The acute trust are keen to increase their workload and see cases of lower clinical priority once again. The PCT and practice-based commissioning (PBC) consortia on the other hand are looking for both financial efficiencies and treating patients nearer to their homes. In my view, these should be dealt with in primary care.

	ANALYSIS

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This raises two questions:

1. The acute trust moved to a competitive approach from a collaborative partnership approach to the issue. By taking this approach, they demonstrate an understandable requirement to meet their own needs first rather than the needs of the PCT. As the power of market forces is unleashed on the NHS, this shall end over-manned, uncompetitive services and the provision of more efficient ones. Will the acute trust be able to maintain this competitive position in the future?
   
2. Where is the real leadership of dermatology services (and perhaps health care in general) by the PCT? The PCT appear to be risk averse, distancing themselves from daily clinical care perhaps due to their primary duty to achieve financial balance. Unless a development is very likely to produce savings, they are hesitant to risk it costing more.
   

There is an opportunity for me, as a GPwSI, to drive forward a medium- to long-term vision of a collaborative approach between the PCT and the acute trust. I have good existing working relationships with colleagues across the interface and could provide clinical leadership in re-designing dermatology services. In identifying joint goals, collaborative partnership requires new thinking, because the problems and opportunities being addressed are complex and the solutions are not readily apparent.

Why do the acute trust and the PCT not currently practice in this way? It seems to me they are:

• Too busy looking after the interests of their own part of the health-care system and not considering the patient or other parts of the local health-care system;
  
• Used for short-term measures only as solutions to problems that arise, e.g. waiting list initiatives rather than radical service re-design;
  
• Not talking to each other and having a shared plan or vision for the future;
  
• Not making good use of the resources available (across the whole health-care system). GPs would benefit from education on management of common dermatology conditions seen in primary care. Appropriate use of skill mix.
  

A ‘third way’ would be for parties to work together in a collaborative partnership, focusing on a vision for patients with skin problems in the local community. My vision, which I hope in time will become a shared vision is

‘to achieve an integrated, flexible, efficient and good quality service for all patients with skin problems in our local community, as near to their homes as practically possible by working together across the primary and secondary care interface’.

The gap between current reality and vision provides, what Senge⁸ called a ‘creative energy’ or ‘creative tension’. The only way this tension is going to be reduced is by either pulling reality nearer the vision or the vision nearer the current reality.

	ALTERNATIVE ANALYSES/MODELS OF SITUATION

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During the preparation for negotiations, the planning must follow the vision. There are various tools that may help to evaluate the problems with the current system and identify possible solutions to meet our goal.

1. One needs to be aware of the resources and the Seven S Model⁹ can be used, which could identify different aspects of our service, which need to support each other. The seven aspects are staff, skills, style, structure, systems, strategy and shared belief. These need to be identified, compared with the goal and each other to identify areas of strengths and weaknesses.
   1. Staff – in primary care, two PCT middle managers, one from commissioning and the other from service delivery. I am the only GPwSI currently but a second one has recently been appointed. One of the hospital nurse specialists does a session alongside my weekly clinic. In hospital there are three consultants, two staff grades, two dermatology nurse specialists and three clinical assistants. They are supported by a directorate manager and other administrative staff;
      
   2. Skills – Doctors generally diagnose and start therapies; the nurses are involved in the management of chronic skin diseases and carrying out therapy;
      
   3. Styles – fairly hierarchical hospital management structure; egalitarian primary care but GPs often distant from each other;
      
   4. Structure – referrals to secondary care or GPwSI; in secondary care, the clinicians work out of three sites;
      
   5. Systems – referral systems, when working well, the more experienced clinicians have the more complex caseload, with more detailed management planning;
      
   6. Strategy – working towards a vision and planning the action;
      
   7. Shared beliefs among the health-care team – it may be difficult to obtain the beliefs that other GPs hold, but brief questionnaires may be useful. The value of understanding the beliefs of others is in creating a service re-design that is practical and has the support of its stakeholders.
      
   
   
2. The PEST analysis¹⁰ is a useful way to consider the environment in which change could happen. PEST is an acronym for Political, Economic, Social and Technological. Opportunities and threats may be identified as factors that may affect service in the surrounding environment.

   (a) Political – shift of care from secondary to primary care¹¹ as part of central government policy; consultant dermatologists meet across the region and use each other for support and can hold strong views.
   

   (b) Economical – PCT constantly requires efficiencies to balance its budget, whereas the acute trust needs increased referrals for PbR, which creates a tension. GPwSI dermatology services have been reported to be similar or more costly than hospital outpatient care.¹²
   

   (c) Social – patients wanting better access, nearer to their homes, more timely and flexibly, supported by GPs. GPwSIs in dermatology are more accessible and preferred by patients than hospital outpatient care.¹³
   

   (d) Technological – clinical audit and satisfaction surveys, which show a very high satisfaction level by the patients seen in the local GPwSI dermatology clinic.
   

   
   
3. A stakeholder analysis¹⁴ can help when targeting arguments. As part of this analysis, there is a need to identify those whose support is essential to implement change and whether indeed they support or oppose change at the outset. Support of the service delivery manager and finance director at the PCT is vital. In contrast, the three consultants will probably stick together and oppose change.
   
4. A force field analysis¹⁵ is a useful technique to look at the enabling factors and the barriers to change. Kurt Lewin described this model, in which he described any current level of performance, as being a state of equilibrium between the driving forces that encourage forward movement and the restraining forces that discourage it. The driving forces are generally positive, reasonable, logical, conscious and economic. Restraining forces are often negative, emotional, illogical and unconscious. Both sets of forces are very real and must be taken into account when dealing with change.
   
5. These analyses illustrate different ways of viewing possible change. A rigorous strengths, weaknesses, opportunities and threats (SWOT) analysis¹⁶ is a well-known technique that remains a useful way to start identifying a small number of issues that are the most important to address. In SWOT, strengths and weaknesses refer to the use of resources within the organization, opportunities and threats to the external environment. When working through a SWOT analysis it is important to keep in mind the vision or mission (Box 2).
   

Box 2 Example of SWOT analysis reflections Weakness? Strategic direction unclear How does this affect ability to achieve mission? Low morale in team What lies behind this? Poor management skills on the part of the team leaders

 

Are there any other models we could learn from?

An emerging model is the ‘Doctors in Chambers’ model.¹⁷ We could form a ‘Dermatology Clinicians in Chambers model’ either locally or regionally. Consultants, hospital middle grades, dermatology nurse specialists and GPwSIs could form an independent body, sitting outside the NHS, which responded to offers of tender from PCTs and secondary care trusts. This could have several advantages:

• Flexible, being able to move resources around at various levels of experience, expertise and training;
  
• Ownership, and perhaps having more control of our professional lives;
  
• Improved patient access and progress through the system;
  
• Increase in productivity, if the whole group worked together.
  

Disadvantages would include:

• Risk of being unable to attract business;
  
• Loss of pension and other financial risks;
  
• Employment law – hospital clinicians have traditionally been satisfied with the security of being employed, with staffing and other administrative duties being done for them. Primary care clinicians are more used to running their own business.
  

So, where do I see dermatology services in our local community in five to 10 years time?

Dermatology is a low-tech specialty, and history shows that such industries cannot survive for a long-term in expensive, protected environments. I think they are largely going to be based in the community, and out-with the district-general hospital – certainly, a shift in that direction; in the same way that psychiatry has shifted from being a hospital-based service to a community-based one; dermatology is largely an outpatient service and the need for inpatient facilities is low. UVB and PUVA cabinets could be based at locations in the community where access is easier, in terms of parking and opening times, e.g. walk-in centres, polyclinic or large health centres. Patients requiring these treatments often need to attend two to three times per week; so easy access is very important to them.

GPs may wish to provide more comprehensive range of dermatology services with appropriate consultation, education and advice from specialists and GPwSIs, rather than the transfer of responsibility of patient care to them.⁵ Patients too, need greater education on self care of their skin problems.

How can this vision be achieved?

The vision needs to be discussed with key stakeholders, first at the PCT and local PBC consortia, then the acute trust and other PCTs who refer to it.

• At the PCT, the involvement of the service delivery manager and finance director is pivotal. They will have details of current activity, in particular the volume of referrals and how it breaks down – what could be seen in primary and secondary care. Exploring their vision and plans would be valuable, especially how they aim to have control of activity, in the light of having a third dermatologist and the possibility that they may start accepting cases of low clinical priority. The PCT may wish to screen all referrals. The PCT can also state that they will not pay for procedures of low clinical priority and consider using penalties with the newly introduced legally binding contracts between commissioner and provider. There is a need to get an understanding of tariffs, enquiring about alternative ways of paying outside the tariff.
  While speaking to the PCT officers, it is worthwhile selling the benefits of the dermatology GPwSI service. Referrals are screened and appointments are not offered to patients with conditions of lower clinical priority. Most patients are discharged back to their GP with a management plan and thus have few follow-ups. Information has been collected on re-attendance rate, discharge figures and patient feedback questionnaires. The session is funded on a sessional basis (not tariff). The service is local and close to patient's homes.
  
• At the acute trust there appear to be two groups of people with whom to negotiate, the management team and the clinicians. The consultants have built up their department over the last five years, and do not now want to see it split up. Five years ago, there was only one consultant who was really struggling with the workload and finding it very difficult to recruit – it is now a thriving little unit with a full complement of consultants, middle grades and nurse specialists. For the trust, this is a potentially profitable department, traditionally with a high level of referrals; in addition, they perform plenty of procedures that can be coded as outpatient or day-case procedures, and thus make the trust money through PbR. They could even start doing the procedures of lower clinical priority, such as skin tags and cysts to increase income. (Over the last five years a lot of good work has been done by the PCT and acute trust to reduce GPs from referring conditions of lower clinical priority.) Inpatient beds can still be kept for the 18-week targets.
  

If the consultants and the acute trust are reluctant to change the patient pathway, then to help focus the PCT, the commissioners (possibly with the support of PBC consortia) need to be clear what they want.

There needs to be a dialogue between different parties, with empathic communication so as to reach a win–win solution, where everyone is happy with the outcome. This may mean that the dermatology team still maintain a base, perhaps at the acute trust, but that more clinical sessions are undertaken in the community, the acute trust paid per session rather than per case on a tariff. Encouraging the dermatology clinicians to undertake more local teaching and training to primary care clinicians would hopefully be rewarding in themselves but hopefully lead to more appropriate referrals. An expansion of the GPwSI service may be considered, but this will require more GPs with the interest and will to train up.

	SUMMARY

Top ABSTRACT INTRODUCTION BACKGROUND DEVELOPMENTS IN 2007 ANALYSIS ALTERNATIVE ANALYSES/MODELS OF... SUMMARY APPENDIX 1 APPENDIX 2 References

 
There are several selling points for a GPwSI service, it is local, has a low follow-up rate, it can manage most of the skin conditions that have been referred to hospital until now, it educates referring primary care clinicians both in clinic letters and educational events, it offers sessional rather than tariff payments, so is relatively cost-efficient, and there is good patient satisfaction feedback.

Acute trusts are at a different stage of working out the ‘new world’. While PCTs have gone through change in the last 12 months, for hospitals the changes are ongoing. Hospitals will need to attract income, and dermatology will be seen as good business – they will get the outpatient tariff without the need for any bed occupancy. There is financially less risk in outpatient rather than inpatient care.

While some acute trusts may give lip service, some may discredit primary care services, others may compete. The evidence so far, is that our local acute trust is planning to compete, withdrawing from meetings, sending letters to GPs ‘advertising’ their services and putting on promotional meetings for patients and GPs. A serious conflict between primary and secondary care dermatology services is not sustainable for a long period. They need to understand each other's perspective and this paper has attempted to illustrate these using different models. The way forward, has to be to work collaboratively to achieve an integrated, flexible care pathway, so that patients and the PCT can be assured of an efficient and good quality service.

	APPENDIX 1

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Conditions appropriate to refer to a general practitioner (GP) with special interest

• Mild to moderate eczema or psoriasis – suitable for treatment with topical therapy
  
• Acne or rosacea (not sufficiently severe to require Isotretinoin)
  
• Chronic or recurrent skin infections (e.g. fungal infections, folliculitis, recurrent bacterial conditions)
  
• Scalp conditions including dermatitis
  
• Seborrhoeic dermatitis
  
• Mild inflammatory skin disease, e.g. Lichen simplex, lichen planus, granuloma annulare
  
• Benign skin tumours – where there is no concern about malignancy. It is not appropriate for moles or other conditions of lower clinical priority to be referred to a GP with special interest or the NHS secondary care service for cosmetic removal
  
• Actinic keratosis
  
• Pigmentary disorders.
  

	APPENDIX 2

Top ABSTRACT INTRODUCTION BACKGROUND DEVELOPMENTS IN 2007 ANALYSIS ALTERNATIVE ANALYSES/MODELS OF... SUMMARY APPENDIX 1 APPENDIX 2 References

 
Conditions which should not be referred to a general practitioner (GP) with special interest

• Suspected skin malignancy including melanoma, SCC. These conditions should be referred to the secondary care skin cancer clinic (two-week rule)
  
• Suspected basal cell carcinoma
  
• Severe and acute skin infections, e.g. kerion, extensive herpes and bullous impetigo
  
• Severe inflammatory skin disease including eczema and psoriasis, which may require secondary care investigations or immunosuppressive treatments
  
• Patients requiring specialist services, e.g. phototherapy, patch tests (NB patch tests only useful for contact skin allergies, neither urticaria nor food allergies)
  
• Acute blistering including bullous pemphigoid and pemphigus
  
• Acne patients requiring Isotretinoin
  
• Rare inherited disorders
  
• Extensive skin disease in systemically ill patients.
  

	Footnotes

 
Dr Simon Hargreaves BSc, MB ChB, MRCGP, DPD, DCH, DFFP, GPwSI, Dermatology, Mill Street Medical Centre, 2 Mill Street, St Helens WA10 2BD, UK.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hargreaves, S. Search for Related Content Social Bookmarking                      What's this?