Dermatology in the UK: time for a check-up?
Addressing gaps in care
The public health burden of atopic dermatitis (AD) is significant, owing in part to the high prevalence of this chronic inflammatory skin condition. According to recent estimates from the World Health Organization (WHO) Global Burden of Diseases initiative, more than 230 million people globally have atopic eczema or AD,1 and it is one of the most common skin conditions. The Global Burden of Disease project has shown that skin diseases continue to be the fourth leading cause of non-fatal disability worldwide.1
The new Skincare & Dermatology 2019 special report, issued in The Times this week, is therefore a welcome and timely publication. The report highlights a number of thought-provoking subjects, such as mental health and the role of new technology and teledermatology (stay tuned for coverage on these topics), and ends with a comment on how “patients with skin disease deserve better”. So, the question remains, why are we falling short of delivering more satisfying outcomes for patients with skin disease, and how can we move forward?
The first editorial of the report, “Tackling misconceptions in an under-resourced sector”, sheds some light on this and provides some surprising recent statistics from the United Kingdom (UK). For example, there were 13 million primary care (general practitioners [GP]) consultations for skin disorders on the NHS in 2017-18, at a cost of £723 million. GP referrals for dermatology also increased by 15% between 2013-14 and 2017-18, and 880k referrals were made to specialists during 2017-18. Yet, even though 25% of GP consultations are skin related, there are fewer than 1,500 consultant dermatologists in the UK.
“Most medical schools offer only up to two weeks dermatology education. Clinics are overburdened with a two-week wait for skin cancer referrals, yet the majority seen are not cancer. GPs and primary care clinicians don’t feel suitably equipped to manage skin conditions, including lesions, in the community.”
Dr Angelika Razzaque
Executive chair, Primary Care Dermatology Society (PCDS)
Dermatology skills: stepping up the game
Healthcare professionals insist that patients’ first port of call over any skin worry should be their GP, who should be able to make a referral to a qualified dermatologist if there is real cause for concern. However, it is rarely an area of strategic focus and GPs may have spent less than two weeks of their medical school training learning about its complexities.
Dr Adam Friedmann, consultant dermatologist at The Dermatology Partnership and formerly dermatology teaching lead for University College London medical students, highlights the “enormous” skills gap in primary and secondary caregivers that needs to be addressed. Dr Angelika Razzaque, executive chair of the Primary Care Dermatology Society (PCDS), also agrees that doctors need to improve their skills in dermatology. Dr Razzaque insists: “Most important is that clinicians have enough time to communicate with patients and involve them in decision-making. Closer working between primary and secondary care would be highly beneficial to patients and increase safety and satisfaction.”
“Expertise in dermatology is an extreme rarity. To become a consultant dermatologist usually takes seven to ten years of training exclusively in dermatology. By comparison, general practitioners receive little training in dermatology. For example, in medical school, sometimes as little as only a single week is set aside for teaching dermatology over a five-year course. Given that 15% to 20% of the GP’s workload comprises skin disease, this is clearly disproportionate.”
Dr Adam Friedmann Consultant dermatologist,
The Dermatology Partnership
In recent years, several studies have identified the skin disease-related gaps in knowledge and competence among health professionals working in primary care.2-7 For example, one study that employed a questionnaire to 63 countries showed that 55.8% of 692 responders (the majority of which were medical doctors) perceived their knowledge level of AD to be ‘adequate’.2
They also found that the preferred learning modalities were online guidelines (69.6%) and courses (68.8%) followed closely structured online modules (63.9%).2
Other studies have reported dissonance in the relationship between health professionals, patients and carers in treating and managing their skin condition in primary care.8-14
For example, interviews with GPs and parents of children with eczema identified divergent views between parents and clinicians regarding the cause and treatment of eczema.9 The authors reported that this dissonance will likely only be bridged by clinicians actively seeking out opinions and sharing rationale for their approach to treatment. The authors concluded that involving parents in treatment decisions could improve the management of eczema and patient outcomes.9
The Skincare & Dermatology special report explores how a lack of training and general understanding is leading to a dermatological skills shortage.
Action Eczema is proud to support the PCDS call for better education and workforce training in dermatology.
As a global learning community designed to support all health professionals involved in the care of patients with AD, we provide a range of online CME courses to facilitate increased knowledge, competence, confidence, and performance.
Visit out portfolio and take our ‘self-assessment in atopic dermatitis’ today to test your knowledge of eczema management.
Click here to be kept informed about further educational activities.
1. Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global skin disease morbidity and mortality: an update from the Global Burden of Disease study 2013. JAMA Dermatol. 2017;153(5):406-412.
2. Ryan D, Angier E, Gomez M, et al. Results of an allergy educational needs questionnaire for primary care. Allergy. 2017;72(7):1123-1128.
3. Carey N, Courtenay M, Stenner K. The prescribing practices of nurses who care for patients with skin conditions: a questionnaire survey. J Clin Nurs. 2013;22(13-14):2064-2076.
4. Schopf T, Flytkjær V. Doctors and nurses benefit from interprofessional online education in dermatology. BMC Med Educ. 2011;11(1):84.
5. Ellis J, Rafi I, Smith H, Sheikh A. Identifying current training provision and future training needs in allergy available for UK general practice trainees: national cross-sectional survey of General Practitioner Specialist Training programme directors. Prim Care Respir J. 2012;22(1):19.
6. Schofield JK, Fleming D, Grindlay D, Williams H. Skin conditions are the commonest new reason people present to general practitioners in England and Wales. Br J Dermatol. 2011;165(5):1044-1050.
7. Munidasa D, Lloyd-Lavery A, Burge S, McPherson T. What should general practice trainees learn about atopic eczema?. J Clin Med. 2015;(2):360-368.
8. Meintjes KF, Nolte AG. Primary health care management challenges for childhood atopic eczema as experienced by the parents in a Gauteng district in South Africa. Health SA Gesondheid. 2016;21(1):315-322.
9. Powell K, Le Roux E, Banks J, Ridd MJ. GP and parent dissonance about the assessment and treatment of childhood eczema in primary care: a qualitative study. BMJ Open. 2018;8(2):e019633.
10. Powell K, Le Roux E, Banks JP, Ridd MJ. Developing a written action plan for children with eczema: a qualitative study. Br J Gen Pract. 2018;68(667):e81-89.
11. Santer M, Burgess H, Yardley L, et al. Experiences of carers managing childhood eczema and their views on its treatment: a qualitative study. Br J Gen Pract. 2012;62(597):e261-267.
12. Smith SD, Hong E, Fearns S, Blaszczynski A, Fischer G. Corticosteroid phobia and other confounders in the treatment of childhood atopic dermatitis explored using parent focus groups. Australas J Dermatol. 2010;51(3):168-174.
13. Le Roux E, Powell K, Banks JP, Ridd MJ. GPs’ experiences of diagnosing and managing childhood eczema: a qualitative study in primary care. Br J Gen Pract. 2018;68(667):e73-80.
14. Rübsam ML, Esch M, Baum E, Bösner S. Diagnosing skin disease in primary care: a qualitative study of GPs’ approaches. Fam Pract. 2015;32(5):591-595.