Access

Dermatology is predominantly a hospital outpatient specialty, with the majority of referrals received via GP practices: locally, regionally and nationally. Due to the profusion and variety of different dermatological conditions, a GP can expect to see several patients with skin diseases every day. As such, a comprehensive knowledge of common skin conditions is essential to ensure that patients are referred appropriately (Figure 1).

Patients requiring acute clinical interventions (phototherapy, biologics, monitoring, immunosuppressants, day cases, complex investigations, patch testing) for inflammatory skin disease should be referred under an 18-week pathway (unless urgent) to the hospital outpatient service. The decision to admit or treat in an outpatient setting will be made by the consultant dermatologist. Any patient with a suspected skin cancer should be referred directly to the local skin cancer multidisciplinary team (LSMDT) for review; or to the specialist skin cancer multidisciplinary team (SSMDT) for more specialised surgery, such as Mohs.

Wherever possible, patients with chronic skin conditions, such as eczema and psoriasis, should have access to a specialist. For mild to moderate skin conditions, patients should be referred to a community clinic, run by the hospital; or a community provider, such as a GPwSI (GP with a special interest). Given the visible nature of these diseases, chronic skin conditions can have a psychological impact on patients and subsequently affect their quality of life. Self-referrals should be offered to patients who require long-term treatments or complex management.

Fig 1: Dermatology levels of care

Level of care

Location or setting

Who and what

Community healthcare facility

Acute hospital

Level 1

Self-care/self-management

Some

None

People with skin conditions, their friends and family, books, magazines, television, internet, patient groups, local community pharmacists, Expert Patient Programme (EPP)

Level 2

Generalist care — also known as primary care

All

None

First point of contact care; usually GP or practice nurse. Might include community dermatology nurses and pharmacists with special training in skin problems

  Referral to more specialist services  

In the UK the GP acts as the gatekeeper to access specialist services Interface services, eg liaison services, referral management, teledermatology

Level 3

Intermediate specialist services — also known as Intermediate care, Tier 2 services, Clinical Assessment and Treatment services (CATS)

Most

Some or most if the acute hospital is the most convenient location for most patients

Specialist outreach services from consultants, staff grade and associate specialist doctors and/or dermatology specialist nurses

Accredited GPwSIs

Possibly accredited pharmacists with a special interest in dermatology (PhwSI)

Level 3

Specialist care — also known as secondary care

Some

All

Consultant dermatologists and specialist registrars

Staff grade and associate specialist (SAS) doctors, clinical assistants and hospital practitioners, dermatology specialist nurses, GPwSIs (accredited or in training)

Level 4

Supra-specialist care: regional centre— also known as tertiary care

None (usually)

All

Consultant dermatologists and other healthcare professionals with special skills in the management of complex and/or rare skin disorders

Fig 1 reproduced with permission from: JK Schofield, D Grindlay, HC Williams. Skin conditions in the UK: a health care needs assessment. University of Nottingham: Centre of Evidence Based Dermatology, 2009. Fig 1b: Levels of care and their location. www.nottingham.ac.uk/research/groups/cebd/documents/hcnaskinconditionsuk2009.pdf

21/12/2015