Challenges in commissioning dermatology services.

constituency of the NHS is currently the subject of widespread debate. Regular contributors include specialist dermatologists, primary care commissioners, practice-based commissioners, general practitioners (GPs) with a special interest (GPwSI) in dermatology and various patient groups (eg Skin Care Campaign, National Eczema Society, Psoriasis Association). Occasional contributions are made by various government agencies, (eg Care Closer to Home committee) and some lobby groups (eg NHS Alliance). Much heat has been generated, but little light. Current policy initiatives from the Department of Health (DH) may unintentionally conspire to reduce the availability of care for patients who require specialist services and this is of concern not only to specialist dermatologists but, more importantly, to patients. The debate began in 2003 with the publication of the Action on dermatology good practice guide which described new models of care for patients with skin disease and involved a number of pilot sites.1 Subsequent publications included Implementing care closer to home – convenient quality care for patients Parts 1–3,2 Improving outcomes for people with skin tumours including melanoma,3 Models of integrated service delivery in dermatology 4 and Staffing and facilities for dermatological units.5 All of these have embedded unifying themes: dermatology services should be provided in the community and in secondary care; they should be of high quality and demonstrably ‘fit for purpose’; access should be convenient for patients; there should be a seamless and invisible interface between primary and secondary care; and, most importantly, (at least for the commissioners) services provided should be financially sustainable. More recently, ‘patient choice’ has been added to the list of essential service attributes, but this can only be exercised when the services of secondary care are required. For patients who are referred to a local intermediate care service, ‘choice’ is not an option. Where referral management centres (clinical assessment and treatment services (CATS)) have been introduced by commissioners, patients are not usually offered the choice of a specialist consultation; they may instead be diverted to a community provider (eg GPwSI, nurse specialist or third-party provider). There is nothing intrinsically wrong in allowing patients to access care more conveniently or with other providers, who must be appropriately accredited, provided that the patient is able to make an informed decision; lack of explicit information usually prevents this. Referral management centres appear to be financially driven; intermediate care (pre-choice, pretariff) can in theory be more cheaply delivered in the community. In practice, services run by GPwSI have been shown to be more expensive than specialist services so any savings may be illusory.6,7 There is also a real risk of destabilising local hospital departments as a result of loss of tariff income. If intermediate, community-based services can ‘cherry pick’ the more straightforward cases, local secondary care departments are left with a cohort of more complex patients whose cost of care cannot be met by the national tariff. Some commissioners now aim to divert up to 50% of dermatology referrals away from specialist units – no department could survive this loss of income. A survey by the British Association of Dermatologists in July 2007 showed that 64% of English departments were affected by local referral management centres, and 46% of these were aiming to move up to 50% of patients away from secondary care. There is no doubt that secondary care provision will always be required for those patients who have serious life-threatening dermatoses, complex disease, and widespread inflammatory conditions that require hospital admission. It is not clear how these patients would be managed (or by whom) if all services were located entirely in the community. In addition, approximately 30% of current dermatology workload is now surgically based and re-providing operating facilities outside hospital would be wasteful and expensive. Specialist training for junior doctors and teaching of medical students would be difficult if all services were dispersed, and future research, which needs a critical mass of experts, would be severely compromised. However, it is equally certain that much basic dermatological care could and should be provided by primary care physicians. Historically, GPs were able to deal with many common skin problems, and most still do so. About 15% of the population consults their GP each year because of a skin complaint and only 5% of these are referred to secondary care. So 95% of patients with skin disease are already dealt with in the community. EDITORIALS