“Working together better” Dermatology 12 th April 2007 Catherine Smith Clinical Lead for Dermatology St Johns Institute of Dermatology GSTT

St Johns Institute of Dermatology: what are we? Largest UK centre for patients with skin disease Clinical service (GSTT) Research (GKT, Kings College London) Training and education

Clinical Service General Dermatology Specialist Services*  Skin Cancer: lymphoma, melanoma  Inflammatory Skin Disease: Psoriasis, Eczema Blistering disease  Cutaneous Allergy: Contact dermatitis, urticaria Mastocytosis  Genetic Skin Disease  Vulval and Oral Dermatoses  Specialised Diagnostic Laboratory services *includes all those cited in the National Specialist Services Definition Set for Dermatology

Clinical Service: Access General dermatology –Standard referral letter –Choose and Book –Current waiting times 5-6 weeks for routine OPD Suspected skin cancer –via standard 2WW proforma Emergency referrals –On call SpR available 9am-9pm Monday to Friday 9am-1pm Saturday, Sunday

Current Issues for Dermatology Services: Background ‘Our health, our care, our say: a new direction for community services’ (2006) –‘…to ensure the delivery of the most appropriate care to patients in the most appropriate setting in clinical terms, whilst demonstrating the most effective use of available resources’ New Targets –By 2008, no one will wait longer than 18 weeks from GP referral to hospital treatment –5 weeks for first outpatient consultation –6 weeks for diagnostics New guidelines relevant to dermatology services –Improving Outcomes Guidance (IOG) for skin cancer (2006) –Management of paediatric atopic eczema (expected 2008) New funding arrangements –Payment By Results –Practice Based Commissioning Drive for major service redesign and effective referral management

Current Issues for Dermatology Services: Background Dermatology services remain a major focus in the context of this agenda Two out of ‘Top Ten Tips’ in DOH guide to practice based commissioning focus on dermatology services  Nurse led community services for childhood atopic eczema  GPSI led ‘intermediary’ community services Implications for Education, Training, Research and provision of Specialist Services not addressed in detail

Plans and progress to date Established Dermatology Steering Group Purpose: to develop and implement strategy to ensure continued access to comprehensive dermatology services for patients Progress to date: –Agree referral criteria for atopic dermatitis, psoriasis, acne (checklists) –Agree conditions for which treatment is not available on the NHS –Audited current referral practice against national benchmarks to meet demand management agenda –Develop strategy for training and education of primary health care professionals

Methods Proforma developed and reviewed by St Johns staff, PCT (Southwark and Lambeth), interested GPs Layout and data fields revised following pilot in 2 general clinics Period of data collection: –2 weeks –November 13 th -24 rd 2006 –16 lists cancelled due to A/L, S/L (representative) General clinics only Proforma attached to all clinic notes Data entry completed by clinicians in clinic Entered onto spreadsheet; descriptive data analysis

Type of referral Total number of news164 (41%) –Two week cancer wait 14 –New150 –Re-referral10 Total number of follow ups227 (59%) New : follow up ratio1.38 Completed proformas returned for 75% of those attending

Diagnosis* Benign lumps & bumps78 Cancer98 Eczema53 Psoriasis35 Acne19 Urticaria10 Blisters3 Leg ulcers4 Other and not specified**91 *Diagnosis following dermatology consultation ** includes where no data entry given

Inflammatory skin disease (ie: excluding benign skin lesions and skin cancer)

No. of patients seen according to diagnostic category* (*excluding benign lesions, skin cancer and ‘other’)

Number of follow up appointments No. of patients* (* Total number of follow ups seen in any of 6 diagnostic categories given = 128)

Indications for secondary care* (*as defined by PCDS/BAD guidelines)

Summary (1) Response rate 74% 45% of total referrals seen relate to skin tumours (benign and malignant) Of the remaining 55% of patients seen, 29% (n= 114) had eczema, psoriasis and acne New to follow up ratios are below national average A significant cohort of high need patients with skin cancer, psoriasis and eczema are currently on continued, long term follow up in secondary care

Summary (2) Of those patients falling into one of the 6 primary diagnostic categories (eczema, psoriasis, acne, urticaria, blisters, leg ulcer, n= 131) –81% fulfilled PCDS criteria for secondary care –18% (n=24) no data available/no reason given –Commonest reasons cited for for secondary care (across all skin diseases) were Diagnostic uncertainty (30%) Failure of topicals (23%) Need for systemic or phototherapy (22%) Psychological co-morbidity (8%)

Training and education 3 year GSTT charity funded bid developed in collaboration with Lambeth PCT, post graduate centre (VTS) and St Johns ‘Improving dermatology training for general practitioners’ Dermatology Care Module (Nursing and Midwifery, KCL)

Other Service Developments Skin Cancer –Expansion of specialised dermatologic surgery provision –Rapid access skin cancer screening clinic –one of first four services to be integrated into the new cancer centre (Guys) Chronic skin disease –Day Centre for high need patients –Nursing: outreach team, nurse consultant –Chronic disease management pathways Paediatric Dermatology –Paediatric Eczema Clinic –Paediatric Dermatology to be developed alongside Paediatric Allergy services – Eczema education programme Capital projects: move of clinical services to Guys

Clinical News!

Biological therapies approved for psoriasis generic name brand name other name skinjoints T cell targeted alefaceptAmeviveLFA3TIP + efalizumabRaptiva anti CD11a + TNF  blockers etanerceptEnbrelTNF-R ++ infliximabRemicade anti- TNF  ++ adalimumabHumira anti- TNF  +

Qualifying clinical categories for patients with severe disease* At risk of developing (or has developed) clinically important drug-related toxicity Intolerant to standard therapy Unresponsive to standard therapy Disease only controlled by repeated inpatient Rx Standard therapy contra-indicated due to co-existent co- morbidity Life threatening clinical situation Associated psoriatic arthritis fulfilling the British Society of Rheumatology eligibility criteria *BJD 2005; 153:

Toxicity: Anti TNFs versus Efalizumab Adverse effectAnti TNF therapy (etanercept/infliximab) Efalizumab TuberculosisYes – RR 4-8 xNot reported Other infectionsYes – listeriosis, hepatitis (B/C), HIV Yes DemyelinationYes ? RR? Polyradiculopathy Cardiac problemsYes ? RRNot reported ThrombocytopeniaNoYes 1:500 to 1:1000 Drug hepatitisYesNo Disease flareNot reported‘efalizumab rash’ ? PsA All infections? Size of risk CANCER? Size of risk Fewer patients treated overall with efalizumab compared to anti-TNF agents

NICE guidance on skin cancer ‘Referral guidelines for suspected cancer’ –issued June 2005 –covers all cancers (98 pages) –includes specific recommendations on skin – ‘Improving outcomes for people with skin tumours including melanoma’ (IOG) –issued February 2006 –huge document (177 pages) – –3 years allowed for full implementation from date of publication

Referral guidelines for suspected cancer: skin cancer Much of the guideline content is incorporated into the IOG Suspected melanomas and SCCs should be referred urgently (ie 2 week cancer wait proformas) BCCs should be referred non urgently Avoid excision of melanoma in primary care

Referral guidelines for suspected cancer: pigmented lesions 7 point checklist Major features (2) –Change in size –Irregular shape –Irregular colour Minor features (1) –> 7mm –Inflammation –Oozing –Sensation Emphasis on observation over 8 weeks prior to referral for low suspicion lesions

Key Recommendations of Skin Cancer IOG

MDT working Cancer Networks should establish two levels of skin cancer MDT –Local hospital based MDT (LSMDT) –Specialist MDTs based in Cancer Centres (SSMDT). All clinicians who treat patients with any type of skin cancer should be a member of a skin cancer MDT, whether they work in the community or in a hospital setting Expected attendance for GPs – 4x per year

Who can treat what and where? Precancerous Lesions (AKs, Bowen’s)  May be treated and followed up by any GP  If there is doubt about the diagnosis the patient should be referred to the local hospital skin cancer specialist. Low risk BCC  May be diagnosed, treated and followed up by a doctor working in the community who is a member of the local MDT, or a hospital specialist (‘normally a Dermatologist’).

Who can treat what and where? High risk BCC, SCC and MM All patients with skin lesions which are suspicious of these skin cancers, including all suspicious pigmented lesions and skin lesions where the diagnosis is uncertain, should be referred to a hospital specialist (Dermatologist). GPs will no longer ‘be allowed’ to treat these cancers.

High risk BCCs Histological subtype –Morphoiec/infiltrating –Micronodular –Basosquamous Histological features –Invasion below dermis –Perineural invasion Site Other factors –Size, immunosuppression –recurrence