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DRAFT
The National Clinical Programme for Dermatology
Clinical Strategy & Programmes Division, HSE
& the Royal College of Physicians of Ireland
Model of Care for Dermatology
September 2017
September 2017
DRAFT V3.0
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Contents
Acknowledgements ............................................................................................................... 4
Abbreviations ........................................................................................................................ 4
1.0 Contributors & Stakeholders ........................................................................................... 6
1.1 Working Group ............................................................................................................ 6
1.2 Clinical Advisory Group ............................................................................................... 6
2.0 Executive Summary ........................................................................................................ 7
3.0 Dermatology overview ..................................................................................................... 9
3.1 Description of the specialty .......................................................................................... 9
3.2 Skin Cancer ................................................................................................................. 9
3.3 The National Cancer Control Programme – Skin Cancer ........................................... 10
3.4 Psoriasis .................................................................................................................... 11
3.5 Dermatitis .................................................................................................................. 11
3.6 Acne .......................................................................................................................... 12
3.7 Acute Dermatology Service ....................................................................................... 12
3.8 Paediatric Dermatology ............................................................................................. 12
4.0 Background of dermatology in Ireland ........................................................................... 13
4.1 Consultant Dermatologists ......................................................................................... 13
4.2 Specialist Registrar Training in Dermatology ............................................................. 15
4.3 Dermatology Nursing ................................................................................................. 15
4.4 Psychodermatology and allied health professionals ................................................... 17
4.5 The Irish Association of Dermatologists ..................................................................... 17
4.6 The Irish Skin Foundation .......................................................................................... 17
5.0 Overarching aims of the dermatology programme ......................................................... 18
5.1 Quality ....................................................................................................................... 18
5.2 Access ....................................................................................................................... 18
5.3 Value ......................................................................................................................... 19
6.0 Models of Care .............................................................................................................. 20
6.1 Rationale ................................................................................................................... 20
6.2 General Principles underlying Service planning in dermatology ................................. 20
7.0 Key elements of Model of Care ..................................................................................... 22
8.0 Dermatology Clinical Networks ...................................................................................... 23
9.0 Current Organisation of the service and patterns of referral: Patient Journey ................ 24
9.1 Primary care .............................................................................................................. 24
9.2 Secondary Care Dermatology services ...................................................................... 25
9.3 Supra-specialist care ................................................................................................. 29
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10.0 Managing outpatient access ........................................................................................ 32
10.1 Triage of referrals .................................................................................................... 32
10.2 Demand Management and follow up in dermatology ............................................... 32
10.3 Efficient and Innovative ways of dealing with demand ............................................. 32
11.0 Quality and Clinical Governance ................................................................................. 33
11.1 Clinical governance ................................................................................................. 33
11.2 Clinical leadership ................................................................................................... 33
11.3 Clinical effectiveness Use of information and information technology ...................... 33
11.4 Education, training and continuing professional development (CPD) ....................... 33
11.5 Clinical audit ............................................................................................................ 34
11.6 Risk management .................................................................................................... 34
12.0 Collection of data from dermatology departments ....................................................... 35
13.0 Education .................................................................................................................... 38
13.1 Primary Care ........................................................................................................... 38
13.2 Secondary Care ....................................................................................................... 38
14.0 Conclusion .................................................................................................................. 39
References ......................................................................................................................... 40
Appendix 1 Exclusion Letter ................................................................................................ 42
Appendix 2 Waiting lists ...................................................................................................... 43
Appendix 3 Mapping Survey of Dermatology Services 2016 ............................................... 45
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Acknowledgements
Abbreviations
AMNCH Adelaide & Meath Hospital incorporating National Children’s Hospital Tallaght
BAD British Association of Dermatologists
BCC Basal Cell Carcinoma
BIU Business Intelligence Unit
CAG Clinical Advisory Group
CME Continuing Medical Education
CNS Clinical Nurse Specialist
DNA Did not attend
DNC Dermatology Networking Centre
DNE Dublin North East
DOH Department of Health
GP General Practitioner
HIQA Health Information and Quality Authority
HIV Human Immunodeficiency Virus
HSE Health Service Executive
HSH Hume Street Hospital
IAD Irish Association of Dermatologists
ICGP Irish College of General Practitioners
ICHMT Irish Committee on Higher Medical Training
IDNA Irish Dermatology Nursing Association
IMCSR Irish Medical Councils Specialist Register
ISF Irish Skin Foundation
LOS Length of Stay
MDT Multidisciplinary team
MMS Mohs Micrographic Surgery
MMUH Mater Misericordiae University Hospital
NCCP National Cancer Control Programme
NCHD Non-consultant hospital doctor
NHS National Health Service
NICE National Institute for Health and Clinical Excellence
NP New patient
OLCHC Our Lady’s Children’s Hospital Crumlin
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OLOL Our Lady of Lourdes
OPD Out-patients department
OTC Over the counter
PILS Patient Information Leaflets
PSG Patient Support Group
PUVA Psoralen Ultra Violet therapy
RCPG Royal College of General Practitioners
SCC Squamous cell carcinoma
SDU Special Delivery Unit
SIVUH South Infirmary Victoria University Hospital
SJH St James Hospital
SVUH St Vincent’s University Hospital
UCD University College Dublin
UCHG University College Hospital Galway
UVL Ultraviolet Light
WRH Waterford Regional Hospital
WRS Weekly Return Service
WTE Whole Time Equivalent
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1.0 Contributors & Stakeholders
1.1 Working Group Dr Anne – Marie Tobin – Consultant Dermatologist and National Clinical Lead
Kellie Myers – Programme Manager
Sheila Ryan – Nurse Lead
Prof Brian Kirby – Consultant Dermatologist
Dr Sinead Collins – Consultant Dermatologist
Dr Annette Murphy – Consultant Dermatologist
Dr Caitriona Hackett – Consultant Dermatologist
Dr Johnny Burke – Consultant Dermatologist
Dr Patrick Ormond – Consultant Dermatologist
Prof Alan Irvine – Consultant Dermatologist
Susan O’Dwyer – Community Pharmacist
Caroline Irwin – Patient representative
1.2 Clinical Advisory Group
Dr Michelle Murphy- Chairperson
Dr Anne – Marie Tobin – Clinical Lead
Dr Alan Irvine
Dr Annette Murphy
Dr Aoife Lally
Dr Bairbre Wynne
Dr Bart Ramsay
Dr Brian Kirby
Dr Brid O'Donnell
Dr Catherine Gleeson
Dr Catriona Hackett
Dr Cliona Feighery
Dr Dermot McKenna
Dr Emma Shudell
Dr Fergal Moloney
Dr Fiona Browne
Dr Gillian Murphy
Dr Grainne O'Regan
Dr John Bourke
Dr Kashif Ahmad
Prof Louise Barnes
Dr Marina O'Kane
Dr Mary Frances Bennett
Dr Mary Laing
Dr Maureen Connolly
Dr Muireann Roche
Dr Nicola Ralph
Dr Patrick Ormond
Dr Patsy Lenane
Dr Paul Collins
Dr Pauline Marren
Dr Rosemarie Watson
Dr Rupert Barry
Dr Sinead Collins
Dr Sinead Field
Dr Trevor Markham
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2.0 Executive Summary
Skin disease is extremely common, 54% of the population are affected by skin disease
annually with 23-33% at any one time having disease that would benefit from medical care.
Some of the commonest skin diseases continue to increase in frequency, in particular rising
rates of skin cancer. There has also been a significant improvement in the treatments
available for skin disease, and thus in the expectations of a successful outcome to treatment.
Thus there is a need to develop dermatology services in Ireland which have been historically
underfunded. The proposed model of care for Dermatology, when implemented will bring
service provision for patients with skin conditions in line with evidence-based practice and
international standards of care.
Dermatologists diagnose patients with rare skin disorders, manage patients with moderate to
severe common disorders such as psoriasis, eczema and acne and also treat patients with
skin cancer. General Practitioners manage a wide range of dermatology conditions in primary
care and act as gate-keepers for those patients who require treatment by a dermatologist.
The Dermatology Programme aims to:
improve access and services for patients who require care by a dermatologist
support and promote the provision of care for dermatology patients in primary care
promote public awareness, particularly of skin cancer and measures to avoid same,
and self-management of skin disease
In this Dermatology model of care document, we outline a model to ensure that the
dermatology patient is seen and assessed and treated by the right person, in the right place
and in the timeliest manner. The model envisions close collaboration between primary and
secondary care, between GP’s and their local dermatology department by promoting and
supporting dermatology care in primary care through the provision of education. Current work
is underway with ICGP to ensure as many GP registrars receive dermatology training as part
of their postgraduate training programme.
Based on international best practice, we set out both personnel and infrastructure
requirements to ensure that all patients in Ireland will receive the same standards of quality
care wherever they present. This model of care will allow for increased access to dermatology
expertise for patients with skin cancer, chronic inflammatory skin conditions, rare
genodermatoses by increasing the number of consultant dermatologists to 1 per 80,000. This
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will require an additional 15 consultant appointments over 5 years and the development of the
advanced nurse practitioner role in all dermatology services. This will achieve an extra 15,000
new patients being seen. Based on current figures, no patient would wait longer than 8 months
(appropriate wait time should be 3-4 months for routine referrals), some patients are waiting
up to four years at the moment. New Peripheral/Outreach Clinics would be established or
supported and specialist services would be supported.
Investment in infrastructure is required over the next five years, the following departments are
in urgent need of physical infrastructure; South Infirmary Victoria University Hospital, Cork,
Beaumont Hospital, Dublin, Tallaght Hospital, Dublin, Galway University Hospital, Galway.
This current model will undoubtedly evolve and the, future service development is mapped for
the next five years only. Updates of this model and enhancements will require performance
measurement of activity, supply versus demand and ongoing audit of clinical outcomes. There
will also be a requirement for consistency of data collection and a robust reporting and
monitoring system.
The timely and equitable access to the full range of high quality dermatology services with
care delivered at a level appropriate to the severity and complexity of their condition is a
fundamental overarching principle of care.
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3.0 Dermatology overview
3.1 Description of the specialty
Dermatologists manage diseases of the skin, hair and nails in adults and children. As
over 2,000 skin disorders are recognized, of which 100 are common, accurate
diagnosis is fundamental to successful management.
54% of the population are affected by skin disease annually with 23-33% at any one
time having disease that would benefit from medical care.
Skin diseases represent 34% of disease in children; atopic eczema affecting 20% of
infants1.
Skin cancer is the most common cancer in Ireland. Basal cell carcinoma (BCC)
numbers equal all other malignancies combined (www.ncri.ie).
Skin diseases such as psoriasis, eczema and hidradenitis suppurativa cause
significant impairment of Quality of Life equivalent with that seen in conditions such
Chronic Obstructive Pulmonary Disease. Patients with inflammatory skin disease also
have increased co-morbidities such as elevated cardiovascular risk and diabetes2.
Paediatric dermatology is a subspecialisation within dermatology with care delivered
in the three paediatric hospitals in Dublin (soon to be the National Children’s Hospital)
and in paediatric clinics in Cork, Galway, Waterford, Limerick, Sligo, Mullingar and
Drogheda)
3.2 Skin Cancer
Skin cancer (melanoma and non-melanoma skin cancer (basal cell carcinoma, squamous cell
carcinoma)) is the most common form of cancer in Ireland. Between 1994 and 2011, an
average of 6,899 cases of invasive skin cancer were diagnosed per year in Ireland, the figure
for 2015 will exceed 10,000. Malignant melanoma accounted for just over 8% of this number
with 100 melanoma-related deaths annually; the vast bulk of all invasive skin cancers being
non-melanomatous subtypes, of which over 6,300 were diagnosed each year. Over 95% of
these “non-melanoma” skin cancers were histologically diagnosed and almost all were either
basal (68% approximately) or squamous (30%) cell carcinomas (BCC and SCC respectively).
The remaining non-melanoma subtypes were all very rare by comparison and included Kaposi
sarcoma and cutaneous lymphomas, principally mycosis fungoides and T-cell lymphomas.
From the mid 1990’s to early 2000’s there was little overall change in incidence rate for NMSC,
with rates in females remaining fairly level and a slight decline in males. However rates of both
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subtypes have subsequently increased, and for both sexes current rates (2011) are between
33% and 39% higher than those in 2002. An annual percentage change of between 3% and
4% has been recorded during the last 10 years (Cancer Trends. www.ncri.ie).
Exposure to ultraviolet radiation is known to be the major risk for developing skin cancer. The
link between cumulative lifetime exposure and the risk of developing non-melanoma skin
cancer is well-established, whereas melanoma appears to be linked to intermittent intense
exposure in a less defined manner. Sunburn in childhood increases the risk of melanoma in
later life and sunbed users are known to be at increased risk of developing skin cancer.
3.3 The National Cancer Control Programme – Skin Cancer
In 2012, the National Cancer Control Programme published Guidelines for the management
of melanoma with the aim of preventing and treating melanoma. All patients with a suspected
melanoma must be referred to a consultant dermatologist or plastic surgeon via a standardised
electronic referral form and all patients with a diagnosis of melanoma must be discussed at a
multi-disciplinary skin cancer meeting. This has streamlined the care of patients with
melanoma and work is currently ongoing to establish key-performance indicators for the
management of melanoma to promote standardisation of care nationally. An electronic
referral form for such suspected lesions has been rolled out nationally. Since its introduction
all dermatology departments operate rapid access pigmented lesion clinics on a fortnightly or
weekly basis Many of these clinic function as ‘see and treat’ clinics with many patients having
suspected lesions removed at initial presentation. Just under half of the workload of UK
Dermatologists is related to skin cancer3
Guidelines for the Management of patients with non-melanoma skin cancer have been
developed. This will have similar aims of streamlining patients with NMSC care and also
facilitating the discussion of patients with high risk NMSC particularly SCC at MDT.
It is recommended that all melanomas, squamous cell carcinomas and high risk basal cell
carcinomas are managed in a hospital setting. General practitioners act as gatekeepers and
are critical in recognising skin cancers and treating pre-malignant skin cancers such as actinic
keratoses and Bowen’s Disease and basal cell carcinomas as per the NCCP Guideline.
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3.4 Psoriasis
Psoriasis is a chronic cutaneous immune-mediated disease with a complex pathogenesis. It
affects 2-3% of the population, and is associated with an inflammatory arthropathy in up to
30% of patients4. It has been recognised by the World Health Organisation as a chronic
systemic disease5. Patients with more severe psoriasis also have increased cardiovascular
and metabolic risk6. It is estimated that there are 77,000 patients with psoriasis in Ireland7.
Approximately 30% of patients with psoriasis with moderate to severe disease require care in
a dermatology department with either phototherapy or systemic treatments. Patients with mild
disease can be managed in primary care with topical therapy. Psoriasis has significant
psychosocial impact on patients’ lives and it is imperative that those patients who require
phototherapy or systemic treatment have timely access to same.
The advent of biological treatments for psoriasis since 2005 has improved outcomes for
patients with psoriasis and the imperative to treat patients has increased. Dermatologists in
Ireland apply the BAD/NICE Guidelines for the management of psoriasis
(http://www.bad.org.uk/healthcare-professionals/psoriasis) and adhere to the principles of
NICE in the prescription of phototherapy, photochemotherapy and systemic treatments
(https://www.nice.org.uk/guidance/cg153)
3.5 Dermatitis
Up to 12% of adults suffer with atopic eczema and 20% of paediatric patients8. Eczema
causes significant sleep deprivation and can be extremely stressful for families who, because
of its genetic nature, may have several family members affected. Understanding of the
pathogenesis of eczema has advanced and it is apparent that early intervention can alter its
natural history9. New therapies are also coming on stream which will improve treatment
options for patients with severe eczema.
Occupational dermatitis is an important occupational hazard for certain professions including
healthcare professionals, hairdressers, and workers with exposure to chemicals or irritant
such as cutting oils. Hand dermatitis is one of the commonest reasons for disablement benefit.
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3.6 Acne
Acne is a very common complaint among adolescents and young adults. It causes significant
distress and also has the potential to leave permanent scars. Most acne is managed in
primary care (ICGP Guidelines for treatment of acne). Certain types of acne such as scarring
acne, acne conglobata and fulminant acne require urgent and timely treatment in secondary
care with Isotretinoin.
3.7 Acute Dermatology Service
Dermatologists provide important in-patient consultation service in acute hospitals and are
critical to the care of patients with skin failure secondary to severe drug reactions, vasculitis,
graft versus host disease. It must also be recognised that patients with severe skin disease
such as patients with epidermolysis bullosa, erythrodermic psoriasis or eczema may require
hospital admission and treatment. This service ensures that such patients receive the correct
diagnosis and are appropriately managed.
3.8 Paediatric Dermatology
Children attend with severe atopic dermatitis, vascular anomalies, genodermatoses and other
inflammatory skin disorders. There are approximately 10,000 referrals for paediatric
dermatology annually with pressures on the services ever increasing (the number of 0-4 year
olds living in Ireland increased by 17.9% between 2006 and 2011, giving Ireland the highest
proportion of children with the EU. 25% v 19%). A National Clinical Programme for Paediatrics
and Neonatology has been established and clearly outlines a model of care that promotes all
children having access to safe, high quality services in an appropriate location, within an
appropriate timeframe, irrespective of their geographical location or social background.
Currently Paediatric dermatology is delivered regionally in Cork, Limerick, Galway, Mullingar,
Drogheda and Waterford. In Dublin, paediatric dermatology is currently delivered in Our
Lady’s Hospital Crumlin, Tallaght Hospital and Temple Street Children’s Hospital, this service
will be centralised in the new National Children’s Hospital.
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4.0 Background of dermatology in Ireland
4.1 Consultant Dermatologists
There has been a considerable move in recent years to improve the national dermatology
service as service delivery has been hampered by lack of resources and lack of standardised
care pathways. The dermatology outpatient service in Ireland was reviewed by the HSE in
early 2010 as part of the Outpatient Programme of the Quality & Clinical Care Directorate
(QCCD). The stimulus for inclusion of dermatology in that programme was the lengthy
outpatient waiting lists for new patient appointments.
Between 2010 and 2012, an additional 10 consultant dermatologists were employed by the
HSE bringing the number of dermatologists to 45. This investment has led to significant
improvements and innovation in the provision of dermatology services:
An additional 12,224 new patients being seen and a 42% increase in new patient
activity between 2009 and 2014.
The rate of returning patients also fell from 2.08 to 1.6 in the same time period, as
patients are increasingly being educated in self-management of what may be a chronic
condition.
The development of regional dermatology clinics and thus the inception of an
integrated service which supports a local network of GP’s and ensured regional self-
sufficiency as was recommended in a Comhairle Report on Dermatology in 2003.
There are now dermatology clinics in Bantry Hospital, Kerry General Hospital, South Tipperary
General Hospital, Naas General Hospital, Nenagh Hospital, Portiuncula Hospital, Mayo
General Hospital, Cavan General Hospital.
Some of these centres also provide phototherapy (Bantry, Nenagh) which has greatly
increased access to this modality for patients who hitherto could not avail of this service
because of geographical constraints.
* The establishment of pigmented lesion clinics nationally, there are now screening clinics
regionally for all patients with suspected pigmented lesions which has improved access for
such patients and more standardised care in common with international standards and with
other cancers.
* The development of a specialist centre for Mohs micrographic surgery in Cork.
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* The establishment of other dedicated clinics:
Dedicated transplant clinics for patients who have received a solid organ transplant to
detect patients who develop skin cancer, these are run in conjunction with the
transplant team and reduce the number of hospital visits for patients.
Combined rheumatology/dermatology clinics for patients with connective tissue
disorders, this has obviated the need for patients to attend multiple clinics and has
introduced efficiencies in the management of patients with a multisystem disorder.
Systemic treatment clinics for patients with severe inflammatory skin disease such as
psoriasis and eczema.
Combined clinics for the management of patients with hidradenitis suppurativa who
require both medical and surgical input.
Dedicated systemics, vascular, laser, thermography and genodermatoses clinics for
paediatric patients in Our Lady’s Hospital Crumlin.
There are currently 16 training places in the RCPI, ICHMT Dermatology Specialist Registrar
Training Programme with an average of twenty trainees in the programme at any given time
as many engage in clinical research during their training which lasts 5 years.
Table 1
Hospital Group Estimated population No. of Dermatologists
Midlands 800,00 6.8
Dublin East 1000,00 7.5
Dublin North East: RCSI 800,00 5.1
South / South West 1000,00 8
West / North West: Saolta 700,00 6
University of Limerick 400,00 3
National Children’s Hospital 5.6 (if all posts filled)
*Location and no. of dermatologists as per hospital groups
There are currently 45 dermatology posts (when all are in post in the public system), this
represents a ratio of 1 per > 100,000 (4.75 million) (ref census 2016). There is a need for
sustained expansion in consultant numbers to bring this ratio to 1 per 80,000 initially and then
62,500 as per BAD Guidelines.
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4.2 Specialist Registrar Training in Dermatology
The Irish Committee on Higher Medical Training (ICHMT) programme for dermatology
specialist registrars was established in 1999 and is formally accredited by the Irish Medical
Council. The training schedule is 5 years duration with formal annual appraisals to meet
requirements for entry to the Irish Medical Council’s Specialist Division of the Register in
dermatology. There are currently 16 training places in the RCPI, ICHMT Dermatology
Specialist Registrar Training Programme with an average of twenty trainees in the programme
at any given time, as many engage in clinical research during their training. As of July 2017
34 doctors will have completed Specialist Training in Dermatology. The programme has a
well-established teaching structure lead by the National Specialty Director Dr Michelle Murphy.
4.3 Dermatology Nursing
It is well recognized that dermatology nurses play a key role in delivering dermatology services
(BAD 2014, Comhairle na nOspidéal 2003). There are currently 3 Registered Advanced Nurse
Practitioners, 28 Clinical Nurse Specialists and approximately 26 staff nurses in Dermatology.
Staff nurse posts in dermatology vary from sole specialisation in dermatology and allocation
to the service for a specific time allocation (e.g. outpatient nurses allocated to dermatology
clinic). In Ireland dermatology nurses are mainly employed in dermatology departments with
3.8 posts in peripheral hospital services. There are no dermatology nurses in Ireland in primary
care.
The allocation of dermatology trained nurses is considerably lower than their counterparts in
the UK and Northern Ireland even in dermatology departments. There are some dermatology
services where there is no dermatology nurse specialists and restricted access to staff nurses
trained in dermatology. These services often rely on general trained nursing staff. Services
that rely heavily on general trained nursing staff are often unable to develop and operate
appropriately essential dermatology services such as phototherapy, patch testing, disease
education clinics, topical treatment clinics.
To meet current patient demands there is a need to develop and expand the dermatology
nurse role. Academic programmes that facilitate the training of dermatology nurses in the
specialty and also that allow progression to the clinical nurse specialist role and advanced
nurse practitioner role is needed in Ireland. There are no educational programmes in Ireland.
Nurses wishing to train in the specialty can only access courses in the UK.
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There is also significant scope to expand the role of dermatology nurses so that they can take
on additional roles that will help meet the current long waiting times for dermatology services.
In the UK dermatology nurses are employed in both primary, and secondary services taking
on advanced roles in patient consultations, nurse surgery, skin cancer management, chronic
disease management. Sub-specialisation in the UK includes Paediatrics, Skin Surgery, Skin
Cancer, Phototherapy, Biologics, Contact Dermatitis, Community, Teaching, Laser, and
disease-specific posts (Epidermolysis Bullosa, Xeroderma Pigmentosa, Psoriasis and
Eczema). In the UK dermatology and oncology nurses are employed in skin cancer nursing
posts.
In relation to secondary care there is a lack of dermatology nurses employed in peripheral
services. However it is worth exploring developing dermatology services here to bring key
dermatology services closer to the patient. One dermatology service (ULHG) has developed
a day treatment service (providing phototherapy, patch testing, wound care and nurse
education) at their secondary care site by employing 1.8 dermatology staff nurses. The service
is supported by staff from the dermatology department for leave and clinical supervision.
There are several advantages in developing dermatology nursing services
Provision of dermatology treatment services (Comhairle na nOspidéal 2003)10
Increasing patient capacity in dermatology services (Gradwell et al 2002)11
Provision of services closer to the patient (Courtenay and Carey 2007)12
Improving chronic disease management (Cork et al 2003)13
Improved co-ordination of patient pathways especially in skin cancer.
There is scope to expand the role of dermatology nursing. To do so the pool of dermatology
trained nurses needs to be increased. In addition academic training in the speciality and
development of subspecialist skills (phototherapy, paediatrics, surgery and skin cancer
recognition and management) needs to be developed in Ireland. For further development
dermatology nurses will need support to access nurse prescribing and masters programmes
already available in Irish Universities.
The Irish Dermatology Nurses Association
The Irish Dermatology Nurses Association (IDNA) was established in 2002 to provide support
for the practice and development of dermatology nurses on the island of Ireland. It is a cross
border organisation in which all nurses working in dermatology can become members. It has
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currently over 70 members. The group holds an annual conference and offers educational
bursaries to members.
4.4 Psychodermatology and allied health professionals
Cutaneous disease may be the manifestation of psychological disease e.g. in conditions such
as dermatitis artefacta and delusional parasitosis or other monodelsuional presentations.
Furthermore patients with severe common skin diseases such as psoriasis and hidradenitis
suppurativa are known to suffer increased levels of anxiety and depression. This in addition
to adverse health behaviours such as smoking, excess alcohol consumption, lack of exercise
and obesity are over-represented in patients with psoriasis and hidradenitis suppurativa.
While there has been Irish clinicians involved in research in this field for many years, there is
a dearth of access to psychology, dietetics, smoking cessation programmes for patients with
cutaneous skin disease in all dermatology departments. This is a deficit that must be
addressed to promote self-care and quality of life in a significant number of dermatology
patients.
4.5 The Irish Association of Dermatologists
The Irish Association of Dermatologists is the professional organisation of which all Irish
Dermatologists are members. It is a cross-border organisation and is affiliated with the British
Association of Dermatologists. The organisation holds bi-annual meetings promoting clinical
education and research.
4.6 The Irish Skin Foundation
The Irish Skin Foundation (ISF) is an independent organisation and has charitable status.
Patient advocacy at all levels including the Health Service Executive and the Department of
Health is a key aim of the ISF, as well as supporting education (patients, the public, primary
care practitioners, non-dermatology hospital medical and nursing staff).
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5.0 Overarching aims of the dermatology programme
The national clinical programme in dermatology, in line with all the clinical programmes from
the Clinical Programme & Strategy Division, has 3 main goals; the delivery of improved quality
of care and improved access to care for patients to dermatology services while at the same
time delivering on value which will ensure the sustainability of the programme into the future.
These goals will be realised over the next 5 years.
5.1 Quality
Increase OPD capacity
Additional new consultant dermatologist appointments
Improve productivity by ensuring availability of key resources
Establishing the new GP e-referral system – as recommended by HIQA
Nurse led clinics for chronic skin disease
Facilitate and support the self-management and primary care management of patients
with skin problems as appropriate
5.2 Access
To facilitate the “right person, right place, first time” assessment of patients with skin disease
Primary care
To reduce the overall numbers of patients referred to dermatology OPDs by promoting
dermatology education and improving the management of patients in primary care
Introduce standardised referral criteria to secondary care dermatology services and
improve access for those patients who require dermatology care in a secondary care
setting in a timely fashion.
Secondary Care
To reduce the OPD waiting lists for all dermatology referrals to < 6 months
To fast track patients with suspected melanoma and rapidly growing skin cancers
To fast track patients with severe inflammatory skin disease
To increase and make more effective the satellite /hub dermatology service delivery in
smaller hospitals under the supervision of the larger/hub hospital departments of
dermatology
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To ensure that the majority of patients can access care closer to home
5.3 Value
To identify potential efficiencies and savings within the system
To avoid more expensive options by providing local Day-Care services e.g. patient with
psoriasis attending for UVL locally rather than commencing systemic medications as
a first step
Improve overall efficiency of outpatient management
Maximise use of existing staff, space and resources
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6.0 Models of Care
Models of care for people with skin conditions should be developed to ensure that patients are
seen by the “right person, in the right place, at the right time” and can move readily between
the levels of care as necessary. The underpinning principle of all guidance documents
published in this area is that services should be integrated and are best designed by
stakeholders based on local assessment of need. Broad stakeholder engagement and
enthusiastic clinical engagement by GPs, consultant dermatologists, dermatology nurses is
essential for the success of this process.
6.1 Rationale
The current traditional service model of care for dermatology in Ireland has been under strain
especially in the past decade, due to a crisis in the numbers of trained dermatologists; a
significant increase in demand; and a dramatic increase in the treatments available. The result
of these changes has been unacceptable waiting times for new appointments.
6.2 General Principles underlying Service planning in dermatology
An equitable and patient centered service
Regional self sufficiency
Collaboration between primary and secondary care
It is essential that service models are patient driven and orientated.
The starting point for quality of care, wherever it is based and however organised, is
an accurate diagnosis
Care should be delivered as close to the patient’s community as is consistent with safety and
cost effectiveness. This means that primary care will continue to take responsibility for the
more straightforward parts of the management of long term skin diseases, and in particular to
facilitate effective, safe and informed patient self-management. Dermatology needs to be a
core element of general practitioner training. It is helpful for trainee general practitioners to
attend dermatology clinics and for more interactive teaching to be developed between local
dermatology consultants and GPs.
Those functions and facilities that are limited to hospital practice must continue to be
supported and the educational role of secondary care acknowledged and developed.
Outreach clinics in smaller peripheral hospitals deliver excellent care when connected to a
21
dermatology department. In the Comhairle 2003 report it was emphasised that since
dermatology is an outpatient based service that there should be regional sufficiency and that
a network of peripheral or outreach clinics should be developed.
The current economic environment makes the proposed improvements to the delivery of care
challenging, however it can also be used to advantage as a stimulus for change.
22
7.0 Key elements of Model of Care
To develop a series of Dermatology Networks within each Hospital Grouping to ensure
equitable provision of high quality, clinically effective services.
Primary care treatment and screening of a majority of skin diseases and skin lesions and
referring on, if necessary, for diagnosis and management to the network of hospital services
in that area. Maximise health promotion and reinforcement of self-management.
Secondary Care:
Outreach clinics in peripheral hospital to support a local network of GP’s, provide care
closer to home for patients and provide onsite dermatology consultations for inpatients.
It is also envisioned that phototherapy would be provided in peripheral clinics, this is
currently available in certain peripheral clinics.
Dermatology departments in teaching hospitals with OPDs, day-care, patch testing,
management of complex skin diseases, surgery for skin cancer, multidisciplinary care
of chronic skin disease and skin cancer MDTs.
Supra specialist services - provision of highly specialised care for specific disease
investigation/care:
Mohs micrographic surgery (St James’s Hospital and South Infirmary Victoria
University Hospital)
Phototesting – Mater University Hospital.
The skills and knowledge of the healthcare professionals should always match the level of
care provided, whatever the location.
23
8.0 Dermatology Clinical Networks
Table 2. Dermatology Networks
Hospital
Grouping
Dermatology
Departments
Peripheral Clinics
Ireland East St Vincent’s University
Hospital
Mater University
Hospital
St Michael’s Hospital Dun Laoghaire,
Kilkenny University Hospital
Midlands Regional Hospital
Mullingar (MRHM)
Dublin Mid
Leinster
Tallaght Hospital
St James’s Hospital
Naas Hospital
Dublin
North East
Beaumont Hospital
Our Lady of Lourdes
Hospital Drogheda
Connolly Hospital
Cavan University Hospital
University
of Limerick
Hospitals
Limerick University
Hospital,
Ennis Hospital
Nenagh Hospital
Ireland
South
South Infirmary Victoria
University Hospital
Waterford University
Hospital
Kerry General Hospital Tralee
Bantry Hospital
Mallow Hospital
South Tipperary General Hospital
Clonmel
Saolta University Hospital
Galway
Sligo University
Hospital
Portiuncula Hospital Ballinasloe
Mayo University Hospital
Letterkenny University Hospital
24
9.0 Current Organisation of the service and patterns of referral: Patient
Journey
9.1 Primary care
The community pharmacists
Community Pharmacists are often the first point of contact for patients with a dermatological
condition and provide a vital form of contact for patients who are self-managing, 75% of the
Irish population use community pharmacy at least once a month. The majority of pharmacists
are confident in the day to day management of common skin conditions. Advice and sale of
non-prescription items (OTC sales) and dispensing of prescription items with advice about
their correct usage is all part of an important role that pharmacists play. Expanded scope of
practice in recent years includes medication management and monitoring (e.g. INR
management), parenteral administration of medicines (e.g. flu, pneumococcal and shingles
vaccinations), emergency administration of medicines (e.g. adrenaline, glucagon, naltrexone).
Increased education at undergraduate level and post-graduate level could support and
promote self-management in particular sign-posting of available information and patient
support groups.
Examples of Pharmacist Delivered Dermatology Services;
Self-management support for chronic disease such as psoriasis, eczema , acne
Medication adherence support
Medication management – examples include, supply of Dovonex without Rx in
accordance with guidelines from PSI
Rational/cost effective use – emollient use, adherence, cost considerations
Health promotion – e.g. structured smoking cessation programmes
General Practitioners
A large proportion of dermatological conditions are managed in primary care by general
practitioners. Studies in the UK show that up to 24% of the population see their GP each year
for skin disease and approximately 5.5% of these patients were referred for specialist advice,
the vast majority within the NHS system. The skin complaint may not be the sole reason for
the visit to the general practitioner13, 14. There are no available similar figures in Ireland
however it is likely to be representative of the numbers of patients visiting their GPs as the
25
same gatekeeper system prevails. Thus with a population of 4,757,976 (2016 census) primary
care in Ireland could currently be accounting for >1,000,000 visits each year. If, as in the UK
some 6% of those who attend their GPs are referred for specialist advice that would lead to
approximately 68,000 new referrals to consultant dermatologists annually in Ireland. In 2016
there were 42,493 new patients seen at dermatology outpatients and 70,753 return patients,
thus there is likely to be considerable unmet needs particularly in more rural areas.
There is an urgent need to promote dermatology education at undergraduate and
postgraduate level for general practitioners. Given the ubiquity of skin conditions presenting
to primary care it is important that GP’s feel confident in managing and diagnosing the most
common skin conditions. Work is currently underway devising a dermatology module with
ICGP to facilitate GP registrars receiving clinical training in dermatology.
Written patient information: involving patients in choice and decision-making about their care
has been improved by quality information such as BAD Patient Information Leaflets (PILS)
available at http://www.bad.org.uk and other websites such as the http://www.dermnetnz.org.
These are available in all departments of dermatology, they are reliable excellent sources of
information for patients and should be made available to patients in primary and secondary
care.
9.2 Secondary Care Dermatology services
Secondary care is delivered by consultant dermatologists, dermatology registrars or
registrars working in either a teaching hospital or outreach/peripheral hospital.
Peripheral Clinics:
There are a number of examples of clinics delivered in outreach hospitals (Cavan, St Michael’s
Hospital, Midlands Regional Hospital, Naas Hospital, Nenagh Hospital, Clonmel Hospital,
Bantry Hospital and Kerry General Hospital). The service provision varies from a monthly to
twice weekly clinics, ward consultation, UVL (Bantry, Nenagh, Naas) or other day care
treatments. This brings the service closer to the locality of the patient and also provides
education and support for regional GP’s. Patients requiring patch testing, complex surgery
are sent to the hub or base hospital dermatology department.
26
Requirements at peripheral/outreach clinics
Adequate OPD clinic rooms
Adequate Clerical support
Nursing which can include clinical nurse specialists attending from the “base hospital”
Day Care to include UVL therapy with adequate staffing
Minor surgery equipment as necessary
Secondary Dermatology Services
Skin cancer clinics - dermatologists screen over 90% of skin cancer referrals and
treat approximately 75%.
Facilities for dermatological surgery, cancer multi-disciplinary teams (MDTs) and data
collection compliant with NICE guidance.
Medical or surgical dermatology for complex problems, often in MDT clinics with
other specialties such as rheumatology, gynaecology, plastic & reconstructive
surgery, maxillo-facial surgery allergy specialists and paediatrics
In-patient care of sick patients with severe skin diseases or skin failure, sometimes
requiring intensive care.
Phototherapy, wound care and other day treatments
Paediatric dermatology services including laser surgery
Investigation of cutaneous allergy and occupational skin disease by patch and prick
testing.
Investigation of photodermatoses, which affect 18% of the population reducing
quality of life, psychological welfare and employability.
Management of skin problems in hospital patients with other illnesses thereby
reducing length of stay (LOS).
Skin cancer screening for organ transplant recipients
Genital skin diseases.
Diagnosis and management of genodermatoses.
Cutaneous infections, tropical diseases and HIV skin diseases.
Teaching, training and assessment of medical students, GPs, trainee dermatologists
and other healthcare professionals.
Collection and analysis of clinical data, clinical audit and compliance with clinical
governance requirements
Clinical research including therapeutic trials
27
Requirements of hospital-based service
A dermatology service should provide patient-centred care focusing on outcomes that meet
national standards. To achieve this, all staff must be correctly trained and accredited.
Staffing16,17
Hospital-based services require at least one whole-time equivalent consultant
dermatologist per 80,000 population. This is less than the currently stated requirement
in the UK of one dermatologist per 62,500 population, where there is a shortfall of over
250 WTE dermatology consultants for a population of 61,800,000.
A sustained expansion in the number of dermatologists will lead to:
o A reduction in waiting times and waiting lists for patients
o Continued improvement in the clinical management of patients with skin
cancer:
o Diagnostic accuracy of skin lesions is highest among dermatologists which
results in efficient triage of patients with skin cancer and avoidance of
unnecessary treatments in patients who have benign lesions.
o Improved treatment for patients with severe inflammatory disease and patients
with rare skin disorders
Dermatologists treat skin cancer and pre-cancerous lesions with a number of
modalities including surgery, topical treatments and photo-dynamic therapy.
Dermatologists are most expert at recognising and monitoring patients at high risk of
skin cancer e.g. transplant recipients.
Innovations in service delivery and the development of a truly integrated service e.g.
e-referrals provide the opportunity for dermatologists to provide advice to GP’s and
deflect referrals to secondary care. Expansion of consultant numbers with dedicated
clinical time to such a service could provide a significant efficiency saving to the health
service.
NCHDs including senior house officers, registrars and specialist registrars form an
integral part of the team in many hospital units. In some dermatology units there are
no NCHDs, this must be taken into account when assessing what services can be
delivered. The drive to a more consultant delivered service and the reduction in the
number of NCHD’s should be seen as an overall improvement as a result of the more
senior and experienced clinical decision making.
Specialist trained Dermatology Nurses who;
o Treat patients in day-care units and onwards
o Provide and supervise phototherapy
28
o Assist / perform patch testing under consultant supervision.
o Perform surgical procedures
o Nurse prescribe
o Run monitoring clinics for isotretinoin and biological/systemic treatments for
inflammatory skin diseases.
o With paediatric training, run hospital/outreach services for children with chronic
skin disease.
o Establish and run community clinics.
o Co-ordinate the patient journey in skin cancer including provision of
psychological support
o Provide skin cancer support and skin surveillance services
o Manage and care for wounds and ulcers.
o Provide patient information, demonstrate and apply treatments, dress wounds,
remove sutures and review follow-ups.
o Assist in operating theatres and advise patients undergoing surgery.
o Advise and train professional colleagues caring for patients with skin diseases
in the hospital/community.
Clerical staffing sufficient to support all the department activities.
Pathology support is a vital component with weekly review conferences and teaching
of registrars. Pathology review of skin cancers discussed at MDT.
Physics support of activities such as phototherapy
Structural facilities required at hospital level
A fully integrated department with outpatient clinics, outpatient Day - Care treatment centre
and dedicated day surgery facilities is the gold standard in hospital dermatology service
delivery. In Ireland there are remarkably few such well integrated departments with the notable
exceptions of the dermatology department in St. Vincent’s University Hospital and OLCHC,
both of which benefited from additional external funding. Below is an outline of the necessary
structural provisions for a modern integrated department.
Dedicated outpatient units with rooms for patient education.
Areas for contact allergy testing with storage areas for allergens meeting national
published standards.
Surgical facilities meeting national standards for space, cleanliness and equipment,
with storage for liquid nitrogen.
29
Laser-safe areas where required
Facilities for Mohs' micrographic surgery where required, meeting national standards.
Day-care centres staffed by dedicated dermatology nurses.
Phototherapy units for adults and children staffed by trained dermatology nurses who
can also provide skin care, meeting national standards for equipment and safety.
Medical physicists should monitor UV output. A named consultant dermatologist
should be responsible for the service.
Hospital beds staffed by trained specialist dermatology nurses with 24 hour medical
care is the gold standard. This is difficult to attain with an increasing demand upon
acute medical beds and thus there are few or no dedicated dermatology beds.
Dermatology patients require a specialised dermatology nurse to apply treatments and
provide education, with adequate bathing and treatment rooms.
Diagnostics Laboratory support including chemical pathology, haematology,
microbiology, mycology, histopathology and immunopathology and radiology.
IT hardware and software that is robust, modern, reliable, fast, in the right place and
immediately available.
Medical photography services
Appropriate accommodation for paediatric dermatology clinics and inpatient care in a
dedicated paediatric area, staffed by paediatric trained nurses.
9.3 Supra-specialist care
This type of care usually takes place within an acute hospital and is carried out by consultant
dermatologists and a range of other healthcare professionals with special skills in the
management of complex and/or rare skin disorders. Identified links should be established
within each network though there are a few national supra-specialties which will require linking.
Examples include the following:
Table 3. Supra-Specialist Services
Supra-specialist
service
Types of conditions
seen
Services offered Current Locations
Genetic
dermatology
Rare and severe
inherited skin
diseases
Diagnostic and
genetic counselling
service, outreach (to
community and
OLCHC,
Accredited
National Rare Skin
Disease Centre
and member of the
30
general hospital )
nursing service
European
Reference Network
for rare and
undiagnosed skin
disease
Photodermatology Skin disorders
related to sunlight,
including rare
conditions such as
porphyria and
xeroderma
pigmentosum
Specialist diagnostic
services, including
light testing.
MMUH
Epidermolysis
Bullosa and
Fragile Skin
Sub types of
Epidermolysis
Bullosa and Fragile
Skin disease
Diagnosis and
Multidisciplinary
management
OLCHC
(paediatrics)
SJH (adults)
Dermatological
surgery
Complex, large and
difficult to manage
skin cancers.
Access to Mohs
micrographic surgery
and complex
reconstructive
surgery involving joint
working with a range
of specialist plastic
and reconstructive
surgeons.
South Infirmary
Victoria University
Hospital
St James’s
Hospital
Vascular
anomalies clinic
Venous, lymphatic,
arterial and
overgrowth disorders
Multidisciplinary
management,
including radiology,
plastic and
reconstructive
surgeons,
haematology,
occupational therapy
and specialist nurse
OLCHC
31
Paediatric
connective tissue
disease clinic
Connective tissue
disease and
Autoinflammatory
disorders
Multidisciplinary
management,
including
rheumatology
consultants and
nurse specialists.
OLCHC
Paediatric atopic
eczema clinic
Atopic dermatitis
clinic
Multidisciplinary
management, with
consultant allergist
and clinical
nutritionist and nurse
specialist
OLCHC
32
10.0 Managing outpatient access
Referrals to hospital dermatology departments are increasing. In order to deal with the
demand there has to be some form of referral management but care must be taken to
ensure that the process works well for patients.
10.1 Triage of referrals
Referrals to specialist services should be triaged by experienced clinicians working as part of
the same dermatology team in order to facilitate the “right person, right place, first time”
approach. Within each department there will be dedicated clinics and the experienced clinician
will know where best to direct each referral. It is essential that GPs can have immediate access
to senior decision makers within the department. It is envisioned that e-referral may enhance
communication between primary and secondary care and that advice could be returned to the
referring GP and might obviate a visit to the dermatologist. At the moment this clinical activity
is undertaken by many consultants but is not recorded as clinical activity this must be
addressed.
In a health care system such as the HSE resources are inevitably limited, thus an arbitrary
line has to be drawn on who can and cannot access and benefit from HSE provided care. The
National Clinical Programme for Dermatology has introduced an exclusion letter for benign
lesions that will not be treated or seen in secondary care unless there is diagnostic uncertainty
(Appendix 1).
10.2 Demand Management and follow up in dermatology
Patients should have rapid access to re-enter the OPD system when needed. This process
can be facilitated with active management.
10.3 Efficient and Innovative ways of dealing with demand
Pigmented lesion clinics with one-stop treatment
Skin Lesion clinics
Urgent new patient clinics
Rapid re – access clinics e.g. patient with a chronic disease such as psoriasis
Specialised review clinics e.g. psoriasis, eczema
Nurse triage clinics
National Haemangioma referral pathway
33
11.0 Quality and Clinical Governance
It is essential that clinical governance arrangements are embedded in clinical practice to
enable services to constantly review and measure themselves in terms of effectiveness, safety
and patient experience.
11.1 Clinical governance
Clinical governance should be embedded in the clinical practice of all services in order to
standardise and constantly improve clinical effectiveness.
All specialist services should audit their clinical effectiveness alongside ongoing reviews of
safety and patient experience, following the specific guidance for their specialty.
11.2 Clinical leadership
Specialist services for people with skin conditions (those led by consultants on the specialist
register of the IMC for dermatology) should provide clinical leadership, including supervision,
training, clinical expertise, clinical management and research into skin conditions.
11.3 Clinical effectiveness Use of information and information technology
All services should review their clinical effectiveness including waiting list and activity data at
regular intervals. Information technology should be developed and used to support clinical
governance within and across organisations by supporting clinical and data reporting
requirements. A diagnostic database and clinical information system are important
requirements to support the clinical effectiveness of services.
11.4 Education, training and continuing professional development (CPD)
It is essential that all providers of care for people with skin conditions are appropriately trained
and competent to deliver care. Specialist providers of dermatology care should support the
provision of training for the management of the full range of skin conditions.
Procedures should be in place for the dissemination and implementation of new evidence-
based practice, disease and treatment specific guidelines, research, national standards and
audit outcomes to achieve quality service delivery.
34
11.5 Clinical audit
All specialist providers of services for people with skin conditions should, as a minimum, audit
annually elements of clinical practice against current local and national guidelines and
evidence-based pathways and procedures.
11.6 Risk management
All providers of services for people with skin conditions should have procedures in place to
minimise risk to both service users and staff. All services should be compliant with local and
national requirements. Clear mechanisms should be in place to report, review and respond
formally to all clinical incidents and complaints using, for example:
incident and near-miss recording, with investigation and root cause analysis.
audit of current practices and standards and of medical records
35
12.0 Collection of data from dermatology departments
It is accepted that the accurate recording of all activity that takes place within each department
of dermatology is essential. The vast majority of dermatology activity is at an outpatient level.
Currently the data collection within hospitals can be variable. It is important that each patient
visit is recorded in a similar fashion throughout all departments. The service delivered to
patients is essentially the same in each department though there may be some minor
differences in some subspecialty treatments such as Mohs micrographic surgery or
phototesting. The data submitted to the HSE must be standardised across each department,
only then can outpatient activity and complexity be measured. Hard data will in the future
underpin developments that are to be funded.
Although dermatology is primarily an outpatient based speciality, there are also activities that
take place outside the outpatient department and which need to be recorded as such activity
is part of the day to day clinical service delivered to patients.
Essential data should include:
Current staffing
Staff Category Grade WTE / session commitment Funding (Internal / External)
Medical
Nursing
Administration
Other
Activity Levels
Type Month 1 Month 2 Month 3 Month 4 Total
New patients seen
Return patient seen
New: Return ratio by clinic
DNA rates
36
Waiting list
0-30
days
31-60
days
61-90
days
91 – 120
days
121-180
days
181 –
365 days
Total
New
patients
Return
patients
Number of nurse led Clinic attendances
OPD NP
Assessment
OPD
Review
Biopsies Dressings Camouflage Education Patch
Testing
New
patients
Return
Patients
Day care & Surgical Activity
Day Care Procedure Total
Narrow band UVB
PUVA
Phototesting
Surgery Procedure Total
Minor Surgery (Cons delivered))
Minor Surgery (Cons supervised)
MMS
Laser treatments
37
Collection of this data will facilitate recording the KPI’s proposed for the service plan (see
Table 4 below)
Table 4. Proposed KPI’s for Service Plan
Clinical
Program
Performance indicators Data
collection
Dermatology
OPD
Number of new patients waiting >6
months for dermatology OPD
appointment
Duration of wait for dermatology
outpatients with conditions requiring
urgent assessment
Duration of wait for dermatology
patients referred from clinic for
treatment
BIU (SDU)
BIU (SDU)
BIU (SDU)
Inpatient consultations/ward referrals
Systemic patients:
From the NCP dermatology mapping survey of 2015 it is estimated that there are 3,000
patients attending dermatology departments with inflammatory skin disease requiring
treatment with medications such as:
Biologics
Methotrexate
Outcome measures;
Numbers of patients waiting over 3 months for new patient appointment
New patient: return ratio
Duration of wait for patients with suspected rapidly growing SCC or a melanoma,
Clinic to definitive excision – for skin cancers
Duration of wait for severe inflammatory disease difficult to measure?
Clinic to Day Care e.g. UVL therapy for psoriasis
38
13.0 Education
13.1 Primary Care
A 2011 publication in the British Journal of Dermatology used surveillance data collected in
the Weekly Returns Service of the Royal College of General Practitioners which monitors
sentinel practices in England and Wales to assess the frequency of consultations for skin
disorders. It confirmed that compared with other major disease groups, skin conditions are the
most frequent reason for consultation in general practice (the prevalence estimate is 24%).
These findings have important implications for education and training in primary care. This has
been discussed with the ICGP. The amount of time devoted to dermatology undergraduate
and post-graduate medical, nursing and pharmacy training bears little reflection of the
importance of skin disorders in their future clinical experience.
GP Registrars are attending dermatology clinics on a weekly basis in many hospitals
There is currently a group formed to review the curriculum of General Practice
Registrars in training after a meeting with ICGP Chair and CEO
At a postgraduate level plans are underway to deliver a module of Dermatology education
through an online platform to facilitate the delivery of an educational package. The package
should include practical educational material on the presentation, diagnosis and management
of selected common skin diseases.
It must be acknowledged that levels of dermatology expertise vary widely amongst members
of primary care teams.
13.2 Secondary Care
The role of the Clinical Nurse Specialist and Advanced Nurse Practitioner needs to be
developed. The expertise of nurses could be optimised to monitor return or follow-up patients
and free up clinic slots for new patients. Also specialist nurses can be an important source of
advice to patients and may obviate unnecessary appointments. The career of nurse specialist
in dermatology should also be promoted by the rotation of trainee nurses through the
speciality.
39
14.0 Conclusion
All services should be delivered by appropriately trained staff with standardisation of
educational provision. Specialist dermatology services should play a key role in supporting the
delivery of education and training across the range of providers.
Patients should be seen by the right person in the right place with suitable facilities; those with
special or specific needs, such as children, should be seen by appropriate staff in facilities that
meet their specific needs.
Patients should be fully informed about their diagnosis and management and be involved in
decisions about their care.
Patients should have access as needed to all approved treatments and treatment should be
carried out in a safe, competent and timely manner according to national standards.
40
References
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Allergy. 2014 Jan;69(1):3-16. doi: 10.1111/all.12270.
2. Health-related quality of life in patients with psoriasis: a systematic review of the
European literature. Obradors M, Blanch C, Comellas M, Figueras M, Lizan L.
Qual Life Res. 2016 Nov;25(11):2739-2754.
3. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Risk of
myocardial infarction in patients with psoriasis. JAMA. 2006 Oct 11;296(14):1735-41.
4. How can dermatology services meet current and future patient needs, while ensuring
quality of care is not compromised and access is equitable across the UK?. The
Kings Fund 2013.
www.bad.org.uk/shared/getfile.ashx?id=2348&itemtype=document.
5. High prevalence of psoriatic arthritis in patients with severe psoriasis with suboptimal
performance of screening questionnaires. Haroon M, Kirby B, FitzGerald O. Ann
Rheum Dis. 2013 May;72(5):736-40.
6. Global Report on Psoriasis - World Health Organization
apps.who.int/iris/bitstream/10665/204417/1/9789241565189_eng.pdf
7. The Burden of Psoriasis - Irish Skin Foundation https://irishskin.ie/wp-
content/uploads/2016/.../Burden_of_Psoriasis_Report_final.pdf
8. Public Health Burden and Epidemiology of Atopic Dermatitis.Silverberg JI. Dermatol
Clin. 2017 Jul;35(3):283-289.
9. Can early skin care normalise dry skin and possibly prevent atopic eczema? A pilot
study in young infants. Kvenshagen BK, Carlsen KH, Mowinckel P, Berents TL,
Carlsen KC. Allergol Immunopathol (Madr). 2014 Nov-Dec;42(6):539-43
10. Comhairle na nOspidéal (2003) Report of the Commitee on dermatology Services.
Comhairle na nOspidéal, Dublin
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11. Courtenay, M., Carey, N. (2007) A review of the impact and effectiveness of nurse
led care in dermatology. Journal of Clinical Nursing, 16(1), 122-128
12. Cork, M.J., Britton J., Butler, L., Young.S.,Murphy,R., Keohane, S.G.. (2003)
Comparison of patient knowledge, therapy utilization and severity of atopic eczema
before and after explanation and demonstration of topical therapies by a specialist
dermatology nurse. British Journal of Dermatology. 149(3). 582-589.
13. Gradwell,C. Thomas, K.S., English, J.S.C., Williams, H.C. (2002) A randomized
control trial of nurse follow-up clinics: do they help patients and do they free up
consultants time ? British Journal of Dermatology 147. 513-517
14. Skin conditions are the commonest new reason people present to general
practitioners in Englang and Wales BJD 2011 165, 1044-1050
15. Schofield JK. Grindlay D, William HC. Skin Conditions in the UK a Health Needs
Assessment (2009) http://www.nottingham.ac.uk
16. Staffing and Facilities for Dermatological Units, BAD. Nov 2006. (www.bad.org.uk)
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services. British Association of Dermatologists, London
42
Appendix 1 Exclusion Letter
Department of Dermatology,
Hospital,
Address
Contact phone and email
Date
Re: Exclusion criteria for referral to dermatology services
Dear Doctor
In order to ensure that patients referred with skin cancers and inflammatory dermatoses are
seen and treated in a timely manner, it is necessary for our department to decline referrals
and not to treat certain benign lesions. If there is diagnostic doubt or clinical concern referrals
will be accepted. Patients should be made aware that treatment will not be offered if it is
thought to be either benign or cosmetic.
The exclusion criteria have been developed by the National Clinical Programme for
Dermatology to ensure appropriate referral, to improve services and to benefit patients.
List of conditions for which referrals will normally declined
1. Viral warts including verrucae, molluscum 2. Seborrhoeic warts/keratoses 3. Skin tags 4. Dermatofibromas 5. Spider naevi 6. Epidermal cysts 7. Sebaceous cysts 8. Lipomas 9. Tattoos 10. Xanthelasma
Yours sincerely,
CEO of the Hospital, Department of Dermatology
43
Appendix 2 Waiting lists
Numbers waiting for dermatology outpatient appointments by time-band, end May 2017
Dermatology OPD Waiting list May 2017
0-3 Months
3-6 Months
6-8 Months
8-12 Months
12-15 Months
15-18 Months
18-24 Months
W_24TO36_MNTH
W_36TO48_MNTH
W_GTE48_MNTH
Bantry General Hospital 109 39 3 7
Beaumont Hospital 688 300 120 203 131 95 253 188
Cavan General Hospital 161 154 80 154 99 77 82
Children's University Hospital Temple Street 229 120 72 154 166 6
Connolly Hospital - Blanchardstown 77 177 40 108 74 58 107 114 15
Cork University Hospital 69 21
Galway University Hospitals 820 506 255 458 270 227 75
Letterkenny University Hospital 244 125 9
Mater Misericordiae University Hospital 1008 552 250 545 338 165 235 151
Mayo University Hospital 81 77 55 93 53 68 103 90 6
Midland Regional Hospital Mullingar 301 242 180 253 173 131 236 190 5 3
Naas General Hospital 356 188 69 108 87 73 145 82
Our Lady of Lourdes Hospital Drogheda 1159 594 334 425 211
Our Lady's Children's Hospital, Crumlin 570 291 139 202 171 164 295 166
Portiuncula University Hospital 73 77 48 85 41 28 17
Sligo University Hospital 410 33 2
South Infirmary/Victoria University Hospital Cork 1505 607 313 654 362 202 197 92
St. James's Hospital 1130 288 153 92 1
St. Luke's Hospital Kilkenny 37
St. Michael's Hospital 107 46 15 15
44
St. Vincent's University Hospital 1033 454 102 24 55 60 36 1
Tallaght Hospital - Adults 680 407 218 451 161 94 186 255 42 13
University Hospital Kerry 248 106 59 147 105 23
University Hospital, Limerick 1128 637 333 328 137 99 81
University Hospital Waterford 1014 467 295 707 406 109 60 11 1
Total 13237 6508 3144 5213 3041 1679 2108 1340 69 16
Data Source: NTPF
Please note this data is preliminary and subject to change
Reference - BUI
Information Request Number: 3375
Date report created: 07/07/17
Data Source: NTPF
45
Appendix 3 Mapping Survey of Dermatology Services 2016
DERMATOLOGY MANPOWER Survey
Dublin Midlands Hospital Group Estimated population 800,00 Group CEO: Susan O'Reilly Chair: Frank Dolphin
number of consultants
No of Spr
no of Registrars
No. of SHOs
CNM CNS Staff nurse HCA Administrator
Coombe Women's and Infants University Hospital
Naas General Hospital 0.5 0 0 0 0 0.2 0 0.2
St James Hospital + St Lukes Hospital
3.8 1 1 0 0 3 4 Yes 4
Tallaght Hospital (Adults) 2.5 2
NCHDs 3.8
CNS/CNM
0 0.5 3.6*
Midland Regional Hospital Portlaoise
Midland Regional Hospital Tullamore
TOTAL 6.8 1 1 0 0 3.2 0 0.5 4.2
46
Dublin East Hospital Group Estimated population 1,000,000 Group CEO: Mary Day Chair: Thomas Lynch
number of consultants
No of Spr
no of Registrars
No. of SHOs
CNM CNS Staff nurse HCA Administrator
St Luke's Hospital Kilkenny
0 0 0 0 0 0 0 0 0
Wexford General Hospital
0 0 0 0 0 0 0 0 0
St. Colmcilles Hospital Loughlinstown
St. Michael's Hospital Dun Laoghaire
St. Vincent's University Hospital Elm Park
4 1 2 1 3 2 8 1 3
National Maternity Hospital Holles Street
Royal Victoria Eye and Ear Hospital Dublin
Midland Regional Hospital Mullingar
0.6 0 0 0 0 0 0.4 0 1
Our Lady's Hospital Navan
47
Cappagh National Orthopaedic Hospital
Mater Misericordiae University Hospital
2.9 1 1 1 0 4 1 0
TOTAL 7.5 2 3 2 3 6 9.4 1 4
48
Dublin North East: RCSI Hospital Group Estimated population 800,000 Group CEO: Bill Maher Chair: Anne Maher
number of consultants
No of Spr
no of Registrars
No. of SHOs
CNM CNS Staff nurse HCA Administrator
Cavan Monaghan General Hospital
0.3 0 0 0.2 0 0.5 0.2 0 1
Louth County Hospital
Our Lady of Lourdes Hospital Drogheda
1.7 1 2 1 0 2 2.5 0.25 4
Beaumont Hospital (+St Joseph's Hospital Raheny HSE)
2.5 1 1 0.5 1 2 3.6
Connolly Hospital 0.6 1 0.6
Rotunda Hospital
TOTAL 5.1 2 4 1.7 1 4.5 3.3 0.25 8.6
49
South / South West Hospital Group Estimated population 1,000,000 Group CEO: Gerry O'Dwyer Chair: Geraldine McCarthy
number of consultants
No of Spr
no of Registrars
No. of SHOs
CNM CNS Staff nurse HCA Administrator
Bantry General Hospital
0.5
Cork University Hospital (inc. CU Maternity Hospital)
Kerry General Hospital
Mallow General Hospital
Mercy University Hospital Cork
South Infirmary University Hospital - Victoria
5 1 1 0.9 1.3 1.6 0 4.8
South Tipperary General Hospital
0 0 0 0 0 0 0 0 0
Lourdes Orthopaedic Hospital Kilcreene
Waterford Regional Hospital
3 1 1 0 0 1 2.5 0 2
TOTAL 8 2 2 0.5 0.9 2.3 4.1 0 6.8
50
West / North West: Saolta Hospital Group Estimated population 700,000 Group CEO: Maurice Power Chair: Niall Higgins
number of consultants
No of Spr
no of Registrars
No. of SHOs
CNM CNS Staff nurse HCA Administrator
Letterkenny General Hospital 0 0 0 0 0 0 0 0 0
Sligo General Hospital 1 0 1 1 0 1 2 0 1
Galway University Hospitals
4 2 0 1 0 0 2.6 0.5 4
Mayo General Hospital
0 0 0 0 0 0 0 0
Merlin Park Regional Hospital
Portiuncula Hospital General & Maternity Ballinasloe
0 0 0 0 0 0 0 0 0
Roscommon County Hospital
TOTAL 5 2 1 2 1 1 4.6 0 5
51
University of Limerick Hospital Group Estimated population 400,000 Group CEO: Colette Cowan Chair: Noel Daly
number of consultants
No of Spr
no of Registrars
No. of SHOs
CNM CNS Staff nurse HCA Administrator
Mid-Western Regional Hospital
2.6 1 0 0 0 1.7 2.6 0.1 2
Mid-Western Regional Hospital Ennis
0.2 0 0 0 0 0 0 0
Mid-Western Regional Hospital Nenagh
0.2 0 0 0 0 0 2
Mid-Western Regional Maternity Hospital
Mid-Western Regional Orthopaedic Hospital Croom
St. John's Hospital
TOTAL 3 1 0 0 0 1.7 4.6 0.1 2
52
National Children's Hospital Group
Group CEO: Eilish Hardiman Chair: Jim Browne
number of
consultants
No of
Spr
no of
Registrars
No. of
SHOs
CNM CNS Staff nurse HCA Administrator
Our Lady's Children's Hospital Crumlin
2.5 2 0 1 0 4 0 0 2.6
Tallaght Hospital (Children’s) 0.2 1 1 0 0 1 0 0 0.3
Children's University Hospital Temple Street
1.6 0 0 0 0 2.5 0 0 1
TOTAL 4.3 3 1 1 0 7.5 0 0 3.9
Overall totals
40
13
12
7.2
4.9
26.2
26
1.85
34.5
