Speech to All Party Parliamentary Group on Skin

Speech delivered on Thu 14th Oct 2004

First can I start by thanking the All Party Parliamentary Group for inviting me to speak this evening.

All Party Groups play an important part in the work of both Houses, they inform and education, they lobby and campaign.

I think all Members of Parliament benefit from the work of All Party Groups. I know that I do.

And that is certainly the case tonight.

I think this must be one of the most prolific and thoughtful All Party Groups. The reports you produce on dermatology are excellent. Indeed they were essential reading for this speech!

I don't want to claim any great expertise on dermatology. There are plenty of experts here tonight and I am keen to listen and learn from you.

It is worth rehearsing some of the figures.

Skin disease affects between 1 in 4 and 1 in 3 of the population at any one time.

1 in 5 of all GP consultations are about skin conditions.

These generate over 600,000 referrals to secondary care and some 60,000 inpatient episodes every year.

So it is hardly surprising that dermatology departments are busy, very busy.

One of the reasons dermatology does not register on the radar is that the NHS is focused on mortality and cure.

I think that we need to concentrate more on morbidity and prevention.

Like many long term medication conditions the approach to managing skin diseases is totally different.

It is crucial to adopt a model of care that addresses the biological, social and psychological needs of the person.

I was struck as I prepared for tonight by some of the research into the impact that skin disease have on people's lives.

From the most normal and mundane of things like going to a hairdresser, what job you do, taking part in sports, having sex.

For the most the severely affected there is the fear that they will never meet a marital or lifetime partner.

How we look matters. It matters to us it matters to the people around us.

For a person with a cosmetically disfiguring skin disorder, such as vitiligo the fear of being rejected is real. The consequences for that person are more than skin deep. The impact of a lifelong disfigurement can be devastating.

For some the condition leaves them feeling stigmatised. The mental health consequences need to be better understood and there should be more research in this area.

Access to a comprehensive service that treats or manages the condition as well providing the psychological and social support are more the product of happenstance, the personal interest of a local clinical leader.

The All Party Group in its reports has documented the skill gaps and the shortages.

Provision is patchy.

So what is to be done?

Well there are building blocks in place. I am not one for throwing out the baby with the bath water.

The Government is putting in huge extra resources and I believe that the NHS is responding.

I think that the 15 Action on Dermatology pilot sites and the good practice guide that drew on the experience, knowledge and expertise gained from them is very welcome.

But rolling it out so that it becomes the norm is the challenge.

I think we need more training and less targets.

The target culture is an obstacle to getting the best fit between the resources available and the needs of people.

One PCT Chief Executive told me recently that after he had allocated the budget to all of the must do's there was nothing left. Indeed he was over budget!

So scrapping targets would help.

That does not mean I would not want to have the Healthcare Commission collect and publish waiting time data for the whole patient journey. I most certainly would want such data to be widely available.

Nor does scrapping targets mean no standards; I think National Service Frameworks and NICE Clinical guidance are innovations that should survive the present Government.

Talking of NSFs, others here may have more up to date information, but the focus of the NSF for long term conditions has been neurological conditions. It looks like the NSF will omit inflammatory skin disease from its long list of conditions.

One criticism I have of the long term conditions NSF is the lack of solid epidemiological data and a failure to invest in the capacity to better understand the prevalence of a whole range of long term conditions. Without this data, both nationally and locally it is difficult to make sensible planning and commissioning decisions.

I said training is vital.

It has been suggested that there are more people with skin disorders referred into secondary care than necessary. That more could be treated or managed in the community.

Certainly the consequence of such high referral rates is long waits. The response to long waiting lists has been to adopt short term measures such as temporary clinics.

What is needed is a patient centred review of the way dermatology is delivered. I favour a model of care that brings healthcare closer to home.

That means making sure that the primary care team is better equipped to recognise skin disease diagnosis as the complex issue it is.

I think that the All Party Groups proposals for the training of community pharmacists, nurses and GPs offer a way forward.

The role of the pharmacist can be particularly important as a point both of advice and referral.

Nurses also have a key part to play in management of skin conditions. Nurse led clinics can make a huge difference both to the management of the condition and the way people cope with the psycho-social impact. This could form part of supporting self-care.

The development of distance learning material clearly has a part to play for both pharmacists and nurses.

GP training clearly has to change. If the management of long term conditions is really to become the raison d'etre then it can't be right that a GP can enter general practice without having had any training and on average no more than six days of training in dermatology.

While I think that the development of practitioners with a specialist interest is an important way of developing new care pathways they remain fragile and vulnerable to the person leaving for a new job. It is vital that the whole primary care team goes through an upskilling exercise.

The only group to be fully trained are the consultants. And there are too few and there are vacancies.

Redesigning services to deliver better dermatology services in the community will only work if the consultant workforce is at the right size. Redesigning is not a substitute for consultants it is the way to make the best use of a scarce resource.

So in conclusion. I hope I have given a flavour of the approach that Liberal Democrats want to take.

The aim is to deliver health and care in ways that fit around people's lives rather than forcing people to fit their lives around the NHS. That means bringing both the delivery and accountability for healthcare closer to home.