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Improving dermatology services and training

he ISF is a national charity dedicated to improving the quality of life of people with all kinds of skin diseases and conditions, as well as promoting skin health and the prevention of skin disease by providing support, information, engaging in advocacy and raising awareness.

It recently made a submission to the Oireachtas Future of Healthcare Committee, which has been seen by the Medical Independent. The first part of the submission contained an overview of the prevalence of skin conditions and the current state of services in Ireland. It noted that over half of the Irish population experience a skin condition each year; between 15- 20 per cent of GP consultations specifically relate to the skin. This represents up to five million GP consultations per year, which generates a significant number of referrals for consultant dermatologist advice.

Most skin consultations with GPs concern a small group of the most common skin conditions, such as skin lesions, eczema, psoriasis, acne, wounds (including leg ulcers), contact dermatitis and viral warts.

Many skin disorders, such as eczema, are increasing in frequency, the submission document noted; approximately one-in-five children and one-in-12 adults have eczema.

The ISF pointed out that Ireland has one of the highest incidences of skin cancer in the world, with 984 new cases of melanoma and 9,786 new cases of skin cancer in 2013. It is expected that diagnoses of these diseases will increase by over 300 per cent by 2040. The increasing instance of skin cancer alone threatens to overwhelm secondary-level dermatology services.

At secondary level, dermatology has the fourth-longest public waiting list, with 34,805 patients, and an average waiting time for routine assessment of 12-to-18 months.

Skin diseases cause over 180 deaths each year in Ireland, including 113 deaths due to malignant melanoma, the vast majority of which are avoidable through early detection and better-resourced services, the ISF highlights.

While new specialist posts have been established in the past six years, the HSE has not provided sustained resources for additional posts or adequate investment in clinic infrastructure and development, states the ISF submission. “Consultant dermatologist staffing is 50 per cent below international best practice. Access to predominately outpatient-based treatments early and easily reduces the health and financial impact of skin disease for patients and for the healthcare system,” the document states.

The submission document contains five key recommendations, with professional medical training in dermatology a key element. The ISF notes that despite the clear and increasing demand for dermatology care at primary and secondary level, undergraduate medical training in dermatology does not receive enough attention. “Many undergraduates will receive as little as six hours’ dermatology education (if any) throughout their entire training. Moreover, universities and medical schools have very limited personnel dedicated to clinical academic positions for medical undergraduate teaching in dermatology.”

It also notes that while there are a small number of GPs who have developed considerable expertise in dermatology, at present there is no recognised national competency and guidelines framework for accrediting and maintaining standards for dermatology skills acquired through such training. More recently, some secondary-level dermatology clinics have begun to train GPs, “which is a welcome development, bringing badly-needed skills to primary care”, the ISF acknowledges.

Key recommendations of ISF submission document to Future of Healthcare Committee

Recommendation 1: Tackling skin cancer. Sun-safe practices lead to a reduction in skin cancer incidence. To tackle the increasing prevalence of skin cancer, a concerted, long-term strategy to educate the public about prevention and early detection is required. Changes to legislation are needed to place a duty of care on local authorities, schools, recreation/ sporting clubs and employers to protect the public, children and employees from UV damage. Sunbeds should be banned, completely, for public and private use.

Recommendation 2: Reduce out-of-pocket expenses for patients.
Reduce out-of-pocket expenses paid by patients for moisturisers, emollients, bandages, dressings, specialist clothing and sunscreens by eliminating VAT on these products. Expand the limited choice of products available via medical card and Drug Payments Scheme (DPS) for preventing, treating and managing skin disease. Provide sunscreens on prescription to patient groups at particular risk of sun damage and skin cancer (eg, immunosuppressed patients, such as transplant recipients).

Recommendation 3: Supporting patients in primary care. Support patients in primary care by resourcing dermatology training for all GPs, to provide universal access to the widest range of dermatology care to all patients in Ireland. Policy-makers must examine options in primary care in consultation with all healthcare professional representative bodies and other stakeholders.

Recommendation 4: Supporting patients in secondary care. Increased funding for secondary care dermatology should include, but not be limited to, an increase in consultant dermatologist numbers and must include greater investment in the infrastructure, equipment, specialist nursing and support staffing in dermatology departments. Service planning and development must provide sustained investment for consultant dermatology posts (to increase numbers of consultant dermatologists from 46 to 74, ie, from one per 100,000 population to one post per 62,500), dermatology clinical nurse specialist (CNS) and advanced nurse practitioner (ANP) roles, along with the necessary administrative support.

Recommendation 5: Medical and nursing education in dermatology. Ensure that medical, nursing and GP training (undergraduate and postgraduate) is sufficient, so that doctors have a basic knowledge of dermatology for common and important diagnoses. Basic nurse and pharmacist training must include dermatology and those specialising in dermatology should have easy access to post-qualification training in Ireland. This will widen the pool of clinicians with some dermatology expertise and facilitate earlier diagnosis and treatment.

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