Anyone commissioning services is well aware of the need to commission for quality, innovation, productivity and prevention and to use resources in the most cost-efficient manner. As the way that services are commissioned continues to evolve, the twin challenges of assessing the quality of care offered by various service providers and ensuring that patients can access care of a high standard remain. These standards are intended as a reference guide to what constitutes a good-quality service for both commissioners and providers of care for patients with skin conditions.
There are eight standards and each comprises a series of recommendations, with rationales and references to support these, a list of implications for commissioners and at least one key performance indicator. This executive summary highlights only the key points from each standard.
Standard 1: Principles of Dermatology Care
This covers the overarching principles that should underpin the provision of care for people with skin conditions. These principles are absolutely crucial to the delivery of good-quality care and should be viewed as non-negotiable. Every local health economy must provide for full and fair patient access to the full range of high-quality dermatology services at all levels of care – to this end, models of care should be developed using stakeholder commissioning groups. Consistent, nationwide high-quality care that meets independent quality standards, such as those developed by nice, is a cornerstone of the 21st century –it can only be achieved if there is clear local support for independent quality standards.
People with skin conditions should have their care managed at a level appropriate to the severity and complexity of their condition, acknowledging that this may vary over time. All services should have access to a range of supportive services that can help meet the holistic needs of people with skin conditions – these could include psychological support, access to medical social workers, camouflage services and occupational therapy.
Standard 2: Patient and Public Involvement
The best way to design and develop user-centered dermatology services that meet the needs of people with skin conditions is to involve potential and current service users in their design, development and ongoing governance. Commissioners should develop and support a stakeholder commissioning group that includes patient representation, as outlined in the primary care contracting document Each dermatology service, whether integrated or stand-alone, should have a patient panel that is involved in its development and governance.
Standard 3: Appropriately Trained Staff
Individual competencies will depend on job role and should be relevant to services being commissioned, ie they should match the patient need. Healthcare professionals are responsible for maintaining their competence, but this must be supported by commissioners and providers working together within the context of a local governance framework that is commissioned and regularly monitored. Specialist dermatology services should play a key role in supporting the delivery of education and training across a range of providers. Standardization of educational provision (across professional disciplines and educational providers) is important, and lack of standardization represents a risk.
Standard 4: Clinical Assessment and Management
Patients should be seen by the right person in the right place with suitable facilities; those with special or particular 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 treatments approved by national agencies, eg nice, and treatment should be carried out in a safe, competent and timely manner according to national and local standards. Those with long-term conditions should be offered appropriate ongoing care and access and re-access to services as needed.
Standard 5: Models of Care and Links to Other Services
Models of care for people with skin conditions should be developed by stakeholder commissioning groups using consensus guidance to ensure they reflect the needs of the health community. All services for people with skin conditions should be integrated to ensure patients can move between levels of care as necessary. This requires established links between generalist, specialist and supra-specialist services to facilitate advice, support and onward referral, irrespective of provider. All health communities should establish clinical care pathways with other clinical services – these should be clear, agreed and used by all service providers to ensure equity of access for all patients. For patients with skin cancer the specific national guidance on care pathways should be followed. Triage and referral management, where used, should be performed by experienced, suitably trained clinicians with the sole aim of ensuring that patients are seen in a timely fashion by appropriately trained healthcare professionals.
Standard 6: Diagnostic Investigations
Dermatological investigations should be requested, carried out and reported by appropriately trained staff in accordance with local and national guidelines. Specimens should be transported in a safe manner. Results should be available and reported to the patient in an appropriate time frame.
Standard 7: 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. Commissioners should ensure that requirements for clinical governance are explicit in all contracts with providers of dermatology services and should monitor services against the agreed standards. Specialist services must be able to show the results of regular audit against national and local guidance – this will support compliance with care quality commission requirements. Strong clinical leadership is required for clinical governance to work well, and specialist services should provide this within local health communities.
Standard 8: Information Governance
Patient and public involvement it is the responsibility of all commissioners and clinical stakeholders to ensure that patient and public involvement is an integral part of all service developments and governance and has sufficient status, direction and leadership to be as effective as possible. Patient involvement the best way to design and develop user-centered dermatology services that meet the needs of people with skin conditions is to involve potential and current service users in their design, development and ongoing governance. It is vital to seek the views of patients regarding the services they currently receive and those that would improve their treatment experience. These views should be used to inform the delivery, development and continuing governance of all services. It is the responsibility of commissioners to develop strategies to involve a diverse range of people with skin conditions across the local skin health community. This process begins with education and support for all concerned including clinicians and commissioners in how to best involve people with skin conditions effectively.
These standards explore the opportunities and challenges involved in ensuring that people with skin conditions are seen by healthcare professionals with the appropriate skills and competence to meet their care needs. The standard does not comment on every professional group that may provide care for people with skin conditions, but the recommendations are intended to be applicable to all, wherever care is delivered.
Standard quality standards for dermatology recommendations note that the rationale appears in italic type after each recommendation. Competence to deliver services people with skin conditions should be cared for by appropriately skilled healthcare professionals who have demonstrated their competence to fulfill the required role. This includes the particular requirements, skills and training needed for those working with children and young people. Because of the high prevalence of skin conditions in the community, it is particularly important that all healthcare professionals providing generalist care achieve an appropriate level of competence in managing skin conditions. Individual practitioners are responsible for maintaining their own competence but must be supported in this by their employers and commissioners.
Rationale a range of healthcare professionals with varying levels of knowledge and mix of skills delivers services relating to the management of skin conditions. Appropriate competences will depend on job role and to an extent professional discipline. Competencies should be relevant to the service that is being commissioned (patient need) and individuals should work within the scope of their own competence. The standards required to achieve a particular competence should be the same, regardless of professional group (e.g skin surgery skills). Different professional groups may have different guidance on certain competencies and the steps required to ensure safe practice, e.g in relation to prescribing.
Clinical leadership the clinical leadership required to support education, training and ongoing clinical governance arrangements for all providers of dermatological care should be both explicit and commissioned. Clinical leadership should always be strongly supported by dermatology specialists working in partnership with other providers of care for people with skin conditions. Rationale providers of specialist dermatology services should have a key role in supporting the delivery of education and training across the range of providers. Their expertise should be harnessed and commissioned to support local service development and provide leadership in all education and training issues. Specialists are particularly useful in educating interns and other primary care professionals to help them improve the diagnosis, management and/or referral of people with skin conditions. While clinical leaders are usually consultant dermatologists, this need not always is the case.
Patients should be fully informed and subsequently updated on their skin condition. The following principles should be followed for all forms of management. Patients should be fully involved in and informed about decisions concerning the management of their skin condition. Healthcare professionals should always clearly explain to the patient the possible effects of any intervention, both beneficial and adverse. The patient should know who to contact to discuss further management of their condition. Patients should have access to all forms of effective treatment irrespective of where they live. The prescribing of high-cost drugs should be in line with national guidance and not determined by local commissioning decisions. If a treatment is not available, this should be explained to the patient and they should be told where it is available, so they can make an informed choice.
Management decisions should be made taking into consideration evidence-based practice, local and national guidelines and protocols, including nice guidelines, within a clinical governance framework. Prescribing of all treatments should be by appropriately trained staff in accordance with local or national prescribing policies. Patients should be informed as to whether their treatment will be prescribed by the primary care or specialist team or by a shared care protocol. Treatment should be carried out within a reasonable time and in accordance with local and national standards. All treatments should be delivered by competent individuals in a suitable and safe environment, respecting the patient’s privacy and dignity. Treatment includes topical treatments and dressings, which are an important part of care for many people with skin conditions.
In order to maximize safety, adequately maintained equipment (including resuscitation equipment where appropriate) and suitably trained personnel must always be available. All healthcare professionals managing people with skin cancer should comply with nice guidelines. Inpatients should be treated by staff skilled in the treatment of patients with skin conditions. Whilst conducting a review and ongoing care, patients should be given clear information about how to manage their skin condition, plans for review and, for those with a chronic inflammatory skin condition, advice on how to access care if they need further advice quickly because their condition deteriorates or they are concerned about it. Certain patients should remain under specialist review where appropriate.
Patients who are undergoing skin cancer management and follow-up their ongoing care should meet national guidance if these patients are discharged from specialist care, they should ideally have their skin condition assessed annually by a member of the primary care team. Ideally, too this should be linked to a medicines review and include, where appropriate, a risk assessment for associated conditions cardiovascular disease for people with psoriasis and a psychosocial assessment. Patient-reported outcome measures and quality-of-life tools may be used in standard clinical practice to help assess response to treatment. there should be arrangements in place for integrated shared care with other services, especially for those patients with chronic conditions. Since patients with skin conditions often require input from other specialties apart from dermatology, so dermatology services should have links with the full range of other specialties.