By Richard Nelson, managing editor, April 02, 2012
Each month Dermatology World tackles issues “in Practice” for dermatologists. In this month's "International Issues in Practice," three dermatologists from the United Kingdom, Susan Burge, MD, Christopher Griffiths, MD, and Roderick Hay, MD, discuss the positive and negative aspects of practicing dermatology there and compare their experience to that of the United States.
As dermatologists in the United States ponder how their specialty may change as the provisions of 2010’s health system reform law go into effect, they may cast their eyes to the United Kingdom, whose system many critics of the law point to as an example of the sort of medicine Americans can anticipate. Three dermatologists from the United Kingdom shared their thoughts on the pros and cons of their system with Dermatology World — and their perspective suggests that dermatologists can find different ways to thrive inside a system that focuses more on primary care — or outside of it, as patients can choose to pay for care on their own and see non-National Health Service (NHS) providers. Thriving within such a system may require some American dermatologists to relate to general practice physicians in a different way than they are currently accustomed to, though — while the existence of dermatology nurses in the UK is perhaps unsurprising to their American counterparts, the fact that they sometimes practice in primary care offices and help triage patients to dermatologists may surprise.
Free for all
All three British dermatologists began their discussion of the pros of their country’s national health system by noting that care is free for patients. Roderick Hay, MD, said, “Everyone can see a doctor without charge and whatever their condition. If they are chronically ill, a child, or over 60 years of age they can obtain medicines free — otherwise they pay a standard fee per item. All areas of the country are covered equally for medical care; there is the same access to health care in cities and rural areas.”
Susan Burge, MD, noted that the system also features strong care coordination, with a single physician who knows any given patient’s history and oversees treatment. Christopher Griffiths, MD, agreed. “Primary care is highly respected,” he said, “as is the expertise that resides within the NHS in general. Our emergency care is probably second to none.”
The British system offers physicians different incentives than the American one, Dr. Burge noted. “There is no financial incentive to do procedures or bring back patients repeatedly as all NHS doctors have a salary paid by the hospital (along with good pensions, holidays, and study leave).”[pagebreak]
All is not roses, of course. As Dr. Burge explained, the National Institute for Health and Clinical Excellence (NICE) recommends treatments that should be funded by the NHS on the basis of the best evidence. While this leads to evidence-based care, it also leads, she said, to “some variability in availability of expensive treatments,” as the Primary Care Trusts in each region determine what treatments should be offered given the health needs of their particular population.
This can make a big difference when treating some dermatologic conditions, Dr. Griffiths said. “There are restrictions around prescribing biologic therapies for psoriasis. Eligibility criteria are dictated by NICE guidelines and approved by local Primary Care Trusts. Thus, patients with severe psoriasis must meet stringent criteria before they are deemed suitable for management with biologics.” Dr. Hay noted that the responsibility for making a case for a particular therapy for a particular patient can fall to the physician. “Our government has endeavored to make balancing cost versus benefit the responsibility of physicians rather than administrators,” he said. “In my practice we use potentially highly expensive anti-virals and some antifungals and there is often an argument with the central purchasing unit of the hospital pharmacy; so far we have usually won.”
These encounters may sound familiar to American dermatologists accustomed to debating coverage with insurers. So, too, is Dr. Burge’s concern about the fact that NHS does not cover cosmetic treatment. “Where should one draw the line? For example, in our area, we do not treat vascular birthmarks in adults with laser surgery. The NHS only funds laser surgery for facial port wine stains in children (up to age 18).”
While physicians may see their treatment options limited by cost-control measures, patients, too, have their choices limited under the British system — particularly regarding specialist care, Dr. Hay said. “Our contracting system involves every patient consulting a general practitioner before seeing a specialist,” he said, and the funding scheme by which hospitals (and the specialists who work in them) to whom GPs might refer are paid creates a perverse incentive not to refer, he added, because the Primary Care Trusts which purchase on behalf of GPs may retain unused funds.
Unlike most American dermatologists, UK dermatologists are among the specialists at the hospital. “Dermatologists are based in departments in hospitals (secondary care) alongside other medical and surgical specialties,” Dr. Burge said, “and do not work in isolation in offices.”
With only 350 dermatologists in a country with a population of more than 62 million, GPs must see most skin disease cases for the system to function, and they do. “Most patients with skin disease are managed in primary care; indeed, it is estimated that 15 percent of a GP’s workload is accounted for by management of skin disease,” Dr. Griffiths said. “Paradoxically, most GPs have very little training in dermatology,” he added — though all medical students have some dermatology education. Dr. Hay noted that 85-90 percent of skin disease cases are seen in general practice, and referred on only if problems arise with diagnosis or management. As a result, Dr. Griffiths said, “dermatologists in the UK have a more complex caseload than their counterparts in the U.S. and management of warts and mild acne, eczema, and psoriasis would be unusual.” Problems, he said, arise “when financial pressure is exerted on practices; they are less willing to refer and patients may have to resort to private consultations in order to see a dermatologist. However the articulate patients can usually obtain a referral — the problem is with those who are less fortunate.”
In an initiative that may remind some U.S. dermatologists of the burgeoning number of physician assistants and nurse practitioners working with them, Dr. Griffiths noted that the UK — which does not have PAs — has seen the empowerment in recent years of dermatology specialist nurses, who play a large role in the management of chronic skin diseases. “Nurses are now taking biopsies and performing laser practice,” he said. Dr. Burge said the training of nurses to excise skin tumors has increased efficiency at Oxford, where she also noted that dermatology nurses run their own clinics for patients with acne, eczema, and psoriasis. All of those nurses work in the same secondary-care setting as dermatologists and can consult with them as necessary. Nurses also help with triage of patients who may need subsequent care after an initial visit with a dermatologist, Dr. Hay said. “We try to discharge patients back to their referring doctor and increasingly utilize specialist nurses to liaise with the practice for continuing advice — these in turn will, where appropriate, arrange for the dermatologists to see patients again.” Meanwhile, Dr. Griffiths noted that some nurses in primary care settings have enough expertise in managing skin disease to provide education about topical therapies and their application.[pagebreak]
Competition and wait times
After they are referred to a dermatologist, patients in the UK face the same things American patients do: A wait. “Wait times to see a consultant dermatologist are long in some parts of the country,” Dr. Griffiths said. However, he noted that there has been significant improvement in this area. “Waiting lists are significantly less than they were 10 years ago. For a routine appointment in 2011 the wait was less than eight weeks. In 2000 there were waits for almost a year in some parts of the country!”
Patients who do not want to wait eight weeks for NHS care do have the option of seeking care outside the system. “There is considerable concern in the UK about competition from independent providers of health care,” Dr. Griffiths said. Partly, he said, this is because “there is no provision for cosmetic dermatology on the NHS; dermatologists who provide this service do so in private practice.” Similar to the U.S., he said, there is significant competition from non-dermatologists for delivery of cosmetic dermatology services, including dentists, GPs, gynecologists, and others.
About the contributors
Susan Burge, MD, is in a National Health Service academic practice based in the Oxford University Hospitals and sees primarily pediatric and medical dermatology patients. Christopher Griffiths, MD, is in academic practice with the Dermatology Centre in Greater Manchester. Roderick Hay, MD, is in a hospital-based and private practice after spending most of his career as a clinical academic.