Skin doctors

THE treatment of skin disorders is estimated to take up almost a fifth of GPs’ consultation time while increasing demand for outpatient appointments has seen waiting lists rise in recent years.

The specialty has been highlighted by the Department of Health (DoH) as an area where GPs with a special interest (GPwSI) could have a significant impact by reducing waiting lists and delivering modern, patient-centred care.

A GPwSI is defined as a doctor who:

• takes referrals that may otherwise have gone directly to a secondary care consultant
• is first and foremost a generalist
• is able to act without direct supervision
• has a level of skill or competence that exceeds the core competences of the individual’s normal professional role and
• is accredited to deliver specialist clinical services directly to patients.

Dermatology GPwSIs have various training options: dermatology (Group 1); dermatology and skin surgery (Group 2); and dermatology, skin surgery and community skin cancer (Group 3).

Training

A GPwSI competency framework for dermatology was developed in 2007 and updated in 2011. The revised GPwSI guidance also provides detailed information to ensure that accreditors know the kind of evidence and competences that may be expected to be seen and tested during the accreditation process set out in Implementing care closer to home: Convenient quality care for patients, Part 3: The accreditation of GPs and Pharmacists with Special Interests. The competences required to deliver a GPwSI service are seen as a development of generalist skills as outlined by the RCGP and BAD in Dermatology for General Practice Trainees. There follows on from this a curriculum for GPwSI training. This is considered to be the minimum core curriculum for any generalist wishing to offer more specialist dermatology diagnosis and management services.

Practitioners are expected to show they have completed recognised training, which may include acknowledgement of prior learning and experience. This can be acquired in different ways:

• Relevant, current or recent experience (within the last five years) in a specialist dermatology department
• Successful completion of an appropriate postgraduate qualification in dermatology and/or dermatological surgery (e.g. diploma) – this is recommended as a good way of obtaining and demonstrating structured learning
• Self-directed learning via the internet with evidence of the completion of individual tasks
• Attendance at recognised meetings/lectures/tutorials on specific relevant dermatological topics.

Practical training is tailored to the service requirements of the GPwSI, who must attend sufficient clinics to obtain the necessary training and experience to demonstrate the competences required for accreditation. A number of different teaching and learning methods include:

• Attachment to a dermatology unit under the supervision of a consultant dermatologist (or plastic surgeon for surgical skills)
• A periodic case note review by the supervising consultant
• Attendance at a structured course of lectures/tutorials designed to cover basic dermatology
• A combination of clinical assessments and direct observation of practical skills.

Postgraduate diploma courses in clinical dermatology are offered by universities including Cardiff University and the University of London (Queen Mary College) with final examinations at the end of the course. However, possession of the diploma does not endorse the practitioner to work as a specialist in dermatology as they would still need to meet the requirements set out in DoH guidelines.

GPs interested in becoming GPwSIs are encouraged to approach their health board/PCT/GP consortium to make proposals or to get advice on services required locally. Trainees with special interests may consider doing a diploma or other training during their vocational training scheme, although this is not essential.

In practice

The proposed dermatology service is likely to be accredited first, and the dermatology GPwSI will then be accredited in the context of the service to be provided and the competences required to provide it.

Accredited GPwSIs can take referrals from local GPs to carry out clinical services beyond the scope of traditional general practice. Most will continue to be practising GPs, and will only perform GPwSI duties for a limited number of time slots (or sessions) per week.

Accredited GPwSIs are normally appointed and paid for by the health board/PCT/GP consortium based on local need and must also have their service accredited. Trusts may also employ GPwSIs to deliver services within the hospital or for contracted community dermatology services but employment contracts and financial arrangements will differ between areas.

GPwSIs can choose to set up a number of different service models, including:

• A community based service with strong links to the local dermatology department.
• A community based clinic for patients with chronic skin problems such as psoriasis, eczema or leg ulcers, all within a multidisciplinary setting.
• Specialist or enhanced skin surgery performed by trained GPs with suitable facilities.

There are a number of essential elements in providing a GPwSI dermatology service, including access to consultant dermatology support, support from a trained dermatology specialist nurse and adequate consulting rooms with good facilities for diagnosis and treatment procedures. Ideally, there would be a computer link to the hospital-based dermatology department with telemedicine facilities.

The future

The changes set out in the 2010 White Paper Equity and Excellence: Liberating the NHS will, as they are implemented, have an impact on the way in which GPwSI services in England are commissioned and accredited. But while some of the details of the process will be subject to change, the principles set out in DoH guidance are expected to remain valid.

Links:

• Doctors interested in becoming a GPwSI in dermatology should consider membership of the Primary Care Dermatology Society – http://www.pcds.org.uk/

• British Association of Dermatologists – http://www.bad.org.uk/

• Revised guidance and competences for the provision of services using GPs with Special Interests (GPwSIs) Dermatology and skin surgery www.tinyurl.com/3o48mas  

• Providing care for people with skin conditions: guidance and resources for commissioners (NHS Primary Care Commissioning 2008) www.tinyurl.com/3ukx8kz

Joanne Curran is associate editor of GPST

Tania von Hospenthal is Clinical Services Manager at the British Association of Dermatology

Q&A Dr Fiona Collier, GPwSI in dermatology

What attracted you to a career as a GPwSI in dermatology?

I worked as a part-time clinical assistant in dermatology while having a break from general practice and I found it a fascinating field. After returning to general practice I decided to do the Cardiff diploma in practical dermatology and was fortunate to pick up a session in dermatology at the department I had previously worked in. I then approached our local dermatology department about creating a GPwSI post. This coincided with a redesign of dermatology services, and they incorporated three posts into their plan.

What do you enjoy most about the job?

It’s refreshing to be able to concentrate on one aspect of a patient's problems. I find in general practice, patients often throw in their skin problem as a third or fourth item on their list and it’s hard to do it justice. It’s also very interesting to see the health service from the secondary care viewpoint and speak to hospital colleagues who are often interested/puzzled by various aspects of primary care. The GPwSIs are very much part of the multi-disciplinary team in dermatology and I enjoy the support and exchange of ideas within the team.

Are there any downsides?

One problem with being a GPwSI is that this is a 'non-standard' post, with a locally-negotiated contract. This means that we have no automatic right to any salary increase awarded to other NHS staff and have to argue our case for any uplift in our remuneration.

What do you find most challenging?

It can be challenging to balance the demands of the two different jobs, particularly ensuring I am back in the practice on time for my commitments there. Also, I must admit that quite a lot of my GP consultations have a dermatology flavour, due to intra-practice referrals, and patients hearing by word-of-mouth that I am interested in skin conditions. I don't mind this at all, but it means that my other patients can have some difficulty in getting appointments.

What about the role has most surprised you?

I hadn't realised how much other areas of my practice would benefit from spending time getting more expertise in a particular area. It seemed to rejuvenate my enthusiasm for keeping up-to-date and improving my skills in other aspects of general practice.

What is your most memorable experience so far?

My most memorable experience was giving a talk to local GP colleagues about a particular skin disease, hidradenitis suppurativa, which I felt was a neglected and under-diagnosed condition. I was quite apprehensive about lecturing to my peers, but they were very supportive and it was a very positive experience.

What advice would you give to a trainee GP considering a career as a GPwSI in dermatology?

Sit in on some dermatology clinics to see if you enjoy it – it’s not everyone's cup of tea. Then investigate the various options for a postgraduate diploma in dermatology. Many of these are now largely distance learning, with local clinical attachments. The diploma gives you a solid knowledge base and training in the specific clinical skills of dermatology. It’s worth trying to make links with your local dermatology department, so they know your face if any opportunities arise. I think having a special interest helps maintain enthusiasm and balance in general practice and it’s something I'd recommend to any GP at any stage in their career.

From GPST Issue 03, pp 8-9 

GPST03
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