integrated care

Published: 13/02/2003, Volume II3, No. 5842 Page 32

Long waits for dermatology outpatient appointments stimulated the establishment of a successful community service. Sally Cocker and Laura Elliott report

Two years ago, the then Pinderfields and Pontefract Hospitals trust asked local primary care groups to find ways of improving access to dermatology clinics. In June 2001, there were 518 patients waiting over 13 weeks for a dermatology outpatient appointment and the longest wait was 45 weeks.

Five GPs in the area with an interest in dermatology approached their local PCGs with the hope of developing a community dermatology service.

The PCGs - Castleford and Normanton, Pontefract, and Wakefield South East - developed a joint proposal with the acute trust and made a bid for funding from the Modernisation Agency's Action On programme. The project received£112,000 from the Modernisation Agency and£50,000 for capital development. The capital funds were used to refurbish rooms at Castleford, Normanton and District Hospital to provide a minor operating theatre, treatment room and specialist dermatology equipment. In addition to the GPs, the community service employs two nurses and reception and clerical staff. Running costs of the community service -£90,000 - are provided by Eastern Wakefield primary care trust, which was formed by a merger of the three PCGs in April 2001.

The service began at the end of June 2001. It takes referrals directly from GPs and those redirected from hospital. Capacity is flexed to meet demand.

Up to 12 clinics are held each week, lasting from two to three-and-a-half hours each. These include two evening sessions. The GP specialists work in pairs for support, seeing from eight to 18 patients per session. By October 2002, the number of patients waiting more than 13 weeks for a hospital dermatology appointment had fallen to 32 and by January this year it had reduced still further to 18.

We expect that by the end ofMarch there will be no patients waiting more than 13 weeks.No-one waits more than 10 weeks in the primary care service as capacity is flexed.

As part of this integrated service, a rapid access clinic is held every Friday at Pontefract General Infirmary by a consultant and GP specialist. It enables the primary care service to refer patients directly to hospital for further advice, management, hospital-only prescriptions or specialist investigations.The clinic also sees urgent cases and provides supervised training for GP specialists.A nurse-led cryotherapy clinic has been set up as part of the community service to treat suitable patients referred by the GP specialists.There are plans to set up a leg-ulcer clinic.

The funding and support from the Modernisation Agency helped break down professional and organisational barriers and smoothed the development of an integrated service.The consultant dermatologists needed to feel confident in the skills of the specialist GPs and were involved in drawing up the training and accreditation framework. Initially the GPs found it difficult to appreciate that things moved slowly in large organisations and procuring equipment was not as fast as it would be in general practice, due to purchasing regulations.And there was a shortage of surgery packs.After a few months, the hospital consultants reduced the time spent supervising the primary care clinics as this was taking them away from their other work.

By the end of the first year, the primary care service had received at total of 887 GP referrals, plus a further 420 which had been diverted from hospital clinics.A total of 278 clinics had been held in which 1,050 new patients and 1,229 follow-up patients were seen.A total of 341 minor surgical procedures had been carried out and 251 cryotherapy treatments had been undertaken by nurses.The community service is now receiving up to 265 GP referrals a month.

Key to the service's success has been the GPs' willingness to be flexible and responsive to demand.

If waiting times become too high, the specialist GPs see when they can fit in extra sessions.

A survey of 41 patients found that all rated the service good or very good and the evening sessions were particularly appreciated.GPs have said they appreciate being sent a helpful management plan after the patient is seen in a clinic.The system's computer system can produce letters with details of diagnosis, treatment and management to go to the patients'GPs by the end of the consultation.The letters are signed at the end of each clinic.

We believe the enthusiasm of the GPs and the hospital's desire to reduce waiting times and improve access have been the drivers behind the scheme's success. l Sally Cocker is service improvement manager, East Doncaster primary care trust.She was previously project manager, dermatology department, Pontefract General Infirmary.

Laura Elliott is primary care development manager, Eastern Wakefield PCT.