Survey Reveals Major Discrepancies In Care Of Patients With Psoriasis, UK

Main Category: Eczema / Psoriasis
Article Date: 21 Feb 2008 - 2:00 PDT

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Psoriasis patients across the UK are experiencing differing and sometimes sub-standard levels of care, according to a new survey by the British Association of Dermatologists and Royal College of Physicians.

Dr Colin Holden, President of the British Association of Dermatologists said: "Psoriasis is a chronic inflammatory skin disease which can have a huge physical and psychological impact, and as such patients require a high standard of care. This audit has produced data clearly showing that on a national level, the NHS is failing to provide patients with the level of care they deserve. Basic elements such as bathing facilities, appropriately trained staff and access to treatments are lacking to a worrying degree."

Key survey results of hospital dermatology departments:

- 20% of units have no dermatology specialist nurses
- 32% do not have adequate bathing and showering facilities for adult in-patients
- In 41% of units, topical treatments were applied by nurses who had no dermatology training, or by the patients themselves
- Only 40% of units had clinical psychology services available for patients
- 5% of units did not have the appropriately trained person, a medical physicist, monitoring the UV output of the phototherapy equipment, despite this being mandatory
- 39% are restricted in prescribing the new 'biologic therapies' which target the cause of psoriasis rather than the symptoms
- However, the average waiting time for routine appointments is only 10 weeks - below the maximum 12 week wait

Background:

Psoriasis is a chronic, recurrent disease that affects between one and three percent of the population and can require lengthy in-patient hospital treatment.

Dr David Eedy, dermatologist in County Armagh and one of the study's authors, said: "Until recently most skin disease has been managed either by GPs, or for more severe or persistent cases, in hospital by specialist dermatologists with access to day-care and in-patient services. However, the Government's initiative to provide 'Care Closer to Home' is changing the way such services are delivered. The care for patients with psoriasis is also changing with the advent of more effective treatments such as the biologics.

"We therefore conducted an audit of a hundred Dermatology Departments ('units') in the UK to assess their staffing and facilities for patients with psoriasis. The results exposed major discrepancies and a 'postcode lottery' in the care of patients. We will be making the government aware of our findings."

1. Staffing

More than one in ten units (11%) have consultants who work in isolation, without other dermatologists. Furthermore, specialist dermatological nurses greatly enhance patient care, but one in five departments had no specialist nurses.

Dr Holden said: "Our audit shows that some dermatologists still work alone, but we would like to see clinical networks developed so that all consultants work within teams and have the support of colleagues. Also worrying is that 20 percent of units do not have dermatology specialist nurses to support and educate patients with chronic inflammatory skin diseases, which enhances patients self-managing their treatment. This shortfall needs to be addressed."

However, one positive finding of the audit is that patients with inflammatory skin diseases were waiting a median of 10 weeks for routine appointments - below the maximum 12 week wait.

2. Infrastructure and resources

The nature of certain topical treatments is such that precise application by trained staff is required to ensure no damage to healthy skin occurs, and that bathing facilities are available to remove the medication safely after the treatment time is complete. However, according to the audit, a third of units did not have adequate bathing and showering facilities for adult in-patients. In addition, in 41 percent of units, topical treatments were applied by nurses who had no dermatology training, or by the patients themselves.

Dr Holden said: "Patients must have access to baths or showers - it is greatly disappointing that such basic facilities were perceived to be inadequate in a third of units. It is also worrying that so many nurses caring for dermatology inpatients have had no dermatological training and many in-patients have to apply their own treatments."

The effect of the psychological, social and physical burden borne by patients with psoriasis is considerable. Indeed the emotional impact of psoriasis is such that as many as one in ten patients contemplate suicide, especially those of younger age.

However, the survey revealed that clinical psychology services were available for adults and children in only around 40 percent of units.

Dr Holden said: "The cumulative effect of the psychological, social and physical burden borne by patients with chronic skin diseases, such as psoriasis, is considerable and clinical psychology services should be much more widely available for dermatology patients."

3. Treatments

Conventional treatments for psoriasis include phototherapy (treatment with ultraviolet light), as well as tar preparations and a medication called dithranol, which are both applied to the skin. According to the survey, thirty-eight percent of units would consider using more crude coal tar and forty-six percent more dithranol if facilities were staffed by trained nurses, as skill and expertise are needed to apply and remove such treatments. Scalp treatments were not provided in a quarter (26%) of units. Over one third of pharmacies could not readily provide coal tar or dithranol preparations.

In 95% of units, a medical physicist monitored the UV output of the phototherapy equipment. It is mandatory that the UV output of phototherapy machines is monitored by a medical physicist- the safety of patients is compromised in those units (5%) without such arrangements.

According to Dr Holden: "Old fashioned treatments such as dithranol or tar are safe, effective and relatively cheap, albeit messy. Coal tar and dithranol still have a place in the management of some patients with psoriasis - both outpatients and inpatients - but units should invest in trained nurses and pharmacies to apply and supply the treatments respectively. Scalp psoriasis is particularly problematic for some patients, but a quarter of units denied patients the opportunity of outpatient scalp treatment."

Advances in our understanding of psoriasis in the last two decades have emphasised the importance of the immune system in the development and maintenance of plaques of psoriasis. This has led to the development of a range of new therapies known as the 'biologics', which target the disease in the immune system rather than treating the symptoms. Evidence from large randomized, controlled trials demonstrates that biologic therapies significantly reduce the physical severity of psoriasis and improve quality of life. Biologic therapies seem likely to play an increasingly important part in the treatment of chronic inflammatory skin diseases such as psoriasis.

However, thirty-nine percent of units stated that prescribing of biologics for psoriasis was restricted for financial reasons. Dr Holden said: "This somewhat exposes the myth of one NHS for all. Patients are experiencing a 'postcode lottery' for biologics in the treatment of psoriasis, where there are wide differences in availability of the drugs. This is similar to the differing prescription charges across the borders."

Dr Holden concluded: "Apart from feeding back to the individual hospital trusts we plan to feed key findings from this audit to parliamentary bodies. We will work with patient support groups to bring organizational deficiencies to the doorstep of the government."

Chief Executive of the Psoriasis Association Gladys Edwards said: "The Psoriasis Association welcomes this much needed, long overdue initiative to clarify the treatment people with psoriasis are receiving. Sadly this report indicates that services for people with psoriasis, in many areas, falls short of acceptable standards. This report clearly highlights where there is room for improvement and we look forward to working with the BAD to emphasise the problems and ensure that people with psoriasis get a better deal in future."

David Chandler, psoriasis patient and Chief Executive of the Psoriasis and Psoriatic Arthritis Alliance, said: "The report supports anecdotal evidence from those that contact us about the inconsistencies of treatment and facilities in the UK. Living with a disease that affects you 24 hours a day, 365 days a year is depressing enough, but to then find out that if you lived in a different location you would get better care is just an added burden."

Study details: "An audit of provision of dermatology services in secondary care in the United Kingdom with a focus on the care of people with psoriasis", commissioned by the British Association of Dermatologists, conducted by the British Association of Dermatologists and the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians. Responses from 100 units in England, Scotland, Wales and Northern Ireland were received between February and August 2007 and the national report compiled in January 2008.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.

The Royal College of Physicians is a registered charity that aims to ensure high quality care for patients by promoting the highest standards of medical practice. It provides and sets standards in clinical practice and education and training, conducts assessments and examinations, quality assures external audit programmes, supports doctors in their practice of medicine, and advises the Government, public and the profession on health care issues. The RCP Clinical Standards Department produces guidelines and clinical audits, working closely with specialty societies and other organisations in the field to improve patient care.

British Association of Dermatologists