‘Not just on the surface’: Improving support for patients with skin problems

by Emma Le Roux, GP with a dermatology special interest. Formerly Senior Clinical Research Fellow (NIHR-in-Practice) at the Centre for Academic Primary Care, University of Bristol

Skin problems are among the most common reasons patients to go to the doctor. As a GP, I often reflect on the patients I see, such as the 35-year-old man who suffers with psoriasis. Over 15 years he has struggled with managing his itchy skin symptoms but of more concern to him is his related low self-esteem. Because of the appearance of his skin he felt unable to take part in leisure activities, such as taking his son swimming. He lacked understanding of treatment options and was unaware of the condition’s associations with arthritis and cardiovascular disease. His experience reflects the evidence that skin problems are known to have a heavy physical and psychosocial burden.

Most patients with skin problems are seen and treated in primary care. Many of the long-term skin conditions including eczema, psoriasis and acne are of mild to moderate severity which can be treated effectively with creams and ointments. However, high levels of self-care are needed, with treatments varying with symptoms. Poor disease control is common due to low adherence to topical treatments. Better shared decision making, whereby the clinician and patient work together to combine an evidence based approach with the patient’s preferences, may improve self-care.

From our research of GP consultations, most skin problems are presented alongside other complaints, limiting the time to discuss the problem to around 4 minutes. Shared decision making about treatments is uncommon and GP support inconsistent, with no signposting of patients to written or online information. Previous research has found that that patients and carers feel that their skin condition is not taken seriously by their healthcare professional, although they want personalised care with both verbal and written supportive information.

How can primary care provide improved support?

GP training in dermatology has been historically poor with doctors reporting knowledge gaps and uncertainty in managing skin conditions. There is, therefore, a need to help clinicians working in primary care, to improve their knowledge of and confidence in caring for patients with skin problems. One resource to support this is the recently developed freely accessible RCGP Dermatology Toolkit, which includes clinical and learning resources for practitioners, alongside high quality information and support for patients and carers to which patients can be signposted.

Clinicians should ask about disease severity, along with an assessment of the psychosocial impacts and patients’ treatment preferences. Personalised care planning through preparation of self-management plans together with signposting to supportive information could also improve treatment adherence.

Despite the challenges of supporting consultations for skin conditions alongside the competing demands of an ageing population with complex co-morbidities, there are opportunities for improvement. The introduction of Primary Care Networks seeks to develop pro-active and personalised care, which could include reviews of long term skin conditions potentially delivered by nurses or pharmacists.

Returning to the man with psoriasis, I have been driven to look at a potential model within my own practice for long-term reviews of patients with psoriasis with the aim of improving self-efficacy and increased screening for psoriasis co-morbidities. Using a Quality Improvement approach we are creating a process that will enable all patients coded with psoriasis to be invited for an annual review, which will be undertaken by our practice pharmacist. To support me with designing and evaluating this service I have found the tools and methodologies from a recent Quality, Service Improvement and Redesign (QSIR) course I attended invaluable. Our hope is to test out our ideas for change in a controlled way on a small scale before implementation on a larger scale, perhaps at Primary Care Network level.

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