Dermatology Workforce Service Forecast

Dermatology Workforce Service Forecast

Health Workforce New Zealand

November 2014

Table of Contents

Executive Summary

Introduction...... 6

Methodology...... 7

Dermatology in New Zealand

What is Dermatology?

The burden of disease

Skin cancer

Health Loss

Data on Hospital Services

Data on GP Services

Comparative ratios of Dermatologists: Population

Academic Dermatology

Current New Zealand Dermatology workforce

The vision for Dermatology in 2020

The proposed model of service delivery in 2020

Discussion

Dermatology service in New Zealand

Workforce

Specific service issues

Appendix 1: Dermatology Workforce Service Forecast Group

Appendix 2: Examples from literature (New Zealand and overseas)

Appendix 3: Vignettes

Appendix 4: ACC Claims

References

Executive Summary

From July to November 2013, the Dermatology Workforce Service Forecast group (the Group) was formed to develop a vision for dermatology services in New Zealand in 2020 and beyond, describing possible model or models of care that are patient-centred, team based and build in primary care where appropriate.

The Group’s vision for dermatology in New Zealand in 2020 is ‘that patients will have equitable access to an integrated, consultant-led service that delivers high quality health care’.

The Forecast was informed by literature reviews, the experience and knowledge of the Group members, the use of scenarios to illustrate current practice and information provided by individual district health boards (DHBs) and Health Workforce New Zealand (HWNZ).

This process highlighted a number of issues, the main ones being highlighted below.

• There is an urgent need to develop a career pathway for public hospital dermatologists and to increase Senior Medical Officer (SMO) dermatology posts. There are very few SMO dermatologists working in public hospital practice, compared to private practice due to a lack of substantive public positions.
• Access to publicly funded dermatology services in New Zealand is currently very limited and varies greatly across DHBs and regions.
• The range of dermatology treatments offered varies from region to region.
• There is an urgent need to ensure the continuity and development of centres of excellence in public hospital dermatology.
• Supportive management structures are required to facilitate public dermatology.
• Stronger dermatology training and academic capacity is required in New Zealand to enhance the service in New Zealand.
• There are very few nurses working specifically in dermatology, with limited or no opportunities for training and further qualifications.
• As services are increasingly being delivered outside of the hospital setting, there is a need for more education for General Practitioners (GPs), achieved through better integration with public dermatologists.
• A consistent approach to dermatology is required in New Zealand, with agreed pathways, standards and guidelines developed and implemented. This is particularly relevant to the diagnosis and treatment of skin cancer.
• Data on dermatology in New Zealand is hard to access and is not routinely recorded or centrally collected

In order to address the access issues highlighted, the model proposed by the Group for 2020, identifies the core services that should be delivered safely and efficiently at primary care, DHB, regional and national levels. Delivery of services requires appropriately trained staff, working in collaborative teams to provide accurate diagnosis and treatment plans, which can be delivered in a safe and timely way.

The report notes that support is needed for public Dermatology as a specialty as a matter of urgency. The report proposes that Health Workforce New Zealand, business units of the Ministry of Health and district health boards develop a cohesive plan that provides a sustainable, public sector dermatology service and workforce in New Zealand for 2020.

Introduction

The Workforce Service Forecasts (forecast) are to provide important input into HWNZ planning and decision-making around workforce purchasing intentions and other workforce initiatives.

In July 2013, Dr Darion Rowan was invited to form a Workforce Service Forecast group, to look at the future needs for dermatology in New Zealand. Group members were invited who brought skills, experience and knowledge of dermatology, both in New Zealand and overseas, a dermatology nurse and a local GP. A full list can be found at Appendix 1.

The aim of the forecast was to develop a vision of the relevant health service and workforce for 2020 and beyond, and models of care that are patient-centred, team based and build in primary care where appropriate.

In developing the vision and model the Group needs to take into consideration:

• that the outcomes from this forecast are applicable to the delivery of dermatology services nationally across New Zealand
• a likely doubling of health service demand but only a 30-40% increase in funding over the next ten years
• that the population is increasing and ageing
• maintenance of quality in service provision
• a continued need to address inequalities
• increased access to quality services
• the interface with Plastic Surgery, particularly in relation to skin cancer
• a reduction in duplication of services
• the ‘triple aim’ of:

• an improvement in individuals’ experience of their health care and better individual health outcomes
• an improvement in the health and well-being of communities
• a reduction in the per-capita costs of health care

• that the status quo is only acceptable if there are no superior alternatives, which is not an option for dermatology.

The process began in July 2013 and was completed by the end of November 2013.

Methodology

Three face-to-face meetings of the Group were held, all of them at Greenlane Clinical Centre, Auckland. A part-time project manager was contracted to assist with the process. Email was the main form of correspondence and information sharing between the Group.

At the first meeting of the Group, a background document was tabled, which was a starting point for information gathering about the current dermatology workforce and service delivery model being used in New Zealand. The Group then developed the first iteration of their vision for dermatology and determined the scope of the project. It was decided to define the core dermatology services and how these should be provided, to ensure equity of access and then use a range of patient journeys to describe the current and then the future service delivery model. The Group identified the information that would be useful to inform the project and the need to consider overseas work.

The second meeting included reviewing the information that had already been collected, which included:

• analysis of prescriptions relating to dermatology to demonstrate the burden of disease
• analysis of the distribution of dermatologists by FTE and DHB and the issues that this raises
• overview of the documentation provided by Group members, particularly the literature from overseas.

The Group reviewed and amended the vision, refining the original statement. In addition, they shared their experiences of working overseas under differing models of provision. Group members then tabled their ‘patient journeys’ and discussed how these could be improved in the envisioned future delivery model.

The third meeting involved the Group focussing on the key issues raised, which had been drafted onto an initial report format.

The Group worked on key findings, relevant data sources and recommendations to include in the report to HWNZ, which highlight the current situation of very limited public dermatology provision and the requirements for the envisioned service for 2020.

A three-hour teleconference was held to agree the final version of the report.

Dermatology in New Zealand

What is Dermatology?

Dermatology is the study, research and diagnosis of disorders, diseases, cancers, cosmetic, ageing and physiological conditions of the skin, fat, hair, nails and oral and genital membranes. It includes the management of these by different investigations and therapies, including but not limited to dermatohistopathology, topical and systemic medications, dermatologic surgery, phototherapy, laser therapy, superficial radiotherapy, photodynamic therapy and other therapies that may become available.[i]

The burden of disease

New Zealand currently has 4.3 million citizens[ii] and 61 Registered Dermatologists[iii]. By 2021 the New Zealand population is projected to reach just less than 5 million ii. Mean age will rise to 37.9 years and 17% will be aged over 65, an increase from 13% in 2011. By 2026 it is estimated that 1 million New Zealanders will be aged 65 and over.

An increasingly ageing population increases the chances of developing skin-related disorders such as dermatitis, bullous dermatoses, skin neoplasms and adverse cutaneous drug reactions[iv]. Decreased immunity and exposure to a range of external factors, in particular UV light, is likely to lead to an increase in skin cancer. It is predicted that there will be an increased need for dermatologists to meet these projected needs.

Skin cancer

New Zealand’s melanoma incidence is higher than that reported in any other nation. In comparison with Australia, the most recent complete data is from 2009 where the New Zealand cancer registry reported 2212 new melanomas giving a New Zealand incidence of 51.2 melanomas per 100,000 people. For 2009, the Australian government cancer registry published their incidence of 44.8 melanomas per 100,000 people. The United Kingdom melanoma incidence in 2010 was 26.6 per 100,000 people (Cancer research UK statistics). New Zealand’s melanoma rate continues to be the highest in the world and it is rising.

There were 445 deaths from skin cancer in 2009 of which 326 deaths were from Melanoma and 119 from non-melanoma skin cancer (for example, merkel cell carcinoma, squamous cell carcinoma, etc.)[v].

The exact rate of non-melanoma skin cancer is unknown, as currently these skin cancers are not notified. It has been estimated that 67,000 non-melanoma skin cancers are treated each year in New Zealand making both melanoma and non-melanoma skin cancers a significant proportion of all cancers (80%).

While the mortality from non-melanoma skin cancer is low, the large and increasing number causes a significant burden on the health system. The health system cost of all skin cancer in 2006 has been estimated to be $57 million with the additional lost production cost of $66 million[vi]. (Source; The costs of skin cancer: report to the Cancer Society of New Zealand 2009 by Des O’Dea)

Health Loss

In 2006, health loss from skin conditions found 17 408 Disability Adjusted Life Years (DALYs) representing 1.8% of the total health loss and 9479 DALYs for eczema and dermatitis (1% of total). In 2009, there were 95 deaths (58 in 2006) in New Zealand due to diseases of the skin and subcutaneous conditions.[vii]

Data on Hospital Services

Data on dermatology in New Zealand is hard to access and is not routinely recorded or centrally collected. Many patients seek treatment in the private sector and this information is not centrally held or readily accessed.

Dermatology is predominantly outpatient based and therefore relatively inexpensive on a per capita basis compared to other hospital specialties. However, dermatology inpatients are often seriously ill and require prolonged hospital stays with multiple assessments. Many medical and surgical patients develop dermatological complications that require the prompt attention of a dermatologist. The need for inpatient assessments is often not properly factored in to SMO job sizing. Many DHBs will have difficulty accessing dermatologist care for the seriously ill inpatient. Where there are inpatient services offered, there are a high number of inpatient consultations, for example Middlemore Hospital with 973 beds, and 15-20 in-patient consultations per week.

Data on GP Services

Dermnet, the website of the New Zealand Dermatological Society Incorporated, notes that in New Zealand, one in six (15%) of all visits to the family doctor (GP) involves a skin problem[viii].

The document ‘Skin Conditions in the UK; A Health Care Needs Assessment’ (2009), found

• Previous studies on unselected populations suggest that around 23-33% have a skin problem that can benefit from medical care at any one time and skin conditions are the most frequent reason for people to consult their general practitioner with a new problem.
• Surveys suggest that around 54% of the UK population experience a skin condition in a given twelve-month period. Most (69%) self-care, with around 14% seeking further medical advice, usually from the doctor or nurse in the community.
• Skin conditions are the most frequent reason for people to consult their general practitioner with a new problem.[ix]

Given New Zealand’s high level of skin cancers described above, it is likely that the figures for New Zealand are higher than those described in the UK.

Comparative ratios of Dermatologists: Population

Recommended ratios of dermatologists are based on the numbers of referrals and may vary for community based and hospital based clinicians[1].

Table 1

Country / Recommended / Actual
UK / 1: 62 500[x] / 1: 85 124[xi]
Canada / 1: 50 000 / 1: 61 734[xii]
Australia / 1: 50 000 / 1: 66 506[xiii]
USA / 1: 25 000 - 30 000 / 1: 31 250[xiv]
New Zealand / (see below) / 1: 274 146 (public)

There is no researched recommended figure for New Zealand. The Group’s recommendation is a minimum of 1 FTE: 100 000 of public dermatologists and is a higher ratio than other countries which reflects the amount of private practice in New Zealand.

Academic Dermatology

There is currently no academic department, or Professor of Dermatology in New Zealand.

Current New Zealand Dermatology workforce

Dermatologists

Dermatologists are medical doctors. In New Zealand, after completing six years of medical school, the trainee dermatologist must complete a general medical training programme, which usually takes 3 to 4 years. After a rigorous basic physician training examination, Fellow of the Royal Australian College of Physicians (FRACP), he or she is then eligible to enter advanced training.

The advanced training in dermatology involves at least a further four years of intensive study, research and practice in a variety of approved training centres in New Zealand and overseas. The position is usually that of a registrar or training fellow who is closely supervised by experienced dermatologists.

As of November 2013, there are five training positions in New Zealand (two each in Auckland and Waikato DHBs, and one at Counties Manukau DHB). It is expected that two years of the required four will be spent overseas (usually UK, USA, Australia or Canada). In total, a dermatologist has a minimum of 13 years of training before becoming vocationally registered with the Medical Council [xv].

A study of the work types of medical doctors in New Zealand carried out by HWNZ in 2009, notes the average hours worked and the average age of practitioners across all doctors.[xvi]

The average age for all doctors was 44 years, with dermatologists having an average age of 51 years. The average hours worked by all doctors was 43 hours per week, with dermatologists working an average of 40 hours.

Nine of the practising dermatologists in New Zealand are overseas trained (six in UK, two in USA and one in Canada). Only one of these studied medicine as an undergraduate in New Zealand, the remainder immigrated to New Zealand later in their careers and all are middle aged. This a relatively small proportion compared to other specialties.

A survey of the dermatological workforce carried out in 2010 by the New Zealand Dermatological Society Incorporated (NZDSI) was completed by 85% of those invited to participate. This survey showed that even though 53% of the New Zealand population lives in 4 urban centres; Auckland, Hamilton, Wellington, Christchurch; 75% of dermatologists live in these cities. Most dermatologists carry out a mix of private and public work and are often working in a number of settings - 66.3% of respondents who work in public stating that they worked in two or more public hospitals sites and 51.1% reporting that they worked in two or more private settings.

Dermatologists were providing between < 1 and 9 half-day (~4hrs) private sessions per week and between <1 and 8 public hospital sessions per week.

32.1% of respondents stated that they were planning to reduce their hours, retire or move overseas in the next 5 years, with 20.8% stating that they are planning to increase their hours.[xvii]

Requests to all of the DHBs as part of the workforce service forecast demonstrated the distribution of the dermatology workforce across the country. This showed that all DHBs were providing some dermatology services, but often this work was provided by visiting specialists, locums or through private contracts. By looking at publicly funded dermatology by FTE (Fig 1), the limited provision and therefore public access to dermatology is clearly shown, with a ratio of 1:274 146 across the country (based on the current population of 4 496 000 and adding FTE and part time work together, giving a national FTE of 16.4).

Figure 1: Distribution of Dermatologists by DHB (as at Sept 2013)

Data provided from dermatologists and staff at each DHB. Population data from Ministry of Health http://www.health.govt.New Zealand/new-zealand-health-system/my-dhb (Last accessed 19.11.13)

Dermatology Nurses

Dermatology nursing in New Zealand does not have a defined definition or scope of practice. There is currently no specific dermatology training or qualification for nurses in New Zealand and experience is gained through on the job training and practice.

There is one practicing Dermatology Nurse Specialist in the Dermatology Clinic at Christchurch Hospital.