Most patients with long-term inflammatory skin problems, including eczema and psoriasis, have mild to moderate disease and are able to rely on topical treatments to manage their condition. Low adherence to topical treatments is an ongoing concern of NHS England, who are focused on improving the use of core treatments for people with long-term skin conditions, seen as an important part of enabling self-care and improving health outcomes. 5 In relation to more severe disease, GIRFT has found wide variation between trusts in the uptake of biologics used to treat these conditions. In collaboration with NICE, NHS England asked dermatology units for the reasons behind this, and found much depended on how CCGs interpreted NICE guidance. 13 56% of trusts said that they have to wait for CCG approval before prescribing NICE approved drugs, whilst 12% of trusts said CCGs had told them they could not prescribe certain NICE approved biologics for psoriasis. 13 There are some cases where commissioners prioritise cost as a key driver for treatment decisions with some requesting that the least expensive treatment be chosen. 39 This could be seen as in contradiction to GIRFT, which recommends ‘patients have equitable access to appropriate therapies’ . 13 This approach may also risk losing the cost savings that could be achieved cumulatively over a number of years should sustained disease control result from a faster progression to an optimal treatment. This situation seems to resonate with patient experience, with a recent survey by the National Eczema Society finding that 28% of adults with moderate, severe or very severe eczema face difficulty obtaining the treatment they need to manage their condition. 37 These findings highlight the extent of challenges in access to treatment for those living with atopic eczema and psoriasis, potentially resulting in poorer patient outcomes and undue suffering. As treatments evolve there may also be a need to ensure the workforce is upskilled to feel confident to administer them. Ensuring national guidelines and quality standards are in place for the management of severe eczema in adults would also help, as guidelines are currently only available for children under 12. 4 This could again assist local decision-making, as according to a 2017 freedom of information request sent to CCGs and NHS trusts in England, only 3% of CCGs had a commissioning policy on atopic eczema. 4
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Local restrictions in access to advanced treatments mean that many patients spend years cycling through ineffective treatments before being prescribed the most appropriate treatment, and specialists at Salford Royal NHS Foundation Trust have noted that people with severe psoriasis can often wait ten years before they are prescribed a systemic drug and 12 to 14 years before they are prescribed a biologic. 3
There is also a significant variation in access to psychological support services across the country. In a survey conducted to support the All-Party Parliamentary Group on Skin’s 2020 Mental Health and Skin Report, 98% of skin disease patients reported that their condition affects their emotional and psychological wellbeing, yet only 18% have received some form of psychological support. 14 GIRFT found that workforce shortages were a key contributing factor behind the variation in access to such services, with only 11 dermatologists running psychodermatology clinics in nine trusts. 13 This variation, alongside delays in receiving a diagnosis and accessing treatment, is likely to have a detrimental impact on the quality of life of those suffering from inflammatory skin conditions. Technology barriers and digital poverty impacting follow-up ambitions Reducing outpatient follow-up appointments by 25% against the 2019/20 baseline by March 2023 has been a key NHS England target since the pandemic. 40 PIFU is seen as an important means of delivering that target and NHS England had an initial ambition of moving 5% of outpatient attendances to this pathway by March 2023. 40
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FROM NATIONAL GUIDANCE TO LOCAL ACTION
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