This section seeks to begin this process by examining the first piece of the barrier jigsaw identified – costs of delays to referral to specialist care for atopic eczema and psoriasis patients. It does this by estimating the implications to the NHS of patients being cycled through avoidable primary care appointments prior to diagnosis, and appointments that take place between diagnosis and referral to specialist care. One of the challenges in measuring the impact of inefficient pathways is the lack of data collection on diagnosis and referral rates in England for patients with long-term skin conditions. Data on psoriasis treatment patterns in primary care, particularly for patients who are referred to specialist care, is lacking. 34 In atopic eczema, research has found that most NHS trusts in England do not monitor or track data on outpatient appointments for adult patients with diagnosed or suspected eczema. Whilst some trusts do collect outpatient appointment data for skin conditions, it is not collected in a way that can be broken down further by individual skin condition. 4 A central consideration made in Part 4 of this report is therefore a more systematic collection of national data on diagnosis, referral to specialist care and access to treatment.
BOX 3
The calculations set out below are based on national data on the unit costs of GP care and informed by inferences made from the following reports: • A 2013 academic study on treatment and referral patterns for psoriasis in the United Kingdom • UK data included in the Global Patient Initiative to Improve Eczema Care • Clinical Practice Research Datalink and Hospital Episode Statistics data from 2021 Note: The data on psoriasis is somewhat historic, collected from The Health Improvement Network (THIN) database between 2007 and 2009, whilst the Global Patient Initiative to Improve Eczema Care study includes only limited data on referrals and diagnosis.
Findings and analysis Psoriasis
Currently, as set out above, some patients find it challenging to secure rapid referral to secondary care, in line with NICE guidance on appropriate management. This can result in patients cycling through unnecessary and avoidable GP appointments before being referred onwards, creating financial and capacity inefficiencies. While it is difficult to definitively identify how many GP appointments could be avoided, due to variations in patient presentation and in clinical practice, evidence from analysis of patient records indicates that those patients with psoriasis who are referred on to specialist care have an average of three GP appointments prior to referral. 34 It is likely that some of these appointments could be avoided, through the implementation of the recommendations set out in NHS England’s referral optimisation guidance. 5 Analysis by the National Audit Office into another long-term condition suggests that reducing avoidable GP appointments and expediting access to secondary care is possible and could deliver savings to the NHS, as well as improved outcomes for patients. 45 The table below sets out a series of calculations on the potential impact of changes to referral practices for psoriasis in primary care over a period of 27 months. ii, 34 Alongside an illustration of current practice, the table sets out two scenarios: 1. Reducing the number of pre-referral appointments to one – it is possible that implementing a comprehensive range of referral optimisation solutions could enable GPs to refer following a single appointment. 2. Reducing the number of pre-referral appointments to two – it is conceivable that either a) multiple appointments will continue to be appropriate for some patients, or b) that it will not be possible for all areas of the country to implement referral optimisation solutions in full, reducing their impact.
ii This was the time period covered by the most comprehensive research into referral patterns carried out in psoriasis care
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FROM NATIONAL GUIDANCE TO LOCAL ACTION
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