The UK needs office dermatologists

Before I started training in dermatology in the 1980s my boss suggested that I went to Vienna (a Mecca for all things dermatological) to see how others practised medicine. They accepted me as a visiting fellow, observing clinical practice and doing research. What still shocks me is how differently medical care can be configured.

I had just completed the mandatory pre-dermatology training of one year of house jobs and three years of internal medicine. Things were very different in Vienna. Not only did my new colleagues think I had wasted several years studying subjects peripheral to my career choice, but they were incredulous to hear that UK patients were unable to access dermatological care directly, having instead to go through the gatekeeper of the general practitioner.

I repeated the standard NHS mantra about how patients needed a primary care doctor to help them navigate the complexities of medicine. My Austrian colleagues initially assumed that our differences resulted from linguistic confusion secondary to my rudimentary German. They spoke slower, in English: “You mean that in England, if you have spots, people don’t understand you go to the spot doctor?” The clincher soon followed: “In England, if you have toothache, do people understand you need to see a dentist or do they need a general practitioner to advise them?” I now knew I was talking nonsense on stilts.

The organisation of care for patients with skin disease in the UK makes little sense, and reflects history, neglect, and an unrealistic expectation of the level of clinical skills that generalists can acquire and maintain.

Firstly, skin disease is not a big killer, and historically the NHS has been driven by mortality rather than disability. Skin disease has never been a priority.

Secondly, we continue to overestimate the knowledge and expertise of many doctors, and to underestimate our patients. Any debate about how to improve dermatological care is entirely predicated on the assumption that patients must first see their general practitioner.

The dogma is that if only we could teach more dermatology to our students or trainees then dermatological care would improve. The reality is different: we will only improve dermatological care when we omit general practitioners and let patients go direct to dermatologists who work outside hospitals. The resource that dermatology consumes in general practice simply needs redirecting.

Dermatology is one of the few specialties still heavily dependent on clinical perceptual skills.1 The learning curve is steep, and exposure to many cases is necessary. General practitioners may see only one melanoma every five or more years; this is not the way to remain competent. Most dermatological diagnosis is pattern recognition, so rule-based approaches, the stuff of so much general practice, is often unhelpful.2 Undergraduate training in dermatology is limited to about 10 days or fewer in most UK medical schools, and postgraduate training is even scarcer.3 It is surely conceit to imagine that clinical abilities in this area are meaningfully tested for most non-specialist practitioners at undergraduate or postgraduate level. Patients should know this and be aware of the contrast with much of Europe, where providing skin care outside hospital requires a certificate of specialist training in dermatology (dermatovenereology)—the same as a UK hospital consultant is required to hold.

Skin disease is the single most common reason for visiting a doctor in the UK, with about a quarter of the population attending a general practitioner each year with a skin problem.4 5 In England about 900 000 patients are referred from primary care to hospital each year.4 Skin disease is common, and clearly there is enough work to justify having an office dermatologist close to most people’s home. Unlike many specialties, where hospital referral is influenced by the need for access to expensive resources or teams of staff, the reason for referral for most patients with skin disease is simply to access a single clinician with the right clinical skills. The infrastructure needed for most dermatology is modest, far less than any community dentist or optometrist must provide.

Just as patients are capable of deciding if they need to visit an optometrist or a dentist without visiting their general practitioner, the involvement of general practitioners in skin care should be the exception rather than the rule. Most skin care could be provided by office dermatologists with only a minority of cases needing referral to hospital. Secondary care dermatology would shrink and would focus on those patients with the most intractable and complex problems. Removing routine dermatology care from general practice would allow general practitioners to focus on other areas. I suspect most patients would prefer such a system.