Integrated Skin Care Centre

Dr Sheru George Clinical Lead for Dermatology, Allergy &

Plastic Surgery

“specialty in crisis” In 2009-10, there were 13 million primary care consultations in England for skin diseases and 882,000 (6.8%) were referred to secondary care dermatologists resulting in 2.74 million consultations (17% of total). Accounts for 8-10% of hospital outpatient referrals and about 40% of the Pathology department workload 17% of UK Consultant Dermatology posts are unfilled, or filled by locum consultants without a certificate of specialist training. There are 647 UK consultants and the country needs at least 960 (workforce figures submitted by RCP 2012).

Reasons for shortage of Dermatologists Generic: rising population; rising patient demand; ageing population; new complex treatments Specialty specific: • feminisation of specialty (over 80% of dermatology trainees today are women) • wider roles (repatriation from plastics, increasing specialisation e.g. within allergy & genital dermatology) • exodus to other countries, especially Australia • lure of private practice and cosmetic dermatology • Rising demand

International perspective We found that between 1987 and 2007, the availability of dermatologists to population rose by 60 %, from 2.35 to 3.76 dermatologists per 100,000 individuals. However, the current workforce is already out of balance in several ways.

Saudi Arabia

There are three types of density zone for dermatologists: • high-density zones (> 5 per 105 persons), comprising 24 departments (22% of the national territory) • moderate-density zones (3-5 per 105 persons), comprising 41 departments (47% of the French territory) • low-density zones (< 3 per 105 persons), considered as "dermatological deserts", comprising 30 departments (31% the

national territory) in which 10% of the country's dermatologists are practicing.

France

“In the setting of persistently long patient wait times and difficulty recruiting new physician staff, dermatologists have rapidly turned to Physician Assistants and Nurse

Practitioners to help meet patient demand for care.” US study

Dermatologists/100,000

Germany 6.3

France 5.1

US 3.2

Australia 2.0

Canada 1.6

UK 1.1

UK vs US Population Dermatologists

Suffolk County, UK 730,100 1 (locum)

Suffolk County, Massachussets, USA 732,684 14

B.C. suffers shortage of dermatologists

Dr. Chris Sladden, a dermatologist from Kamloops, flies to Newfoundland for half of every month where he can earn substantially more money.

B.C. dermatologists say the shortage of skin specialists has reached crisis proportions as patients with serious problems are waiting twice as long as they should and care is vanishing in huge swaths of the province. About 60 dermatologists work in the public health system but there are now 24 hard-to-fill vacant jobs and few signs of relief on the horizon. In Kamloops, for example, the home base of Health Minister Terry Lake, there’s only one dermatologist, but he’s de-enrolled from the Medical Services Plan, which means all patients must pay out of pocket if they want to see the lone specialist. In Prince George, the only dermatologist in town serves a population of 300,000. But he’s retiring next month, so by the end of the year, there will be no MSP-billing dermatologists between Kelowna and Prince George.

Canada

20 Nov 2013

THH Dermatology 2007-2011 • Single handed substantive consultant (1 year maternity leave from Jan 2010)

• Difficulty recruiting substantive consultants to the post

• Succession of expensive and poor quality locums

• Core services such as patch testing and skin cancer services absent or deficient

• Skeletal service at Mount Vernon

• No sub-specialist medical or nursing services except genital dermatology and phototherapy

• Poor relations with PCT and GPs

• Less than 75% of PCT dermatology delivered by THH

• Unsafe Community Dermatology service being provided by private companies

• Long waiting times

• Clinical Letters taking 5 months to go out

• No coherent or consistent leadership or strategy

• Department in crisis and serious consideration given to closing down the service

• Contact Dermatitis • Photosensitivity • Paediatric Dermatology • Genital Dermatology • Advanced Surgical Dermatology • Mohs surgery • Lasers • Research - oncology

Since 2011 – STRATEGIC INVESTMENT SPECIALISE

Joint Clinics

• RheumDerm (Rheumatology)

• Vulval (Gynaecology/ GUM)

• MAGIC (GUM)

• Cancer MDT (Pathology, Oncology, Max-Fax,

Plastics, Radiotherapy)

• Paediatric Allergy (Paediatrics)

• Research skin cancer (Oncologists at ENH)

Nurse clinics

• Photodynamic therapy

• Iontophoresis

• Phototherapy

• Minor skin Surgery

Allergy Dietetics

Self Pay Private patients

& REACH OUT - LOCATIONS

Hillingdon

Mount Vernon

Chorleywood – W Herts

Gt Missenden - Bucks

Royal Free - London

Sheru George Mary Lawlor Cloda Bernard Farhana Ravat Nuriah Ismail Mike Hogarth Ophelia Dadzie

Lasers * Photodermatology Skin cancer General Dermatology

Dev Shah Mahesh Kumar Trevor Viegas Alok Misra

Surgical dermatology * Plastic surgery * Maxillo-facial surgery * Mohs surgery

David Orton Reina Wujanto Sarah Wakelin Tanya Wright Jackie Crawford Manjeet Joshi Hasna Syed

Contact Dermatitis * Allergy * Dietetics Paediatric Dermatology

Clinical Team

Year Derm

(Paeds) Derm (Adults) Allergy Total Annual

Increase

2010-11 679 12,710 13,389

2011-12 780 13,081 13,861 3.5%

2012-13 766 14,743 15,509 11.9%

2013-14 851 17,605 397 18,853 21.6%

2014-15 959 21,269 670 22,898 21.5%

2015-16 1,096 22,201 1,155 24,452 6.8%

2016-17 1,126 21,587 1,289 24,002 -1.8%

0

5,000

10,000

15,000

20,000

25,000

30,000

2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Paed Derm Allergy Total

Outpatient Attendances – All commissioners

Hillingdon CCG Community Dermatology service in place

Year Non-HCCG %

2010-11 15

2011-12 17

2012-13 22

2013-14 29

2014-15 33

2015-16 36

2016-17 42

Current Problems

• Significant Estate constraints

* Highly fragmented service; excluding ward referrals, the staff are currently working from 7 locations within Hillingdon Hospital and 3 in MVH. Mitigates against cohesive collaborative working

* No space to deliver one stop clinics leading to gross inefficiencies in business processes and poor patient experience

* Minimal space to deliver training commitments

* Cramped office space at Hillingdon: 8 consultants, 3 juniors, 1 nurse and 1 dietician sharing an office of less than 120 sq. feet. No dedicated space at all in MVH

• Tertiary referrals for Mohs surgery from Watford and Northwick Park still deferred because of location

• waiting times in many subspecialty clinics now over 3 months. Outreach consult clinics are expanding rapidly with capacity issues now arising in surgery, allergy, lasers. The Contact Allergy service provided at Royal Free has grown from a once monthly to a once weekly service in the space of 1 year

• The service despite some relocation to MVH remains geographically lopsided.

• Regional complex patient clinic stalled for lack of clinical space and co-located seminar room

• Repatriation of Plastic surgery from Royal Free not possible without additional theatres and staff

SWOT ANALYSIS

STRENGTHS • Clear vision • Momentum • Cohesive multidisciplinary team • Some well established nationally renowned clinicians • Perceived as progressive and clinically led • Near comprehensive portfolio of services, and

integrated with allergy and dietetics • Widening clinical network • Specialty specific Clinical Information system • Supportive management • Financially sound

WEAKNESSES

• Small catchment population

• Poor and insufficient facilities

• No medical photography

• No Nurse day treatment facilities

• Split site & inequitable core services (e.g. paediatric dermatology)

• No involvement in Specialty trainees education

• Weak branding

• Restrictive private practice contract with BMI

OPPORTUNITIES (gaps in local and neighbouring dermatology services)

New services • Psychodermatology, Plastics (repatriation), Adult

allergy New territory/referrers • South Bucks - patch testing, lasers, Mohs surgery,

adult allergy, general dermatology • West Herts (Watford & Hemel Hempstead) - Lasers,

Mohs surgery, Allergy • East Berks - Lasers, Mohs surgery, Allergy, Patch

testing • North West London (Northwick Park and Ealing) -

Ealing being wound down – Lasers, Mohs surgery • Harefield: General dermatology for inpatients • Milton Keynes – Lasers, Mohs, Patch Testing

THREATS

• Specialised commissioning requirements

• Referring consultants increasingly concerned about our waiting times

• Existing staff becoming disillusioned

• Northwick Park trying to expand with new consultant appointments.

• Delays in Monitor rectifying PbR anomalies

• ? Community Dermatology

Solution agreed by Trust Board Develop a multidisciplinary Tertiary Skin Centre: This option entails retaining core services such as certain outpatient clinics, minor skin surgery and covering in-patients at Hillingdon hospital. The majority of services will be co-located in a single location thus providing the spatial platform that will enable improved clinical quality, operational efficiency and service expansion to further enhance the financial viability of the service. It also allows for the introduction of medical photography and Psychodermatology which is central to obtaining recognition as a specialist centre for specialised commissioning, in Dermatology, Allergy and other specialties Creates capacity on current Acute Site for other developments Sites identified and assessed since Jan 2013 Hillingdon Hospital site • Elderly Day Hospital – dropped because of disruption to other services and lack of sufficient space Non-Hospital sites • Two Commercial buildings in Uxbridge; not pursued because of cost/lack of parking • Pub on other side of Hillingdon Hospital • Dental practice site in Denham • Phoenix House in Tatling End, Denham Mount Vernon Hospital site • Edmunds ward • Daniels ward • Old outpatients • GED-Adams • Car Park adjacent to Treatment centre

Aerial Photograph 2016

Planning permission

Applicant: The Hillingdon Hospitals NHS Foundation Trust (THH) Agent: Nexus Planning Architects: Gray Baynes and Shew (GBS) December 2016

Pre Application Submission to Greater London Authority (GLA)

Proposed Skin Care building at Mount Vernon Hospital

• Introduction to THH and its catchment area • Clinical justification • MVH and it’s Site History • Emerging Masterplan for the site

Site Plan

Artists impression of front of skin centre

Design of new skin centre

8.0 Car parking and Access The current situation The Mount Vernon site has three points of vehicular access. Gates 1 and 2 are off Rickmansworth Road from the east. Gate 3 is from White Hill from the west. Within the site there are currently over 1170 surface car parking spaces and a large bus stop and terminus area. The bus stops are adjacent to the Treatment Centre and the proposed Skin Care building. The 1170 parking spaces are dispersed across the site and include: At least 28 spaces that are adjacent to the Outpatients building that has been closed. These spaces are currently not in use. At least 49 spaces that are adjacent to the Grey Cancer Institute building that has been closed. These spaces are currently not in use. The overflow car park that has a capacity of over 130 spaces. Of these approx. 15 are used on a daily basis. The additional spaces provide an important overflow capacity for times when there is strong demand for spaces. Additional demand for spaces generated by the new building The new building will accommodate approx. 42 staff of whom 9 are transferring from Hillingdon Hospital and 33 are currently employed on site. So the net increase in staff will be 9, generating a requirement for 5 additional car parking spaces. Many patients who currently use other parts of the Mount Vernon site will now be treated in the new building. But as a result of the new building approx.. 18,500 patients will visit the building per annum. They will generate a requirement for 18 additional car parking spaces. The total increase in demand for car parking spaces generated by the new building will be approx. 23 spaces.

Proposed car parking provision The new building will be sited on an existing car park. This will result in the loss of 84 parking spaces. In order to accommodate the new building approx. 107 spaces will be required (84 + 23). Rather than create new parking spaces it is proposed that: The 28 spaces adjacent to the Outpatients building be brought back into use The 49 spaces adjacent to the Grey Cancer Institute building be brought back into use A further 10 – 12 spaces can be used at the frontage to the Grey cancer Institute building Any additional requirement is met by using the overflow car park As part of bringing the currently unused car parking spaces back into use a number of enabling works will be undertaken including additional lighting, signage and ticket machines. A further benefit of bringing these spaces back into use is that it will generate footfall in parts of the site that are currently underused. This will improve surveillance and site security.

Landscape Strategy Benefits of a green roof: • Environmental masking by blending into the

landscape using the permeable land surface that would have been lost.

• Improved air quality through vegetation reduction of pollutants & dust particles.

• Reduced urban heat island effect caused by reflected solar energy.

• Reduced carbon footprint as insulation is improved.

• Reduces the SUDS requirement for storm water attenuation by retaining a proportion of the annual rainfall.

• Noise reduction due to the excellent acoustic qualities.

• Aids biodiversity by providing a healthy habitat in a place that would otherwise be empty, encouraging a wider spread of species in the area.

A few points regarding the construction: · Hand dig only is specified in any area that may have tree roots. Majority of construction is within the car park area where there is unlikely to be tree roots. · Tree protection barriers are to be used during the construction period. · SUDS permeable paving and porous resin bonded paths to be used within the proposed site. · Areas of existing hard surface are to be replaced with new grass. · Existing swale to re-provided in line with specialist recommendations. · South-facing secondary roof that would be suitable for solar panels. · Provision of a green roof (see below) · Sensitive landscaping within the green belt as an extension of the existing treeline.

Thank you

Any Questions?

Year Derm Paed

Derm Adult Allergy Total Increase

2010-11 577 10812 11,389

2011-12 647 10831 11,478 0.8%

2012-13 638 11436 12,074 5.2%

2013-14 698 12652 243 13,593 12.6%

2014-15 795 14321 391 15,507 14.1%

2015-16 852 14237 501 15,590 0.5%

2016-17 786 12687 502 13,975 -9.0% 0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Paed Derm Allergy Total

OUTPATIENTS INPATIENTS

Paediatric Derm Adult Derm Daycase Surgery Outpatients - TOTAL SAVING (£)

Year Activity Income (£) Activity Income (£) Activity Income (£) Activity Income (£)

2013-14 698 96,379 12,652 1,359,674 710 600,763 13,350 1,456,053

2014-15 795 107,262 14,321 1,525,604 690 529,604 15,116 1,632,866

2015-16 852 119,528 14,231 1,513,302 772 541,127 15,083 1,632,830 36

2016-17 786 106,415 12,687 1,410,632 792 577,200 13,473 1,517,047 115,819

2 years total CCG reduction in THH derm activity 1,676

2 years total CCG reduction in THH derm spend 115,855

CCG’s reduction in all hospitals derm spend for last 2 years -144,819

CCG’s likely spend on community derm for last 2 years 1,200,000

Outpatient Attendances – Hillingdon CCG