I don’t tend to blog or write much about the nitty-gritty of some of the day job. And I try to avoid the partisanship that affects so much of medicine in terms of this disease or that disease being a priority…. can we have more research money or money for more doctors etc. But this post is perhaps an exception, and it is written out of utter frustration at the incompetence of the UK health services.
Some data from a paper in press in the JID looking at age-cohort models of melanoma, trying to predict what might happen over time. When I came into dermatology, crude incidence rates for melanoma /100,000 were 5.8. When I retire (if I get that for) they are estimated to be 31.4/100,000. A timespan of one career.
Some context. Yes, this is incidence not mortality; diagnostic patterns have changed over time; and our knowledge of the natural history of melanoma, incomplete. But, in the absence of a major scientific advance that changes the field ( I see little evidence of this), incidence rates will be a key driver of health care needs. Given that melanoma diagnosis is clinical, and that we need to see 10–20 patients to pick up one melanoma, we are looking at a sixfold change in workload over one clinician’s career. And this ignores the more intensive nature of treatment and follow up, so workload will increase even more. Nor is melanoma the most common cancer we see. If cancer is ‘half our work’, melanoma rates are possibly an underestimate of what changes we will see, as the exponent relating incidence to UVR, is even higher for the non-melanoma skin cancers (NMSC).
At present, perhaps 20% of UK consultant dermatologist posts are vacant, and the UK has the lowest number of dermatologists per unit population in the EU by an order of magnitude (certainly in comparison with the German speaking world). I will repeat that: by an order of magnitude. Primary care is in meltdown, too. And while there are lots of well qualified trainees who want to become dermatologists, training positions are essentially static, reflecting classic market corruption by a monopoly. And to cap it all, the Colleges (‘little Englanders’) have recently made the situation even worse, with bizarre changes to dermatology training, that will worsen care in the UK, rather than reflect the changes that will be necessary looking to the future:bracing forward with their eyes on the rear view mirror.
This is not an easy problem to solve. Nor do I think disease rates have to drive doctor numbers in a 1 for 1 way (they don’t); we need to rethink how this profession works. But if you claim to provide a national health service, it is surely negligent not to at least realise that there is a problem — and tell people. My university produces plans. Yes, lots of padding, but also attempts to think how we will function in 2020 and 2025. If you look at health boards, in any meaningful sense, I just see a void. And of course, this isn’t just about dermatology, as my GP politely joined out to me last night: it is across the board.