Date Published: March 19, 2019
Publisher: Public Library of Science
Author(s): E. C. Noels, M. Wakkee, R. R. van den Bos, P. J. E. Bindels, T. Nijsten, M. Lugtenberg, Andrew Soundy.
Rising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution.
A qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi.
GPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs’ education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients’ trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction.
GPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs’ skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.
Rising health care expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. With the Dutch health care system being one of the most costly in Europe, the ultimate goal for the Dutch health care system to make it more sustainable for the future.[3, 4] This may imply substituting tasks to primary care, and preventing unnecessary referrals to secondary care. This potential solution is being explored by various countries, such as the UK and Australia.[5–9]
Although our study suggests stakeholders to generally have moderately positive views regarding substitution of skin cancer care towards primary care, several substantial barriers need to be addressed before substitution of low-risk skin cancer care can be further implemented. Certain strategies such as effective skin cancer education for GPs, implementation of the primary care guideline, and time and financial compensation are regarded as essential preconditions. In addition, several proposed solutions focusing on rearranging the current organizational structure in primary care (e.g., horizontal referral system, clustered consultation hours) and between primary and secondary care (outreach models) may facilitate effective and safe substitution of low-risk skin cancer care. Since investments are required to overcome the reported barriers, further studies should explore whether these solutions are effective.