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4074160-269240-224790-231140Dermatology Service ReconfigurationVCSE Engagement Consolidation Report2447925395605February 2016ContentsPageExecutive summary4IntroductionBackgroundWhat is being consideredHow the proposed model differs from the current modelWhy it is being consideredExpected Benefits to Patients556789Methodology Aims and objectives of the engagement processGeneral approachResearch and engagement methods employedProfile of those engagedReflections on the engagement method101011121214Summary of findingsQuantitative summaryQualitative summary171718Quantitative research findingsIntroductionProfile of RespondentsUse of Skin ServicesExperience of Skin ServicesInvolvement in Care PlanningClinicians’ SupportJoining up Skin ServicesReceiving information to treat skin conditionsUse of technology in diagnosisClinic attendanceTriageTelephone adviceWaiting times2020202324262728303233323535Qualitative research findingsIntroduction Community Partners Qualitative Engagement363637Conclusion53AppendixOne: Skin Survey – Answers to open questionsTwo: Skin Survey – Respondents’ PostcodesThree: Social Value of the Engagement Process548485List of tables and figuresTable one: Research and engagement methods employedTable 2: Engagement Profile by Community Partner Table 3: Respondents by GenderTable 4: Respondents by Age GroupTable 5: Respondents by DisabilityTable 6: Nature of respondents’ disabilitiesTable 7: Respondents by Sexual identityTable 8: Respondents by ethnicityTable 9: Respondents by religious beliefFigure One: Respondents relationship to Skin ServicesTable 10: Respondents relationship to Skin ServicesTable 11: Skin conditionTable 12: Skin Service accessedTable 13: Respondents by Rating of experience of Skin ServicesFigure2: Respondents by Rating of experience of Skin ServicesTable 14: Respondents by Involvement in Care PlanningTable 15: Respondents by Impact of Involvement in Care PlanningFigure 3: Respondents by Impact of Involvement in Care PlanningFigure 4: Respondents by ‘Is there anything more clinicians could do?’Figure 5: Respondents by ‘Should Skin Services be joined up and structured in levels of complexity and care required?’Figure 6: Respondents by ‘Should skin services should be joined up to avoid children having to move between services when they reach 16?’Figure 7: Respondents by ‘If you were able to receive information which helped them to better treat their or their child’s skin condition yourself, would that appeal?’Table 16: Respondents by: ‘How would you like to receive information about managing your/your child’s skin condition?’Figure 8: Respondents by ‘How would you like to receive information about managing your/your child’s skin condition?’Table17: Respondents by ‘When would you like to receive information about your or your child’s condition?’Figure 9: Respondents by ‘When would you like to receive information about your or your child’s condition?’Figure 10: Respondents by ‘Should Skin Services use technology to assist with diagnosing and managing skin conditions?’Figure 11: Respondents by ‘Clinics closer to home?’Figure 12: Offers for convenient appointment timesFigure 13: Respondents by Agreement to specialist nurse triageTable 18: Respondents by Telephone adviceFigure 14: Respondents by 28 days reasonable maximum wait1213202021212122222323242425262626272728293030313132323334343535Executive SummaryNHS Liverpool Clinical Commissioning Group (CCG) commissioned seven Third Sector organisations (community partners) to engage and consult about the reconfiguration of Dermatology services.Two broad research methodologies were employed in the engagement process by the seven community partners. All of the organisations conducted a quantitative survey using the structured questionnaire designed by NHS Liverpool CCG and six employed a qualitative engagement research methodology. This included one to one and focus group discussions but also more innovative techniques such as children’s art workshops and forum theatre. In total 404 respondents completed the structured questionnaire (including those completing the online questionnaire via the CCG website). 179 respondents participated in one or more of the qualitative methodologies. The total number of individuals involved in all engagement activities was 528.These two approaches to engagement have delivered a wide-ranging endorsement of the proposals for reconfiguration of dermatology services. The findings from both the quantitative and qualitative engagement activities are largely supportive of the proposed new model for delivering Skin Services in Liverpool. The quantitative engagement results show substantial majority support for the elements of the proposal including changes to the structure of the service overall. To varying degrees there was also support for the integration of services for adults and children, for patient self-management, the use of digital technology and the triage of conditions. The qualitative engagement revealed insights into how different communities view the provision of services. The findings indicate a common theme across all groups was the high value people placed on receiving courteous and sensitive support by health staff. It was felt that children, in particular, need greater support because of the impact that skin conditions can have on self-esteem. Related to this was the need for support for patients to deal with the psychological effect of their conditions and the need for access to local support groups as well as psychology services within the NHS. There were some objections expressed by the Somali and Chinese communities to the integration of adult and children’s services. Concerns related specifically to integrating clinics as opposed to wider services, or bringing clinics out into the community.INTRODUCTIONBackgroundThis report presents the findings of wide ranging engagement and consultation on Skin Services within Liverpool. The intention has been that users and potential users of Skin Services should be meaningfully consulted and engaged in consideration of a new model for the delivery of Skin Services. Following a dermatology workshop in November 2014, which was attended by both clinical and managerial representatives from Liverpool based GP practices, hospitals, community care and NHS Liverpool Clinical Commissioning Group, a draft model of care for arranging dermatology services has been developed. It has been prepared using best practice evidence and with reference to national policy. What is Being ConsideredThe vision is for a service that joins up adults and children’s services across community, primary and secondary care. It is proposed that the new model should aim to enable patient care to be managed at a level appropriate to the severity and complexity of their condition. Four levels of care are suggested within the model. These are as follows:-Level 1 - Patient self-management People with skin conditions who manage their conditions themselves would be supported with high-quality patient information and input from suitably trained nurses, patient support groups, VCSE/Charities and community pharmacists. Level 2 - GP management / generalist carePeople with skin conditions needing generalist care would be managed initially by their GP and would have access to input from suitably trained nurses and other staff. It is proposed additional input could come from using new technology that can assist with diagnosing and managing skin conditions. For example technology such as ‘Teledermatology ‘which allows GPs to take a photo of a patient’s skin condition and send it to a consultant for their opinion. Level 3 - Community specialist care Consultant Dermatologists would work alongside GPs with a specialist interest in dermatology, Clinical Assistants, GPs, Nurse Specialists, Nursing Staff with specific dermatology training and Pharmacists to offer a one-stop service for patients. This would also include access to psychological support.The service would provide most of the traditional care and treatment currently provided in a hospital setting and would offer a full range of diagnostic procedures. This includes:-Punch biopsyExcision biopsyIncision biopsySkin scrapingBlood testsSwabsDue to the requirement for large pieces of equipment which can be expensive, some treatment which could clinically be provided in a community setting would still need to be provided in hospital, for example phototherapy. Community clinics would be available across the city (locations to be determined) and have links to a plastic surgery day case service, which patients may require onward referral to. There would also be the ability to book appointments for hospital based procedures if required.The service would provide GPs and practice nurses with diagnostic support and treatment advice to help them manage their support their patients better. As indicated it is proposed this could be provided through implementation of digital technologies. It would have links to a specialist skin cancer Multi-Disciplinary Team for patients requiring Skin Cancer Care. Level 4 - Acute specialist careAcute specialist care (hospital care) would only see patients with complex conditions, or those requiring specialist input. This would include urgent referrals for suspected skin cancers, patients requiring phototherapy (due to the requirement of large equipment), patch testing because of the requirement of storage facilities, patients who require a general anaesthetic, level 3 and 4 skin cancer care and patients who need to be seen/treated by a multi-disciplinary team. Current arrangementsAt present a GP decides whether to refer a patient for a dermatology appointment and can refer them to one of:The suspected Skin Cancer Clinic The Hospital Dermatology ClinicThe Community based Dermatology Integrated Clinical Assessment and Treatment Service (ICATs) – Adults onlyThe Community Skin Team – Adults onlyThe Minor Surgery Service – Adults onlyThe patient is seen by the service chosen by the GP, but may need to be referred on to another service if they are not seeing the right clinician. This can involve additional appointments and sometimes returning to a GP to start again. How the proposed model differs from the current service model Most of the elements of the draft model are already provided. The main differences are in how the services are packaged and aligned based on severity and complexity and in the integration of adults and children’s services. These main differences are as follows:Children’s dermatology services would be available in the communityThere is no formal structure at present for patient self-management. The suggested model would offer a platform from which more focus could be given to support patients. This may be through patient information leaflets, or up-skilling pharmacists to offer patients more advice on the management of most common skin conditions.The proposed model streamlines the dermatology provision and removes duplication of services.It proposed digital innovations are implemented to help with diagnosing and managing skin conditions. For example GPs could take a photo of a patient’s skin condition and send it to a consultant for their opinion. Dermatology referrals could be triaged to ensure they are directed to the right service, first time. Triage (assessment and direction) of referrals would take place by an appropriate specialist clinician (with the exception of suspected skin cancers). The specialist clinician would review each dermatology referral letter to determine if the patient is being sent to the appropriate part of the dermatology service. Having assessed a referral, the specialist clinician would either:-Progress a patient’s referral through the system and arrange a telephone consultation or appointment. Contact the referrer and provide them with advice and guidance, eliminating the need for an appointment with the Dermatology service.If appropriate contact the patient and provide appropriate advice rather than an appointmentRedirect the referral to the appropriate services if it is deemed that the referral is not for the Dermatology service. This would be a virtual service and the majority of patients would not notice its existence. It is anticipated that if triage is included in the model referrals would be handled within two working days. Why it is being ConsideredYear on year there has been a 10% increase for urgent 2 week wait referrals for suspected skin cancers. To deal with this demand and achieve the maximum 2 week wait, capacity has been taken away from routine secondary care clinics. In a bid to manage demand, the community service is being utilised as additional capacity. However this is detracting from its original purpose, which was to see less complicated conditions in the community, offering shorter waiting times, and diverting secondary care activity to a community setting. This has resulted in lengthy wait times across all services.One solution to addressing demand would be to recruit additional staff into the service, but the dermatology workforce is limited, both locally and nationally and attracting additional staff is challenging.Added to this, primary care clinicians sometimes lack experience in dermatology conditions resulting in patients being referred to the urgent clinic for suspected skin cancer rather than risk lengthy waiting times in the general dermatology clinics and this puts extra pressure on services. Waiting times at the hospitals vary between 80 and 100 days, whilst the community clinics are currently between 12 and 24 day.The draft model proposes to address these issues by placing a greater focus on increasing knowledge of skin conditions in GPs and Practice Nurses and using digital technology to improve assessment, diagnosis and treatment of skin conditions. It is anticipated that as the confidence of GPs and Practice Nurses increases, less patients will need referring to the urgent clinic for suspected skin cancers and this will alleviate pressure on the service and free up capacity to be used in the community.Within this review we are proposing to work with providers, as part of a phased approach, to reduce waiting times for routine dermatology appointments. The target is to reach a maximum wait of 28 days for routine dermatology appointments. A timescale of 18-24 months will be set for reaching this position.Expected Benefits to PatientsIntroducing digital innovations, such as Teledermatology, would enable GP’s/Nurses to capture photos/videos of skin problems and seek advice and guidance from a Consultant Dermatologist, reducing the need for unnecessary referrals and allowing the GP to manage the patient within primary care.Integrated care pathways that direct patients rapidly to the right person in the right place first time and ensure patients and their carers have a positive experience of care.A model of care that enables people to move readily between the different levels of care as necessary and across Primary Care, Community Care and Secondary Care as appropriate.One service for adults and children, meaning there is no need for transitioning between children’s and adults services. This will offer a level of continuity not previously available.Increased choice of service locations for children accessing dermatology services, with specialist paediatric services closer to people’s homes.Improved communication between specialists and GP’s – leading to improved care planning.Waiting times for routine dermatology clinics that will reduce to a maximum wait of 28 days within 18-24 months.Facilitation of well supported self-management and improved access to advice and information.Introduction of a triage service will mean patients are less likely to have wasted appointments as they will be seen by the right clinician first time.Methodology2.1. Aims and objectives of the engagement process This report is based on a wide range of engagement activities designed to provide NHS Liverpool CCG with comprehensive insights and evidence in respect of the overall aims and specific objectives of the engagement. The overall aims have been:To work with people to influence and shape the new model of care for dermatology servicesTo ensure that the proposed integrated dermatology service meets the needs of the local population.The specific objectives of the engagement have been:Gather knowledge, information and perspectives from local communities to help improve Dermatology services.Understand people’s experience of existing Dermatology services to ensure the new model is shaped in a way that is responsive to the needs of the population Understand people’s views on integrating children’s and adults dermatology services.Understand people’s views on the levels of care described in the proposed model.Identify if there are any issues/barriers with the proposed model that would prevent patients accessing Dermatology services or reduce access.Identify if people would value the implementation of digital technology that could help with the assessment and diagnosis of their skin condition.Understand people’s opinion on the proposed maximum wait of 28 days for routine dermatology appointments and the timescales set for reaching this target.Understand when and where people would like to assess dermatology services.Understand how people want to receive self-care information Understand how we involve patients in their care and encourage informed decision making.To ensure community members are aware of and understand how their input has been considered and used.2.2 General approachSix community partners were contracted to provide these insights and evidence, each one providing a different perspective and insight to the topic under investigation. These insights were based on two broad research methodologies – quantitative and qualitative. In addition, staff from NHS Liverpool CCG’s Choose and Book team attended a range of Hospital and community skin clinics to seek feedback from existing patients on the proposals.The clinics attended wereThe Children’s dermatology clinic at Alder Hey HospitalThe Adults dermatology clinic at University Hospital AintreeThe Adults dermatology clinic at the Royal Liverpool and Broadgreen HospitalThe Community based ICATs clinic at South Liverpool Treatment CentreThe Community based ICATs clinic at Breeze Hill Health CentreThe Community based ICATs clinic at Greenbank DriveThe minor surgery service at Rocky Lane Medical centre The quantitative research methodology employed a semi-structured questionnaire designed by NHS Liverpool CCG. This was administered face to face through a combination of volunteer and professional interviewers and online through a portal on NHS Liverpool CCG’s own website. In total 404 satisfactorily completed questionnaires were analysed to provide the statistical evidence used in this report. The open questions of the questionnaire generated a very substantial number of responses and these have been appended.The qualitative research methodology provided a framework for the community partners to design and apply a number of creative techniques to facilitate engagement and insight. These techniques included drama as well as the more traditional individual and focus depth interviews. The result was a catalogue of insights that delved much deeper than was possible through the semi-structured interviews. In the final analysis 179 people participated in one or more of the qualitative engagement activities. Examples of the approaches used and images from the engagement activity are included throughout the report. The research was undertaken in October, November and December 2015. Research and engagement methods employed The following table shows the different research and engagement methods used by each of the six community partners undertaking the engagement and the number of respondents. Some respondents participated in both methods. Table One: Research and engagement methodsResearch MethodologyStructuredSurveyOne to one discussionFocus GroupsChildren’s Art WorkshopsForum TheatreChinese Wellbeing3030Valley Community Theatre3728Elevate Potential1615Women Reach Women74Kaalmo Youth Development1739Emmanuel Westly Foundation351535Dermatology clinics & on-line survey212 Profile of those engagedHaving reviewed the evidence about population groups, equalities and those more likely to be using dermatology services, the following shows those we particularly aimed to engage with in this process. This may be because they were more vulnerable to developing skin conditions or where risk factors were higher. Within the overall engagement strategy, priorities were established for engaging specific population groups and communities of interest. This table identifies which they were and how many people were engaged by each of the seven organisations:Table 2: Engagement Profile by Community PartnerPraxis CICChinese WellbeingValley Community TheatreWomen Reach WomenKaalmo Youth DevelopmentEmmanuel Westly FoundationElevate PotentialBME (Unclassified)Black Asian Chinese3781283013611363505People with Long term Health Conditions617522DiabetesStomas3642033People With Mental Health Issues20152Older People227412Children and Young People20393519Children and Young People in CareMen1414265157Women161948133524Pregnant Women852Mothers of Young Children222354People With Addiction IssuesPeople Experiencing Poverty2526Carers5241Current/Previous users of Skin Services2393974313523Outdoor Workers7Parents of children with skin conditions921835Total (Regardless of Category)23930537414285312.4. Reflections on the Engagement MethodEach of the organisations undertaking the engagement activity was given the opportunity to comment on the process. The following is the feedback from those who gave it:Elevate PotentialThe survey was extremely long and participants were abandoning the process half way through. We would suggest that future specialist surveys should be quick and snappy and phased throughout the consultation period i.e. one a week.A longer period should also be allowed for the engagement activity. Some groups that you want to work with only have their meetings/gathering on a monthly/bi-monthly basis, which makes planning more difficult.We have offered incentives for completing the survey, but it would be beneficial to offer a broader engagement incentive to encourage participants to continue their involvement throughout the engagement journey.Chinese WellbeingThe method of engagement on this occasion was the right one for the community. Discussions concerning an individual’s skin condition can lead to embarrassment if talking in an open forum.The outreach into the Community and the one to one process used was appreciated and enabled respondents to understand the questions more fully and consider their answers carefully within the context of their ability to access existing and future services. Chinese Wellbeing was able to use its knowledge of the community and its’ service users to engage with participants who have used or are likely to use the skin service in the future. Service Users were given an insight and consulted in proposed changes to local health services which they would otherwise remain ignorant of due to language barriers.Kaalmo Youth DevelopmentFor some health issues the knowledge, views and opinions vary greatly across the generations. Information and questions in a community language is a real asset, as is the ability to work with bi-lingual colleagues in the sessions and when supporting the completion of survey forms.The feedback this time from some was that there were too many questions, so maybe, where possible, the consultation can be planned in two stages?A number of young people who continue to be interested in attending a discussion session about health/lifestyle issues on a weekly basis, and taking the information and new awareness out into the community.Engaging with the whole family through the art sessions gave insights into the range of skincare issues and helped us to get information on good skin care practice in an informal way.The quality of the information provided by the young people attending the discussion groups. Many have attended all the engagements Kaalmo has delivered and good relationships and trust are building up moving forward.Women Reach WomenOne-to-one administration of the questionnaires allowed space for clarification of questions and also encouraged the completion of the questionnaire as it was considered ‘lengthy’ and ‘complex’, and a few volunteers and the sessional worker reported that it took them ‘considerably’ longer to complete where questions were interpreted for participants.The use of bi-lingual volunteers to communicate the messages for those requiring interpretation of the proposed plans, purpose of the engagement and explaining the questions in the questionnaire. This approach made the engagement process inclusive of the diverse community in Liverpool.The use of open space in familiar community venues and coffee shops made it comfortable, accessible and engaging for the participants.Valley Community TheatreWhen engaging a group of ‘hard to reach’ young people, using drama was possibly one of the best methods to use. Although audience numbers were lower than we originally anticipated, this actually worked to an advantage as the young people felt more comfortable contributing in the forum and acting out problems on stage in a smaller group.The forum theatre was particularly effective in starting conversations.It was a good way to get different points across in safe environment.Involving young people validated their opinions, and gave them ‘a voice’Elevate Potential Young Persons’ WorkshopSummary of Findings3.1. Quantitative summaryThe Skin Survey questionnaire was completed by 404 people. The facilitation by the community partners in the engagement means that some were completed via interview as well as those completed on line and on paper by the respondents themselves.The key points from the quantitative engagement are:94% (n=378) of those that completed the Skin Survey had or previously had a skin condition or were the carer or parent of someone that had or previously had a skin condition. 74% (n=299) were current or previous users of Dermatology services in Liverpool or were the carer or parent of someone that was a current or previous user of Dermatology services in Liverpool.68% (n=275) of respondents rated their experiences of skin services in Liverpool as ‘Excellent’ or ‘Good’. 6% (n=24) rated their experiences as ‘Poor’ or ‘Very Poor’.54% (n=218) of respondents agreed that skin services should be joined up and structured to reflect the levels of complexity and care required and 12% (n=48) disagreed.However, a minority, 42% (n=170) of respondents agreed that children’s and adults skin services should be joined up to avoid children having to move between services when they reach 16 and 27% (n=109) disagreed. 66% (n=267) of respondents said that receiving information which helped them to better treat their or their child’s skin condition themselves appealed to them.78% (n=315) of respondents thought that using technology to assist with diagnosis should be offered.80% (n=323) of respondents agreed (or strongly agreed) that dermatology cases could be triaged by a specialist nurse.83% (n=335) of respondents thought that 28 days was a reasonable maximum wait for a routine dermatology appointment. 3.2. Qualitative summaryThere was a positive response to the engagement process across communities and the varied opportunities for discussion were readily taken up. There was a great deal of agreement on key areas across the engagement activities and across communities but also some significant differences which are evident in the detailed qualitative feedback.Access to services was identified as a particular issue. This includes reducing travel and appointment availability but also obstacles to referral and to patients being able to make best use of the service. The key findings here which found agreement across the board were as follows:Patients valued being listened to and their appointments not being moved.Language barriers at appointments were cited as a common problem for minority ethnic communities as was the lack of availability of written information in minority languages.It was felt clinical staff need to show more empathy towards the impact skin conditions have for people. This was a particular issue for young people who identified this as a gap in provision.The need for clinical staff to offer more explanation about conditions and treatment options was identified across most groups. It was indicated improved awareness would be necessary to enable patient self-management.Less travel could be facilitated by more services being community based.Flexible appointments particularly at weekends and early and late in the day were welcomed.Lack of consistency in the staff involved in the treatment of people’s care was raised as a cause for concern.Widespread feeling in some communities that GPs are reluctant to make specialist referrals which is linked to patients lack of confidence that GPs have sufficient specialist knowledge to diagnose and treat their skin conditions.As well as the proposals about increasing access through increasing the flexibility of appointments a number of other features of the new model for services were welcomed, in particular:Information to support self-care and parental care for conditions.The use of technology to speed up and support diagnosis (although there were some concerns expressed about security and confidentiality of, for example, the use of digital images).Support for integrating children’s and adult services but also a small but explicit opposition to this proposal (and there are some concerns about mixed gender clinics, which are not specific to dermatology, within some ethnic communities).Triage was welcomed as increasing efficiency and ensuring the right level of care.There were some specific challenges raised:Will reconfiguring services reduce access to consultant dermatologists?How are the psychological and social aspects of skin conditions to be tackled, particularly as they affect children?Can young people and children see clinical staff without their parents or carers being present?And some pertinent suggestions about how the service could be enhanced, such as:Using Skype and Facetime for consultations.Awareness education in the community.More community based specialist care.4. Quantitative research and engagement findings 4.1. IntroductionThis section of the report details the findings from the semi-structured questionnaire survey developed by NHS Liverpool CCG. As well as quantitative data the questionnaire also contained a number of open questions that produced a large number of individual comments by respondents. These have been appended to the report. In total 404 people completed the structured questionnaire including those completing it online via the CCG website. (Total of respondents for each question has been given along with the total of those not answering).4.2. Profile of respondentsRespondents were asked if their current gender identity was the same as the one that was assigned a birth. 201 answered the question with three saying that it was not and one ‘not sure what the question means’. Table 3: Respondents by GenderGenderRespondents%Female23162Male14038Total371100No answer33Table 4: Respondents by Age GroupAge groupRespondents%Under 18431218-2527726-441163245-641032865-75441276+349Total367100No answer37Almost 60% (n=219) of respondents were aged between 26 and 64. The distribution varied with the different communities but the most significant difference was with the cohort facilitated by Chinese Wellbeing. Three quarters of this group (21 of 28) were 65 or older.Table 5: Respondents by DisabilityDisabledRespondents%No29280Prefer not to say82Yes6518Total365100No answer39Almost a fifth of those who answered the question considered themselves disabled. This was a quarter amongst the Chinese Wellbeing group.Table 6: Nature of respondents’ disabilitiesDisabilityNumberLearning disability6Long term illness that affects your daily activity61Mental illness/distress20Hearing Impairment13Physical disability, Long term illness that affects your daily activity21Visual impairment, Hearing impairment/deaf12Dementia2Clearly the number of citations is greater than the number of respondents who identified themselves as disabled because many of the latter identified themselves as having more than one disability.Table 7: Respondents by Sexual identitySexualityRespondents%Bisexual2<1Gay/Lesbian83Heterosexual29194Other1<1Prefer not to say83Total310100No answer94Slightly more than 3% of those answering the question identified themselves gay, lesbian or bisexual. Estimates of the prevalence of those who are not heterosexual amongst the adult UK population are between 5 and 7%.Table 8: Respondents by ethnicityEthnic originSub-groupRespondentsAsian or Asian BritishBangladeshi37Indian16Pakistani14Afghani1Thai1other2Chinese or Chinese British28Black or Black BritishAfrican16African Caribbean 9Other 3Mixed Ethnic BackgroundAsian & White3Black African & White5Black Caribbean & White4British - Egyptian1West Indian/Irish/Welsh1Other2Other Ethnic GroupArab5WhiteBritish132English71Irish1Scottish2Welsh3Latvian1French1Lithuanian1Other12Total372No answer3260% (n=224) of respondents identified themselves as White; 10% (n=38) as Black and 27% (n=102) as Asian.Table 9: Respondents by religious beliefReligionRespondentsBuddhist9Christian173Hindu7Jewish1Muslim57Sikh8Other religious belief9Total264No answer140Use of Skin Services 94% of those that completed the Skin Survey had or previously had a skin condition or were the carer or parent of someone that had or previously had a skin condition. 74% were current or previous users of Dermatology services in Liverpool, or were the carer or parent of someone that was a current or previous user of Dermatology services in Liverpool.Table 10: Respondents relationship to Skin ServicesCapacity in which Skin Survey was completedRespondents%Carer51Currently attending a skin clinic19147Have a skin condition but not using NHS services4210Other (please specify)266Parent of a child currently attending a skin clinic338Parent of a child who previously attended a skin clinic277Parent of a child with a skin condition but who is not using NHS services328Previously attended a skin clinic4812Total404100Figure One: Respondents relationship to Skin ServicesTable 11: Skin conditionSkin ConditionNumber of cases%Acne21Mole49Skin lesion44Eczema135Dermatitis35Hair disorder21Psoriasis51Skin Tag16Mole3Other 99Total of Cases474Table 12: Skin Service accessedSkin ServiceNumber of cases%Alder Hey Hospital7414Breeze Hill Health Centre173Broadgreen Hospital 10921GP for advice and / or treatment20239GP for lesion removal71Aintree5310South Liverpool Treatment Centre92Greenbank Health Centre163District Nurses41Other 255Total5161004.4 Experience of Skin Services Respondents were asked to rate their experience of using skin service in Liverpool. More than two-thirds (68% n 201) of respondents rated this as either ‘Excellent’ or ‘Good’. 6% (n 17) rated their experiences as ‘Poor’ or ‘Very Poor’.Positive experiences arose from, amongst other things:High standards of care “Attending the dermatology clinics approximately every 6 months to meet a consultant is always positive. Quick and efficient and the consultants themselves are very friendly and welcoming.”The effectiveness of treatment “Good diagnosis and successful treatment and advice”Clear communication about the nature and treatment of skin conditions “Nurse practitioner explained everything thoroughly and left nothing for me to worry about.”Courteous and polite staff “The staff are very kind, very understanding and great to talk to”.Negative experiences arose from, amongst other things:Ineffectiveness of treatment “I was prescribed a course of cream that ultimately didn't affect my eczema”.Delays in diagnosis “Had current condition for six months. There has been a lot of guess work such as 'I think it's such & such' and treatment given without knowing what condition is being treated”.Delays in receiving appointments “Sometimes I have to phone appointments to remind them to arrange an appointment”.Long waiting times at clinics “Gave up waiting for one appointment after waiting two hours”.Table 13: Respondents by Rating of experience of Skin ServicesRatingRespondents%Excellent12643Good7525Average7626Poor155Very Poor21Total294100No answer110Figure 2: Respondents by Rating of experience of Skin Services4.5 Involvement in Care PlanningRespondents were asked if they felt involved in the development of a care plan for themselves or their child. More than half (57% n 216) said they did feel involved:Table 14: Respondents by Involvement in Care PlanningInvolvedRespondents%Yes21657No6317Not applicable10127Total380100No answer24Respondents were next asked how they generally felt about their involvement in the development of care plan for themselves or their child:Table 15: Respondents by Impact of Involvement in Care PlanningFeelingRespondents%In control and better able to understand my care14663More able to take steps to improve how I feel myself4921Challenged and confused but then more confident63Challenged and confused63I wanted someone else to just tell me what was best2310Total230100No answer174Figure 3: Respondents by Impact of Involvement in Care Planning4.6 Clinicians support Respondents were asked if there was anything more clinicians could do to support them in the management of their/their child’s skin condition. Just under half (47% n 171) said they didn’t feel there was, while just under a quarter (24% n 87) were not sure and 29% (n107) thought that there was: Figure 4: Respondents by ‘Is there anything more clinicians could do?’Of those respondents who thought clinicians could do more to support them in the management of their condition, suggestions primarily related to:-Developing the skills and knowledge of staff in Primary Care to better support patients with management of their condition. (“GPs, GP surgery nurses, pharmacists need more training from hospital skin specialists”)Listening to patients more (“Realise that simply dismissing something doesn't leave the patient feeling it is dealt with”)Supporting people with the psychological impact of their condition (“listen more to the problems I have been having, instead of just giving me cream”)Joining up Skin Services The majority of respondents (54% n204) felt that adult skin services across Liverpool should be joined up and structured to reflect the levels of complexity and care required, while just over a third (34% n129) were not sure about this.Figure 5: Respondents by ‘Should Skin Services be joined up and structured in levels of complexity and care required?’Of the respondents who answered no, or not sure to this question, some expressed concerns that joining up services would mean that services would be centralised or concentrated in a smaller number of venues. Others were satisfied with the care they currently receive and were unclear what impact joining up services would have for them. One respondent commented: “This is not a good question as the majority of the patients completing this survey will not understand what such change will actually mean for them in practice based on the information given”.Next respondents were asked if children’s and adults skin services should be joined up to avoid children having to move between services when they reach 16. People were divided on this with 27% (n102) saying no, 31% (n115) not sure and 42% (n159) saying yes. Figure 6: Respondents by ‘Should skin services should be joined up to avoid children having to move between services when they reach 16?’When asked to explain their answer, those who answered yes indicated benefits associated with creating a smoother transition between services. Much of the opposition respondents had to this proposal related to mixing adult and children’s clinics and reflected the view that children’s needs are specific and different from the needs of adults, it therefore did not make sense to join up services. Another particular concern, a number of respondents cited was the psychological and social impact of skin conditions on children and that they were generally greater for children than for adults.Mixing children and adult clinics is not the intention of the proposal and the qualitative feedback indicates this question/element of the proposal may have been clear to participants.4.8 Receiving information to treat skin conditions66% (n225) of respondents said they would like to receive information which would help them to better treat their or their child’s skin condition themselves. A small minority (11% n39) said they would not want this, while twice as many (23% n78) were not sure about this:Figure 7: Respondents by ‘If you were able to receive information which helped them to better treat their or their child’s skin condition yourself, would that appeal?’Respondents favoured receiving information about managing their own or their child’s skin condition from a health professional, closely followed by a local trained pharmacist and then via an information leaflet: Table 16: Respondents by: ‘How would you like to receive information about managing your/your child’s skin condition?’MethodNumber%Healthcare professionals36026Information leaflet32123Personalized tools181Local pharmacy - if they were trained in management of the most common skin conditions34725Websites514Mobile Text, 635Smartphone apps816Support Groups292Training / Education session312Email473Social Media121Other 131Respondents were asked an open question about what sort of information they would like to receive or have access to and the overwhelming number of relevant comments related to the care and management of diagnosed conditions and how to spot the signs of skin conditions such as skin cancer.Figure 8: Respondents by ‘How would you like to receive information about managing your/your child’s skin condition?’Respondents were then asked when they would like to receive information about their or their child’s condition, with the first appointment with the Skin Service being the preferred option followed by the first appointment with their GP:Table17: Respondents by ‘When would you like to receive information about your or your child’s condition?’InformationNumber%At your first GP appointment18625At your first appointment with the skin service, 22431During treatment11916Before seeing a clinician so I can self-manage my condition14420On discharge618Figure 9: Respondents by ‘When would you like to receive information about your or your child’s condition?’4.9 Use of technology in diagnosis A large majority (78% n294) of respondents said they would be prepared to see the use of technology to assist with diagnosing and managing skin conditions. Just 10% (n40) were against this with slightly more, 12% ( n 45), being unsure:Figure 10: Respondents by ‘Should Skin Services use technology to assist with diagnosing and managing skin conditions?’The reasons people gave for not wanting technology to play a role in assisting with the diagnosis and management of skin conditions were mainly attributable to concerns over misdiagnosis if clinicians did not have face to face contact with patients. There was a belief “photographs cannot show a true picture of the condition and wrong diagnosis may be given”. Other respondents expressed concerns that if technology removed the need to see a consultant some of their specialist input and support could be lost to the patient “Yes if it removes or lessens the need to attend hospital and take time off work but such conditions are not purely physical. Will the GP's have the understanding of how the conditions can mentally affect patients and how best to manage this?”4.10 Clinic attendanceRespondents were overwhelmingly (86% n322) in favour or being able to attend a clinic closer to their home as part of the proposed improvements to dermatology services, even if they would usually have been seen in hospital (particularly children). Just 4% (n16) were opposed to this:Figure 11: Respondents by ‘Clinics closer to home?’Those respondents who were opposed to the plans for clinics to be provided in the community expressed concerns that the quality of the appointments would not be the same as they receive at the hospital, they would not be lead by the same specialists or that access would not be available to the specialist equipment they may require.Next respondents were asked about possible options that would it make it easier for them to schedule an appointment at a time that was convenient. A choice of times was the most stated preference followed by a choice of locations:Figure 12: Offers for convenient appointment times4.11 Triage Respondents were asked how they felt about their/their child’s referral being triaged by a specialist nurse who would ensure they were seen by the most suitable part of the service, when they had been referred for skin services. The great majority of respondents (80.5% n 302) either strongly agreed or agreed with this proposal with only 15 people against it:Figure 13: Respondents by Agreement to specialist nurse triage4.12 Telephone adviceRespondents were then asked their views about receiving advice from a suitable specialist nurse on the management of their skin condition, as opposed to booking an appointment at a clinic. Nearly a quarter (24% n 91) said they would not be willing to take telephone advice and would want an appointment and a larger group (31% n116) would be willing to have the telephone advice, but would be worried about not seeing someone face to face. Against this 38% (n145) would be happy to do so: Table 18: Respondents by Telephone adviceAnswerRespondentsI would be happy to receive telephone advice from the specialist clinician if that is what is needed145I would not be willing to take the telephone advice and would want an appointment91I would take the telephone advice but would be worried about not seeing somebody face to face116I’m not sure25Total377No answer274.13 Waiting timesFinally respondents were asked their views on the proposal to introduce a maximum waiting time of 28 days for all routine appointments with the skin service and whether this was a reasonable maximum wait. The majority of people felt this was reasonable (83% n310) with just 9% 9n35) saying it was not and a further 8% (n29) unsure:Figure 14: Respondents by 28 days reasonable maximum waitTo conclude the questionnaire, respondents were asked if they had any suggestions for how we could further improve skin services. This generated a small amount of commentary and suggested improvements related to improving waiting times and providing clear, timely diagnosis for people. With many respondents expressing their frustration at the length of time it took for them to get an appointment with a specialist and then a clear diagnosis for their skin condition. For some, they perceived the lack of specialist knowledge within Primary Care as contributing towards their delay.“I would have liked to see hospital consultant quicker for first appointment waited 7 months.”“My concern is that when non skin specialists have tried to help (they did their best) that is where the condition was guessed at when I think a referral for a swab would have solved the problem quicker and saved me months of trying different things for an unidentified condition which never improved”. “Quicker histology results - I've waited four weeks”.The need for improved awareness amongst clinicians with regards to the psychological impact of skin conditions was also raised. There were suggestions some conditions are viewed as “mild” by clinicians and therefore not “taken seriously” and that “some sympathy and respect for patients would be much appreciated”. This was felt to be a gap in the current provision.5. Qualitative Engagement Findings 5.1. IntroductionThis section of the report provides a detailed account of the qualitative engagement process as undertaken by four of the community partners. Overall there was a positive response to the engagement process and the varied opportunities for discussion were readily taken up. There was a great deal of agreement on key areas across the different communities but also some significant differences which are evident in the detailed feedback.A common theme that emerged across many of the engagements was the high value people placed on receiving courteous and sensitive support by health staff. It was felt that children, in particular, need greater support because of the impact that skin conditions can have on self-esteem. Related to this was the need for support for patients to deal with the psychological effect of their conditions and the need for access to local support groups as well as psychology services within the NHS. One insight was that the lack of attention to this could undermine patients’ capacities for self-management of their conditions. Likewise a failure to fully engage children in the diagnosis and management of their skin condition was highlighted as a potential barrier to good self management and share decision making.Broadly speaking there was support for the proposed changes in the structure and delivery of services and in particular increasing the support for patient self-management of skin conditions, the use of digital technology and the triaging of dermatology referrals.There was somewhat more ambiguous support for the joining up of services and the integration of children’s and adult services in particular. A prime concern appears to be a miscomprehension that joining up services would mean one service for both adults and children. Across communities there were also some concerns that integration would result in a reduction in services. In respect of the integration of children’s and adult services there were objections expressed by Somalis in the Kaalmo Youth Development engagement and by those that participated in the Chinese Wellbeing engagement to this as well as a sprinkling of objections across all the engagements that it was not in children’s best interests.5.2 Community Partners Qualitative EngagementChinese WellbeingChinese Wellbeing used the Skin Survey questionnaire as a framework for one to one discussion. Members of the Chinese Wellbeing senior care team were fully briefed and disseminated the information to service users in the appropriate dialect to ensure a complete understanding of the process and purpose of the engagement activity. The results were as follows:The majority of respondents had used their GP service for advice and treatment.Most respondents were in favour of integrating services, 20% of respondents were not sure mainly as they have not had direct experience of children’s services and do not fully understand the implications of integrating the services sufficiently well to provide a more informed response.Overall there was a positive response to the suggested levels of care in the proposed model with the exception of accepting telephone advice on skin conditions from a specialist nurse. Most respondents would not be willing to take telephone advice with 23% saying that they would but that they would be worried about not seeing someone face to face.Language barriers were cited as a common problem which is an issue for many in the community when accessing any mainstream health service.Almost all respondents agreed with the use of digital technology. Respondents generally felt it would increase efficiencies in the system and that they would benefit from an earlier diagnosis and treatment.There was largely agreement that 28 days is a reasonable maximum wait for services. However, from those who disagreed or were not sure, several respondents suggested that the waiting time should be no longer than 2/3 weeks. With regards to the timescales set for reaching the 28 days target, respondents would like to see this happening as soon as possible.Almost all respondents thought it was a good idea to be able to attend a clinic which was closer to their home. In order of importance, respondents ranked the most important as being the knowledge and skills of the staff, followed by a welcoming environment and then a familiar environment, with the least important being close to a bus or train station.Many agreed with needing to have a better understanding of their skin condition and being educated in self care and prevention. However, the majority of respondents do not speak English as a first language and commented that they would like to receive information in Chinese to ensure the correct level of understanding is achieved. This would help to empower individuals to manage their conditions and instil greater confidence in their own ability to be able do this.Elevate PotentialElevate Potential facilitated completion of the questionnaire and then used this as a framework for one to one discussion of the topics it contained. They also ran an interactive workshop/focus group with a visual summary of what was being considered in a format that young people could easily understand. The workshop enabled the young people to have a democratic voice through the use of a scenario with them taking on the role of the NHS management / decision makers. Scenario to discuss what works well and what could be improved.Key findings from the Skin Survey completed by the young people were:Participants had a variety of skin complaints.Most people visited their GP for initial advice, which they considered to be an average service. Most people thought that this experience could be improved by offering the most effective solution in the first instance and discussing in more details any creams/medication prescribed.Joined up skin services were favourable.Service users were keen to introduce self prescribing. However they felt that the "aftercare” element of the service was missing.People’s preferred information methods were leaflets, contacting their local pharmacy and accessing information from digital channels ie App, Website etc.It was important for patients to receive the information prior to attending their GP if feasible.Participants like the use of photographs to diagnose skin conditions in the early stagesLocal community services were also high on their agenda to improve current services.The highest scoring important features about skin services going forward were; Knowledge and skills, distance to where they live, close to public transport and a welcoming environment.Most of the participants agreed with the 28 day appointment times for routine skin conditions.Most of the participants agreed with the triaged service. Patients felt strongly about being valued, listened to and appointments being kept to their original time.Key findings from the focus group workshop were:Voice of the young person should be crucial. All participants agreed the new model and additional self management options where a good idea.Waiting lists should be reduced. Consistency from being treated as a child through to adult was important. Can young people go to be treated by themselves without their parents at 16 was a question.Leaflets for young people to be created. Young people advisors or peer support groups could be set up to share peer support to keep reviewing the service. Cost of getting to the service or treatment is an issue for young people.Reception staff not being friendly and made to feel unwelcome was an issue raised. Kaalmo Youth DevelopmentKaalmo volunteers and the Community Health worker supported people to complete the Skin Survey questionnaire. In addition is ran three face painting workshops, engaging with 17 adults (13 women and 5 men) and 39 children (aged 3 to 12) from the Somali community. Whilst the artists were working with the young people they talked with the parents and children about skin care and their experience of conditions and use of services. A number of themes/highlights emerged from the engagement:The number of people with skin conditions/allergies, and given the numbers the percentage not accessing NHS services. In the art sessions and discussion groups many participants told us of their experiences of skin conditions and using the services. The services accessed rated very high. To make it a better experience people said there should be more staff; more specialists, and home visits for the elderly and disabled. The continuity of seeing the same doctor was also seen as enhancing the service.There was a general consensus that the services should be joined up – this was unanimous in the group sessions who all thought it a good idea. However survey respondents had 26% saying the children service should remain separate.There are high levels of support for information to support self-care. The range of formats was wide and included the use of social media, a ‘whatsapp’ for the NHS; more use of Skype and Facetime; texts; online services and an emphasis on there being more visual information. One worry was that self-diagnosis might lead to people giving themselves the symptoms. To support this people said there should be training for teachers, pharmacists and parents, alongside more awareness sessions in the community.The use of technology was a debated point. Whilst the majority see it as a positive way to improve and speed up services and treatment, some were worried about the risk of images reaching social media sites.Most are happy with the idea of services closer to home. In discussion some said they would prefer to go to hospital, but if GPs were to get specialist support and training this would make them more likely to go to their doctor. Another benefit is that local services mean less travel and stress.There is a clear call for choice in terms of locations and times for appointments and treatment.The concept of triage in skin care services was welcomed and seen as a way of ensuring those needing priority treatment receive it.Telephone advice split people, with almost as many saying they would want an appointments as numbers happy to take the telephone advice.The discussion groups that Kaalmo facilitated produced a range of other comments :Give clear information on the condition and how to treat it as early as possible so people can help themselves.Use Skype and Facetime for appointments so that the GP can see you and the condition. It would speed things up.Use social media.Train teachers so that they can spot the conditions and help.Parents to be encouraged to attend sessions so that they can get the information they need to support the children/themselves.More information online in an easy to access/read format – lots of images.Train pharmacists in skincare.Use community centres as meeting places where people can come in and learn about skincare.Someone in each street should have a knowledge and awareness of skin conditions and be able to help.A danger of over-diagnosis is possible if not careful.The groups felt it would be great if waiting times were reduced as a result of the planned changes – a number said they had spent a lot of time waiting.A number had been to Alder Hey and their feedback was that they felt hospital was a scary place and very stressful experience.One reason people liked integration of children’s and adult services was the stress of changing doctors – integration could mean consistency.Some said it would be good if the people delivering the service/treatment could come to the house – especially in the case of the elderly and disabled.If doctors are better trained then it means we cut the time waiting for treatment Also if the doctor is better trained the patients will trust their advice more.Less travel also means less stress.Use of technology would lead to better treatment/quicker diagnosis.The preference was for a system that was anonymous if photography and images were to be used – again Skype was suggested so there was no need to go anywhere else.The concern was that pictures could go public/elsewhere, so there was a need for confidentiality and munity specialist care would be much better, as it would give us a higher level of service and care locally. It could also save money and a lot of time.Could also have mobile X-Ray services, etc.The idea of triage and the following referral when explained was felt to be a good way forward as it would mean people getting the right level of service from the start and saving resources for the more serious conditions.A more diverse NHS workforce that matched the city’s population/communities was suggested.More awareness sessions should be held in the community.There needs to be greater availability of translators and translation of information.There were four areas where there were conflicting viewpoints: Whilst there was majority support for joining up services, there were strong feelings expressed in the survey that children and young people should have their own service. There was a significant no ‘vote’ for the use of technology. Where comments were made it was the inappropriateness of its use, or worries over security.Telephone advice split respondents with almost as many saying they would want an appointment as would be happy with the advice givenAlmost a third of respondents to the survey felt that 28 days was too long – this was not the case in the group sessions Valley Community TheatreValley Community Theatre ran one form of qualitative engagement. This was a ‘Forum Theatre’ live debate with audience participation. The Forum Theatre live debate ‘Warts N’ All’ was performed by five actors, who acted out four scenarios, based around ‘typical’ skin clinic and skin related everyday encounters.The first scenario was based around understanding people’s experience of existing Dermatology services to ensure the new model is shaped in a way that is responsive to the needs of the population. Key findings from scenario 1 included:Doctors need to explain medical terms and language more clearly to patients, as there is still a culture of Doctors being seen as ‘gods’ and patients are too afraid of asking them questions about their condition, especially young people.Doctors shouldn’t just assume their patients know what they are talking about.The Doctors need to address the young person as a person and by their name, not as a condition.Doctors need to be more understanding and show more empathy for peoples’ skins conditions.There’s a need for young people to feel confident and comfortable enough to speak to the Doctor if they are feeling frustrated with their treatment / service.You should be able to speak to someone else if you are still unsure about any aspect of your skin service. The procedures for this should be fully available and accessible.The second scenario featured a young person with eczema, who wouldn’t put the cream and bandages on their skin and they were being bullied at school because of their skin condition. They also had little support from their family. Key Findings from scenario 2 included:The Doctor needs to speak to and address the young person directly, not just the parent and ignore the young person with the condition, as this makes them feel invisible and detached from the whole process; ‘putting people off’.The young people can sometimes feel patronised by the Doctor.People wanted more information about their condition, through a leaflet.Young people wanted the Doctor to give them (not the parent) the leaflets, and exact and correct information on their condition, so that they could tell their peers exactly what condition they have, and help to prevent future bullying.People want information about local support groups to increase their knowledge of their condition and to improve their confidence when talking to others about it. This appears to be a gap at presentPeople need local support groups, fully promoted by health care staff.The third scenario featured a 15 year old boy who wasn’t attending his skin clinic appointments because his parents didn’t have the time to take him, school didn’t want him to take time off, and the boy felt nothing was really working for him anyway, as no-one else really seemed to care about his skin condition. Key findings from scenario 3 included:The need for more flexible appointments, including weekends, and before school.The need for the clinicians and the boy himself to make sure his parents are fully aware of the importance of regularly attending the appointments.The need for a skin specialist to be available locally and in the community, fully accessible to all, not all based in one place.The need for being able to see the same specialist, and not having to keep ‘starting over’. Importance of the clinician building a relationship with the young person and treating them as a person, not a condition, and fully explaining exactly what the condition is in basic language – directly addressing the child.When we pushed this scene a little further with the audience, we examined why parents may not be taking their children to their appointments; could this perhaps be viewed as neglect on the parents’ part – as ultimately they are responsible for the health of their child, and missed appointments means their child is not getting the care they need? The audience (both adults and young people) rejected this view. They did not view missed appointments as that bad. The answer seems to lie more in the NHS providing more flexible appointments, with the clinics based closer to home, locally, with text reminders for appointments (maybe text reminders to the young person’s phone as well, so they can remind their parents?).Problems may also arise if parents are divorced, and appointments are missed if the child is staying with the parent who doesn’t usually take the child to appointments, or that parent lives too far from the clinic, or the parents both feel like the other one should be responsible for taking the child to appointments. This can also make the child feel ‘stuck in the middle’ and they may just ‘get on with it’ rather than want to cause more distress to their parents. Scenario 4 featured a 15 year old girl who had gone to see her GP about her acne, accompanied by her father. The GP’s solution was to put the girl on the Pill, which her father was very unhappy about. Key findings included:The young people were very keen on being able to access appointments alone, but were unsure as to what the law was?The young people felt that their parents don’t always listen to their needs, for example the ‘dad’ in the scenario couldn’t see past the fact that the Pill was the best treatment for his daughters’ skin condition, which was causing her psychological distress. The young people felt that their parents can embarrass them in consultations, and over-react to things, again necessitating seeing the doctor alone.The group summarised the discussion as follows:People want a local service.People want more flexible appointment hours.People want information on: local self-help groups, leaflets, diet, lifestyle, home life i.e. dust, cotton sheets etc. Clinicians need to speak to the child more than just the parent.Explain ‘big’ words.Law on the age you can see a clinician unaccompanied.Mixed feelings about the photoKeep with 1 doctor / specialist to build up trust.Use the Arts for more awareness forums as this gives increased empathy for young people without skin conditions, and may result in less bullying at school. Child and adult services should be one service.Clinicians need to be aware of child’s home life which may be acting as a barrier to accessing the service.Valley Community Theatre – Forum Theatre PosterEmmanuel Westly FoundationEmmanuel Westly Foundation ran three forms of qualitative engagement with two linked. These were:Discussion group meetings each involving 15 black African men, all of whom had Vitiligo (a skin disorder in which smooth whitish patches appear on the skin), took place at a local church community meeting room. The meetings took place for two and half hours over three consecutive weeks with one additional session to ask the opinion of the evaluation made.These sessions were informal sessions with two facilitators who could speak French and Arabic. The group were all affected by Vitiligo skin condition. The main facilitator went thought the key themes of the paper questionnaire to start discussion. The discussion agenda was as follows:When were they diagnosed and were What treatment if any are they receiving from the NHS here in LiverpoolThen paraphrasing the questionnaire, to find participants opinion.Facilitator, keeping a note of key themes discussed in each sessionOne to one discussions with specifically invited mothers of children who have skin conditions at five events as well as interviewing them to complete the questionnaires.At each of the five events the children with skin conditions were engaged as a group, creating a creative piece of work that represented what they felt about their condition and their treatment. The facilitator helped each group of seven children work on the creative project over the five events. The children left the piece of work after each of the five events.876300275590Emmanuel Westly creative workshopVitiligo discussion group feedback:The group generally felt very depressed about their condition, as they were consistently told it was a manageable condition not a treatable condition.GPs or consultant failed to explain clearly what the condition was, and the medical practitioners failed to understand the cultural back ground to the condition. Namely, it was associated in tribal culture as ‘witchcraft condition’ and that people were shunned in the community with this condition, not able to marry or work in some cases. This led to an insensitive approach by medics when explain the condition to patientsIndividuals reported they moved around a lot and they had not received the full treatment available for this condition by the NHS, such as photo therapy UVA light treatment. Also, different steroid creams given to each patient, and no coherent cream that could slow down condition.Little understanding of the different types of vitiligo, or what was the official diagnosis of the treatment.Some concerned about misdiagnosis, since many had severe skin conditions from Africa, that was not diagnosed immediately by their GP.Need for more specialist treatment, by GP or consultants who specialise in BME skin. The group felt this form of knowledge is not available in Liverpool.Lack of follow on treatment for the psychological effects of conditions. Patients expressed deep concern of the stigma associated with their condition and had little or no strategy for how to deal with it, which had a negative impact on their mental health.The psychological effects outweighed the need for seeing a consultant. Many viewed this condition as a curse, due to culture beliefs, and many talked about trauma they had escaped from and trauma on travelling to UK. Therefore, the group felt they needed counselling to deal with this skin condition, since their confidence and self esteem were very low due to personal circumstances. For this group just seeing a consultant would not be the answer, the group expressed a joint approach of counsellor and consultation, not as separate treatments.100% against sharing services with children felt it could cause embracement and was culturally sensitive. 80% had no issues with travel, but would like reimbursement for travel.Wider qualitative feedbackWe found that the majority of participants expressed frustration that their condition was not taken in their words ‘seriously; by the GP they had seen. They felt that their concerns were not seen as being a major medical condition. GP used phrases such as ‘I have dry skin and use x cream, try opening the window in your house and turn heat down. This left the patients and their families feeling frustrated and left to find solutions to a problem that was an ongoing medical issue to the family.Families had to buy medication to treat the condition, often given first medication for free on prescription, but had to purchase the other treatment themselves. They viewed follow up visits to their GP as being a waste of time, since they could buy the medicine cheaper in the shops.Good pharmacies were needed to get the local advice on treatment. Participants spoke on the mixed pharmacy service. Those that had a good pharmacy, were happy to go for advice and support. Where others had bad services, such as pharmacy with little people skills, lack of range of products, little explanation of which is better products, led to many buying cream from international food shops, that sell African cream from USA or Cote d’Ivoire with little understanding of impact of these creams or suitability for children.Families did not understand that they had a right to see a specialist or treatment at hospital. The majority of respondents stated that they had not had it explained to them, that they could see a specialist. The lack of information or referral on created a barrier for many seeking extra help.Many expressed lack of trust of GP advice; they felt they did not express themselves as having sufficient knowledge to solve their children’s problems. They spent half the consultation typing in the computer, the other half talking very fast about how normal eczema is in the UK. One client was not diagnosed with anaemia for ten months because the GP failed to understand their parents explanation of the condition, leading to children’s hair loss.Many parents spoke of the psychological impacts their children experience as a result of their skin condition, for example low self-confidence and bullying at school. There was very little psychological support offered to children and this undermined their ability to self-manage their condition. While conditions maybe considered clinically self-manageable it was suggested support to deal with the psychological impact of the condition was lacking and often the psychological impacts were undermined as the condition was viewed as common.Parents whose children have been seen by hospital skin services made comments, such as “attentive professional staff, clear diagnosis of condition by hospital staff”. Parents who left this care, felt an overwhelming sense of relief, that their child’s condition was not only getting treated, but getting better. This was especially true of parents diagnosed with Psoriasis.Parents noted after the initial long wait for appointment, follow on appointments were regular, on a monthly or every two months basis, and were in the same location. This led to less stress for parents, as they could manage the treatment at home, with reassurance that they could see a specialist for advice throughout the year. It must be noted, that attendance at GPs by those who saw a specialist, was low, apart from non skin conditions (such as cold virus etc).Parents generally liked the service at Alder Hey, finding it child friendly and the specialist having a very different approach to children, than some GP’sOverwhelmingly, all participants did not want mixed adult and children service, they believed that services should remain separate. This was to protect the children from a more medical approach to treatment, to ensure the children feel safe and comfortable getting treatment and to ensure children privacy and dignity is retained.It should be noted the objection was more about mixed clinics. The concept of delivering children’s only clinics in the community was not objected too.Parents were less against photographing their children or videoing skin condition, if this meant faster treatment by consultant. But 100% expressed desire to have a some face to face meetings with consultant, as some conditions need further explanationThe parents had mixed views on location, as 50% did not mind travelling, but other 50% did have issues with travel. In my opinion, even the 50 % who expressed concerns on travel would travel if it meant seeing a consultant.Parents were concerned that any changes would reduce chances of seeing a consultant, and their children’s conditions would be side-lined in the growing pressure of resources. These feeling were based on no evidence, but on what they had heard on TV news about cuts.Elevate Potential Young Persons’ WorkshopConclusion There is considerable evidence of a positive response to Skin Services in both their current and proposed forms across the quantitative and qualitative research.The process as a whole engaged with the targeted communities of interest, only missing children and young people in care; people with addiction issues; and homeless people from those who were identified. A key element of the proposed model, the joining up and structuring of skin services in terms of complexity and care required, received the endorsement of slightly more than half of those who responded to the Skin Survey. The integration of adult and children’s services did not have the same level of support among those who responded to the Skin Survey with only 42% supporting the proposal and 27% rejecting it. Among those that participated in the engagement activities there is evidence of support for this proposal but also widespread, explicit rejection of this. In respect of the other elements of the proposed model for services there is evidence of support from both the quantitative and qualitative research. However, the qualitative research raises some relevant, sceptical questions about the consequences of implementing the proposals.Overall, the views of the community partners and the levels of participation and expressions of appropriate and wide-ranging opinions by service users and others indicate that the overall and specific objectives of the engagement have been met.Appendix One: Skin Survey – Answers to open questionsWhat skin condition do you or your child have?Other skin conditionsALEOPECIAAlopecia.AQUAGENIC PRURITUSAs above been a holistic Aricular Accupuncturist. I treat people with skin conditions using my training in traditional chinise medicine where we treat the course not the symton. We have tremendous result. BASEL CELLBCCBCC and actinic keratosisBCGBOWENS DISEASEBURNING OF THE SKINCAME TODAY FOR BIOPSYCANCER SPOTSCHRONIC IDEOPATHIC URTICARIA (HIVES AND SWELLING)Constant itching.CTCLcutaneous hornCyst on head removed a few months agoDISCOID LUPUSDon't know what skin complaint I have.ESR & face lesionFolliculitisFolloculitis FOLLOW UP APPOINTMENT FROM MALIGNANT MELANOMA 2 YEARS AGOGRANULOMA FACIALEI am currently unaware of which type of condition I have? Hopefully I will find out today.I DONT KNOW WHAT IT IS I HAVEI don't know, not explained by my doctor.Keratosis PilarisLeg ulcers LICHEN PLANUSlichen sclerosis + SKIN CANCERLoss of pigmentation on face and body.LumpLump of pigment appearing underarm; hard white spots appearing on faceLupusMAlignant Melanoma, basal cell carcinoma x2MelanomaMELANOMA X2MELASMAnodular prurigoNot diagnosed yet.Not knownNot sureNot sure, that's why i am herePigmentationPink mole.pityriasis rubra dolarisPost ulcer carePREVIOUS MELANOMARaised blood vessels.RashRash on leg.Remember my aunt suffering from Psoriasis...and how painful and unslightly it was.Rodent ulcerRosacea and broken veins.SKIN CANCERSKIN CANCER IN 2012Skin condition is a rash on face, unaware of what the condition is. It could be fungal, eczema or psoriasis. My condition need diagnosis as it is not clearing up. Symptoms for over a year.Skin damageSKIN SUN DAMAGEDSkin very itchy.Solar keratosis - cleared 3 years ago but signs of a recurrence - I was referred by GP (locum) for tests.SOLOR CATOSISISStill under investigation.Thin skin on noseulcerWaiting for diagnosis.WARTWARTSHow would you rate your experience of using skin services inLiverpool?Please tell us what worked well with the care you received and/or what could have been improved.Bad - better information on creams, help to see a consultant.Good - quick appointment time at GPCalcium and vitamin D tablets.Can see GP every week, same advice every week and he did not feel it was severe enough to refer to hospital. Condition has got better with cream made up at Alder Hey, and tested for allergies. Could see GP anytime but his and her knowledge not good enough. Not referred to hospital. Cream prescribed worked well for some time, but children's skin changes and eventually condition came back. Did not take condition seriously, changed GP twice. Different GP all the time, different cream no solution. Do not like treatment by GP, feel as if not taken serious and language barrier. Explained the problem and treatment clearly. Five years my son has still problem, changed diet, cream, no answer to condition. Free creams on prescription, but poor explanation by GP staffGave up on treatment and use products from beauty shop for my daughter. Get creams and can see GP when I want. No cure for the condition, it seems to be getting worse for my son.Getting better. Happy with treatment and adviceHealth visitor spotted the problem and dealt with it, GP did not take seriously enough. Helped my son get better, explained everything and we felt part of the treatment as a family. It was perfect.Keep going back no cure, not convinced the doctors know how to treat my daughter, came from war torn country, may have other causesListened to your concerns, nice attitude but did not offer consultation with consultant. No answer to the problem. More information, choice of appointments as difficult to attend with other young children at school. My young baby still has problem after 18 months, no proper advice. Needed to be referred to Alder Hey but was not. Dermatology services here overstretched.Never used one.Nothing worked well, have not gone to Chinese herbal medicine for my teenage daughter, eight years of nothing but 'she will grow out of it', different cream, not working. Herbalist now says she may be allergic to sugar. Nothing, going nowhere with treatment. Ok but felt not enough advice and options explained. Did not like the idea of living with it. Pharmacy did not help, different locum pharmacist each time, different GP each time, saying the same thing. No referral to hospital. Saw GP on a regular basis but was not referred for further treatment by anyone. Seem to be keeping the condition under control. Early stages of diagnosis was difficult and waited too long and GP knew very little. Signed off by hospital as not severe, can treat at home. No explanation or support.There needs to be more advice on diet and lifestyle and genetic factors that cause skin conditions.They do not care about the effect the condition has on my son.They gave enough cream to resolve the immediate problem, they listened to your concerns. No referral given for hospital as was told to live with condition. Tried their best at GP but need new tests as condition is getting worse with age. Try their best to find answer to child's problem. Waited a long time to be seen, doctors do not explain muchWaiting to hospital doctor, gave good advice and listened to my concern. Would have liked a referral for my Son, not treated as severe enough. ALL ASPECTS HAVE BEEN EXCELLENT, ESPECIALLY THE NURSESAll of the services provided from the staff especially in the Aintree hospital, this is my second visit, my last one being 2 and a half years ago. The only thing that can be improved in my view is that it stays precisely where it is, as the care here is second to none!ALL THE DERMATOLOGY STAFF WORK EXCELLENT AS A TEAMAntibiotics improved acne.Appointment quickly and convenient. Medication prescribed assisted.APPOINTMENT TIME COULD AHVE BEEN QUICKERAppointment upon request.AT THE AGE OF 91 A LATER APPOINTMENT THAN 9AM WOULD HAVE BEEN APPRECIATED - AVOIDING RUSH HOURAttending the dematology clinics approximately every 6 months to meet a consultant is always positive. Quick and efficient and the consultants themselves are very friendly and welcoming.BEING REFERRED FOR MORE ADVICEBeing seen quickly after seeing my doctor.Booking was straightforward. Appointment time was a number of weeks wait.Can't judge yet - first visit.Care received has been outstanding from GP and Greenbank Health Centre. Happy with treatment I received and aftercare advice given.CLINIC AND STAFF EXCELLENTBUT I WAS GIVEN TO EXPECT AN EARLY REVIEW AND I HAD COME BACK TO THE CLINIC BECAUSE NO APPOINTMENT WAS SENT. I WAS THEN OFFERED IMMEDIATE HELPCOMING TO SEE DERMATOLOGY NURSES TO BE BANDAGEDCourteous and polite staff.PromptCreams, dermol, doublebase.DERMAL 2000 AND DIPROVASE CREAM FOR EXZEMADERMATOLOGIST AT ALDER HEY ARE AMAZING AND NEED NO IMPROVEMENTDIAGNOSED AND DEALT WITH VERY QUICKLY AND EFFICIENTLYDoctor was very good. Short wait.DONT FEEL THAT I HAVE BEEN DIAGNOSED CORRECTLY AND THERE HAS BEEN UNCESSANT TREATMENT/PAINDr Bahrati and nurse listen to you.DR PASLOW AND THE NURSES AT THE SKIN CLINIC AT BROADGREEN ARE ALWAYS READY TO TALK AND EXPLAIN, WHICH TO ME IS FABULOUSDUE TO THE NATURE OF MY SKIN LESION REFERRED FROM GP TO HOSPITAL VERY QUICKLY INITIALLY.HOWEVER, HAVE WAITED OVER 8 WEEKS FOR BIOPSY APPOINTMENT EVEN THOUGH NOTES SAY URGENT!EFFICIENT - SCREENS DIRECTING POEPLE WHERE THEY NEED TO GOEFFICIENT ONLINE BOOKING SERVICE FOR APPOINTMENTSEverything explained clearly, nice attitude of staff, very attentive.Excellent care, much better than the GPs as more specific. 18 month GP care no change of condition, immediate improvement after seeing consultant resulting in much better quality of life.Excellent communication skills by all as well as my condition. 10/10EXCELLENT SERVICEFabulous specialist nurse who was knowledgeable, skilled and an excellent communicator. I was very happy with the location of the service, the quality of healthcare provided and the follow up. The specialist nurse and I agreed that my pathology results could be provided by phone instead of me taking time from work to attend. Fairly quick appointment with option left open for further visit.Fast access, good quality care.First appointment quick.First appointment so nothing to comment on yet.First time visit to hospital.FIRST VISIT AFTER OVER 6 MONTH WAIT!QUICKER APPOINTMENTFirst visit.Flexibility of appointments to fit around work as best as could was good. Staff take an interest in you.Friendly and polite, feel at ease.Friendly staff. Waiting room was busy.Given a skin cream.Good advice . informed of treatment - seen quicklyGood diagnoses and successful treatment and advice.Good treatment but appaling appointment scheme.. No matter if appointment was booked as a first appointmentof the day I was never waiting to be seen for less than 1 hr mostly a lot longergot the right treatment and advice, it cleared up within 6 months of seeing the nurse and no further interventions were requiredGP listened, looked at itchy mole, thought everything was alright but referred me to skin cancer clinic to be sure, I was seen within 2 weeks and informed everything was alright.GP NO USE - HAD TO GO PRIVATE. BROADGREEN GOODHad current condition (still not identified) for 6 months. There has been a lot of guess work i.e. 'I think it's such & such' and treatment given without knowing what condition is being treated. Waited from April until Aug until a swab was taken. Just had another swab taken in Nov and may have biopsy in Dec. Current wait for dermatology appts I was advised by GP is 4 months. This is an unacceptable situation for someone who is suffering and may be incapacitated by condition (as I am/was).Had procedure done at Garston (SLTC) and needed stitch removed 10 days late - couldn't get stitch removed at my own doctor/nurse or SLTC, had to go to Childwall Health Centre (took only minutes).HAVE BEEN ATTENDING CLINIC APPROX 15 YEARS. UNDERGONE VARIOUS TREATMENTS. CONDITION NOW MANAGEABLE, FOR MY CONDITION SERVICE HAS WORKED WELL AND STAFF ARE EXCELLENTHOSPITAL IN PATIENT STELARAHUMIRA INJECTIONS AND FUMIDERM WORKED. IT TOOK TOO LONG TO GET ON THESE TREATMENTS. I SUGGESTED HUMIRA BECAUSE IT WAS EFFECTIVE FOR MY MUMI had 4 moles removed and a 5th but it was a shiny round pink area. It turned out to be the one to worry about. I had 6 monthly follow ups to check all my skin.I SAW A SPECIALIST ON OCT 9. SHE SAID THE MOLE NEEDED REMOVING URGENTLY BUT I WAS AWAY IN LONDON OCT 12-18 AND SHE SAID AN APPOINTMENT WOULD BE SENT TO MY HOME. THERE WAS NONE WHEN I RETURNED TO LIVERPOOL.AFTER WAITING FOR THE LETTER UNTIL FRI 23 I PHONED THE HOSPITAL BUT THE SPECIALIST ASKED ME TO PHONE ON MONDAY 26TH TO SEE WHAT WAS AVAILABLE. THE HOSPITAL PHONED ON THE SAME DAY TO ARRANGE AN APPOINTMENT (A CANCELLATION) FOR TODAY OCT 29. IS THIS USUAL?I was prescribed a course of cream that ultimately didn't affect my eczema. The doctor who prescribed my cream was very dismissive of me and suggested it was related to a change in soap powder for laundry and/or shower gel. I ensure that any products that come into contact with my skin will not affect me in this way, as my sister and father both suffer from chronic skin conditions and allergies. As a result I've had to wait two more weeks for another appointment after using cream you can get over the counter, which is not designed for long-term use. I WAS VERY PLEASED WITH THE DOCTOR WHO EXPLAINED EVERYTHINGI would say excellent in Faz hospital but not for Broadgreen (poor).In my experience l have not used any of the aboveIN PAST TIMESCALE WAITING FOR TREATMENT TRYING TO FIND EFFECTIVE TREATMENT SUITABLE FOR INDIVIDUAL NEEDSIt took me years of suffering before it was agreed to give a referral to a Dermatologist who could only give me an appointment in 3 mths time where I told and showed Dermatologist who sent me for a skin specimen. 2wks later had the test 3mths later saw the Dematologist -no results showing was given more cream and come back 3 mths in the mean time I was in pain couldn't sleep scratching continous clothing both night and day time was having to be washed due to blood stains. Doctors just looked changed med and will see me month time. Life just didn't feel like living Saw Neuropsychiatrist sent me on courses Late at night was impossible to sleep so looked at leaflets from medicine only to find This med prescribed by a Doctor DON'T give to an Epileptic should it cause ache, skin peeling not been able to sleep etc looked at the other leaflet much the same. Following day removed all new med felt it impossible to bear nights tried to bring forward appointment for Dermatologist no chance so just carry on suffering I've had different opinions with different GP'S. Older GP's tend to have the attitude of "just get on with it".IVE SEEN THE SAME DOCTORS AND NURSES FOR A DECADE AND THEYVE ALWAYS BEEN WILLING AND OPEN TO TRYING NEW THINGSJUST GOOD.Light therapy at Broadgreen hospital effective so worked quite well but time consuming and inconvenient plus a lot of hassle my attending too many appointments by public transport. Male dermatologist was recommended to me but couldn't help me and treated like a 'guinea pig' trying out umpteen steroid creams and tablets on me. He should have solved my skin problem and in a shorter timescale but never and I have to manage it best I can now. Gave up waiting for one appointment after waiting two hours as couldn't wait any longer so waiting times could have been improved. I ended up getting bus to hospital and home again for nothing so waste of my time and effort. This was in August when usual doctor was away on holiday and so short staffed. A temporary dermatologist if available would have helped because could have seen me and in a shorter time.Long wait for appointment.Long wait.Lovely professional caring manner from my nurse practitioner Maureen. She explained everything thoroughly and left nothing for me to worry about.Lump of pigment: Referred to Dermatology by GP, I was sent away from Broadgreen with no information, just told "it was nothing". Several years later a different GP told me what it was, said it could be removed but is harmless. As I previously have had a benign nevis removed from my eye as a precaution, residual doubt remains.Hard white spots on face: dismissed as non-medical by GP Medication and understanding.MEDICATION SO FAR NOT WORKED AT ALL SUPPOSE WOULD LIKE TO HAVE THE MEDICATION THAT IS MORE TOWARDS 100% TO BE GIVEN OUT FIRST INSTEAD OF LASTMedication, attentive staff.METHERYAXATE Minimal scar in the removal of a sebaceous cyst.MORE COMMUNICATION TO PATIENTS FROM DOCTORS, EXPLAINING STAGES IN TERMS THAT COULD BE EASILY UNDERSTOOD RATHER THAN 'DOCTORS COOES!'MORE INFORM ATION ABOUT WAITING TIMES ET6C ON THE DAYOFFER LATE APPOINTMENTSMore testing.My mother has, and is being treated following leg trauma resulting in ulceration, for the past 17 months and has been receiving care from district nurses, vascular nurses and is now being looked after by South Liverpool Skin Care Team at Garston Hospital. The care overall has been good. Occaisionally nurses appear to contradict each other in caring for my mother's leg. When at the start, May 2014, one nurse would wash my mum's leg prior to dressing it the next week a different nurse would not wash the leg first. Also during the healing process some nurses prior to re-dressing the leg would pick off the scabs or over granulated tissue with tweezers but some would not do this. So that there seems to be a lack of consistency in treatment. Some nurses would also apply hydromol whilst washing the leg in water and others would not. Occaisionally the dirty water was not flushed down the toilet but down the kitchen sink. (?!!!!) The nurses were always kind and respectful and despite their busy schedules they would listen to any concerns that either of us had. All the nurses were pleasant!No improvements necessary - maybe waiting times for appointments.No patient choice about whether to visit NHS hospital for treatment, only given GP for surgery, when much easier to travel to Aintree Hospital from where I live. No direct transport to GP either unlike Aintree Hospital.No waiting times for appointment.NOT SO MUCH AS CARE, BUT IN REGARDS TO IMPROVING THE ACTUAL SERVICE - CONSISTENT USE OF TELEPHONE/TEST REMINDER SERVICE WOULD B EHELPFUL RATHER THAN THE CURRENT 'HIT AND MISS' APPROACHNothing works. On time - informative.Once at clinic the care received is good. However getting access to an appointment is a nightmare.ONCE SKIN BIOPSY DETERMINED CAUSE, FAST ACTION AND DIAGNOSIS WAS MADEPrompt GP referral.Quicker appointments.Reasonable timescale for appointment and only a short wait in clinic prior to the appointment. The doctor was really helpful and informative.REFERRED BY GP AND SEEN IN CLINIC WITHIN 2 WEEKSRegular appointment because of ongoing skin problems.Saw GP first for skin problemReferred to local surgery for removal before seeing dermatology. Local GP performed a wide excision which in retrospect should not have occured until after seeing dermatologist? Scar bigger than it should be. Had further surgery at Whiston with plastic surgeon. Think everyone has been brilliant and fortunately skin cancer had not spread to lymph nodesSeen and treated promptly (2 occasions).Since I have just arrived for my first appointment I am not in a position to answer this and the question above.Sometimes I have to phone appointments to remind them to arrange an appointment.Speed of appointment and great treatment.Spoke to a doctor about my condition (similar) and he didn't seem to know much about it just prescribed E45 which didn't help much so put me off going to doctor's for my daughter.STAFF HAVE EXPLAINED EVERYTHING WELL. BEEN SEEN ON TIMEstaff were great and supportive of my 86 year old mother - listening to her not just me and making her feel at easeSTAFF WERE VERY CALM WHEN CHILD WAS DISTRESSEDThe care and treatment I received has and is excellent especially reassuring are the follow up appointments. However I did have to wait an exceptionally and unacceptably long time before my first appointment which was noted as urgent. I waited 6 months before treatment.The doctors were very helpful.The level of staff at the Broadgreen centre was assuring and the efficiency of the reception staff made a traumatic experience reassuring. The medical staff were very busy but incredibly confident and efficient.THE NURSES AND STAFF ARE VERY HELPFUL AND PRVIDE ADEQUATE INFORMATION AND ANSWER ALL QUERIES THAT I HAVE.THE MEDICATION I AM PERSCRIBED HAS WORKED TO ITS POTENTIAL AND I HAVE SEEN A DRAMATIC DIFFERENCEthe nurses are really knowledgeable and are a god send in managing my mums condition. She is in a lot of pain and the visits provide relief and the ulcer is beginning to get better and healTHE SERVICE WAS OF THE HIGHEST ORDER FROM WHEN I WALKED IN THE DOOR TILL I WALKED OUTThe staff are very kind, very understanding and great to talk to.THOUGHT MY CARE IN THIS HOSPITAL HAS BEEN EXCELLENT. EVERYTHING WAS EXPLAINED TO ME AND WHAT TREATMENT I WOULD RECEIVETreatment hasn't been working. Skin condition is not clearing up.TREATMENT I RECEIVED WHILE ADMITTED WAS VERY GOOD AND DR. PARSLEW WAS VERY GOOD IN EXPLAINING MY CONDITION AND HOW WE WERE GOING TO MANAGE ITTreatment was good, maybe have more appointments after work.Ulcers cleared up very quickly especially as patient well into eighties VERY CARING AND PERSONAL TO PATIENTVERY GOOD INFORMATION FROM CARING DOCTORSVery good, speedy response. Reassuring. Explained everything clearly.VERY PUNCTUAL WHEN ATTENDING CLINICS KIND DOCTOR WAITING TIME FOR AN APPOINTMENT IS TOO LONG (3 MONTHS)Waiting time to get an appointment is long. Stitch removal service was very good.WAITING TIMESWAITING TIMES ARE NOT LONG AND STAFF ARE ALWAYS HAPPYWaiting times between appointments.Waiting times. Explaining more about what's going on.Was seen at Broadgreen site and they kindly referred me to Aintree for phototherapy as it was closer and easier for me to access as the course is three times weekly for 8 weeks.WHEN I HAD 2 MOLES REMOVED ALL THE STAFF WERE VERY HELPFUL AND MADE ME FEEL AT EASEWOULD LIKE CLOSER APPOINTMENT TIMES. APPOINTMENTS ARE TOO FAR APARTYou could improve the communication between the PUVA clinic and the public, I received an appointment which was just sent to me, it was not possible for me to attend on the date, I phoned the appointment line who said they could not change it and then put me throufgh to, I assume, the clinic at broadgreen who then gave me another number, (the puva clinic I think) I phoned this number had to leave an answer phone message, no response, I phoned again and left another message, I got a response and all the person said "oh it wont be until after x/mas now, I have not yet received a date.What more could clinicians do to support you with the management of your's or your child's skin condition?Believe what Mother says about child's condition, instead of thinking I am an overbearing mother. Better diagnosis of conditionExplain different treatment. Explain to meExplain treatment options for my daughterExplain, inform and treat patient with respect. Felt as if looked down on because child drank fizzy drink. Explain, listen and find better treatmentFind out what causes the problem, test in hospital, look at genetics, look at treatment that may cure not keep the thing at bay. Give more information, refer to hospitalHave a plan, not just creams every visit. Let me know what tests are available for my son. Help treat it with a better range of creams and test for underlying problem. Help us see a consultant. I feel helpless after seeing GP for three years, no change in condition. Information - nothing has been explained to me apart from cream. Information and treatment. Let Parents make the choice of going to hospitalLook into what causes the problem, before they go into adulthood. More information. More tests. New treatment idea. Refer to hospital consultantRefer to hospital, or hold special skin clinics for children at sure start children's centre. Refer to special clinic. Special clinics with people that know about treatment. Test for allergic reactions, test for household dust mite problem, is house damp creating problem.Test more for issues affecting children's skin. The clinicians need to spend more time with new patients as they are the ones who bring in more income (Alder Hey).There are recent moves that offer psychological help and counselling to young people with skin disorders.Understand the effects the condition has on my teenage Daughter at school. Allergy tests. More appointments at different times.ALLOW ME TO GO FOR BLOOD TESTS AT MY LOCAL GP RATHER THAN HAVING TO COME TO BROADGREENBe good for my daughter to be referred to a specialist with a knowledge of this condition- she is a teenager and quite conscious and not confident because of it.CHECKING OR ANSWERING QUESTIONS IN BETWEEN BOOKINGSCOULD DISCUSS MORE OPTIONS OF TREATMENTDO MORE TESTS, BE MORE INTERESTED Explain condition and how treatment should/could assist.FIND OUT MORE ABOUT LIFESTYLE AND WORKING ENVIRONMENTGPs, GP surgery nurses, pharmacists need more training from hospital skin specialists at Aintree and the Royal Liverpool to care for patients with minor skin conditions such as eczemaI have attended several courses of narrowband UV treatment over the years. Each couse proves sucessful and whilst I appreciate the NHS's concerns to limit exposure to this treatment, I would love to be able to enjoy more of it over shorter courses but more frequently. To be able to do this I would gladly sign a waiver to personally accept the increased risks. The current availabiliity of this treatment is limited seemingly only to Brodgreen Hospital with expensive car parking but most importantly only available on 3 days per week, days when I work. The pre-screening sessions are inflexible. Even once on a course of tretament you are committed to stay for the duration using the same treatment room and equipment. I really do challenge how using the alternative equipment can make any dofference in overall exposure levels and it would remove the frustration of having to wait for a particular treatment room when the other is free.I'm hopeful that once the doctor sees how my condition has worsened since my last appointment, they will look into long-term solutions, even if it means a repeat prescription. LISTEN MORE TO THE PROBLEMS I HAVE BEEN HAVING INSTEAD OF GIVING JUST CREAMMAKE SURE I GET ADEQUATE FOLLOW-UPMore people involved.MORE THOROUGH TESTS FOR MORE ACCURATE DIAGNOSISRealise that simply dismissing something doesn't leave the patient feeling it is dealt with. Give me the exact name and description for what it is so I can seek alternatives outside the NHSReally require advice on what products to use. Run the right tests to ensure the correct treatment is started.Regular follow-up to my caseStop giving me creams that don't work. I've had this since age 11. The skin on my arms and legs is embarrassing and itchy and painful. Take an interest in their patients see what med you are on or have been taking what the results are State you are wanted to be seen within the month as a follow up Take/do testing in the first instance (or right away for testing e.g. swabs, etc) at walk ins/GP. Condition was treated on the basis of a guess when swabs/testing could have identified the condition sooner and treated properly. My condition started in April now it is almost December and still not sure what skin condition I have. When I have seen staff, however, they have been wonderful and helpful.UNDERSTAND HOW DEMOBALISING IT CAN BEDo you think we should be joining up adult skin services across Liverpool and structuring them in levels of complexity and care required?If No, please tell us why you have chosen this answerDo not know enough of present services to comment. I do not understand who present services work apart from GPJust about cuts. May lead to cuts.May mean cuts in service.May mean cuts to services. Need to understand present system before comment on future changes. People are not made aware of any services at present. (Not sure) At the moment the clinic we attend at Aintree is second to none, it works well with great staff from the top to the bottom. To change this would be a great shame. Travelling to clinics would be a problem if they are combined.Aintree are in control.CHILDREN NEED MORE CARE, SUPPORT, AND UNDERSTANDING, THEY CAN TRAUMATISEDI am 83 years old. I am three bus stops away from Aintree Hospital.I believe that when you join up clinics age groups etc things tend to fall through the cracks.And some people are left out while their condition gets worseI believe the standard of care would suffer, the feeling would be like on a conveyor belt, very inhuman!I believe this would only add to mis-management and trouble for doctors and patients.I didn't think the care I received in Broadgreen matched up to Fazak.I do not think centralised services improve care, indeed they increase difficulties for the patient - travel, etc.I think not because if you join or merge the services that could potentially mean the closure of the clinics that I attend and I would have to travel a fair distance to get to other clinics.Keep it separate.More people involved.More serious conditions need more time and empathy as patients are very anxious.No I believe having dermatology services across different hospitals is beneficial for patients as treatments are often short and over long periods of time. Especially people with no transport or elderly.Nothing - satisfied with service.THIS IS NOT A GOOD QUESTION AS THE MAJORITY OF THE PATIENTS COMPLETING THIS SURVEY WILL NOT UNDERSTAND WHAT SUCH CHANGED WILL ACTUALLY MEAN FOR THEM IN PRACTICE BASED ON THE INFORMATION GIVEN. E.G. IF IM AN OUTPATIENT HACING REGULAR FOLLOW UPS AT BROADGREEN, WHAT IMPACT WILL THE CHANGES HAVE ON ME? I DONT KNOW BASED ON GIVEN FINO!Do you think we should be joining up children’s and adults skin services to avoid children having to move between services when they reach 16?Please tell us why you have chosen this answer.Better to have children's services separate. Better to keep children's services separate as it is a nicer environment for children. Children need own specialist to understand their condition. Do not like adult hospital atmosphere for children. Do not think main hospital has correct environment for children. For dignity of children keep separate. I like the idea of children only service, like at Alder Hey, otherwise what is the point of Alder Hey.If my son was seen at hospital only at Alder Hey, since Royal not safe for kids. It is always helpful to have continuity of care.It's good to continue care in the same place.It's good to continue without bumps.Keep children care separate. Keep children separateKeep children separate. Keep children separate. Children need a safe environment not a scary room full of adults. Keep children separate. My experience at womens not good. Keep separate for children to have nice child like environmentKeep separteKeep things separate to ensure children are a priority. Like Alder Hey hospital need special kids doctors and nurses. Like children separateLike present service, except it takes too long. Like service as it is. Like service at Alder HeyLike the services as it isLike things separateMake things more simple to understand.Please keep children separateSmall children need separate service and approach from doctor. So they don't have to regain a new trust with a doctor or nurse.Stay separate so both children and adults can have the quality care expected. Strongly like children clinic but would except mothers/women and children clinic not men. They should be in one place although adults should be in separate rooms. Why does all dermatology services for children have to be at Alder Hey?Would make the problem worse and timescales longer to see consultant. Would not want to go Royal with my Son. Children and adults should be kept seperate for many reasons; these should hardly need explanationAll children's clinics should be joined up so transition is easierAS ABOVEAs above.As children's skin type to adults is different. Skin changes with age.At the moment, it seems that you can only be seen by specialists if your condition is particularly abrasive. It should be opened up to people with long-term conditions and chronic cases, at any age, to ease children's transition to adults' services and to ensure we're all getting the help we need from a broad, united service.Because although there may be an advantage to not having to move children between services at age 16 it may be less stressful for children to be in their own category (age range).Because I think each service is special to each groupBecause it's easier and cuts the endless red tape and referring BECAUSE PEADIATRIC PATIENTS NEED A DIFFERENT ATMOSPHERE - SEE NEW ALDER HEYBECAUSE SKIN CONDITIONS ARE CAUSED BY VARIOUS THINGS FLARING THEM UPBetter to stay in one place.Child health is a specialised area and needs a different approach, not just cost cutting exercise.CHILDREN AND ADULTS HAVE DIFFERENT LEVELS OF UNDERSTANDING, LEVELS OF REQUIREMENTS, AND AS SUCH THEIR TREATMENT AND INTERACTION WITH MEDICAL STAFF VARIESS ACCORDINGLY. KEEPING THEM SEPERATE MAY POTENTIALLY AVOID UNNECESSARY COMPLICATIONS IN THE SYSTEMCHILDREN NEED A DIFFERENT APPROACH TO CARE AND TREATMENT I THINK THIS SHOULD BE KEPT SEPERATECHILDREN NEED SPECIAL ENVIRONMENTCHILDREN NEED TO BE AROUND OTHER CHILDRENChildren require a different style of care.CHILDREN SHOULD BE SEEN SEPERATELY - BUT MAYBE THERE NEEDS TO BE A SMOOTH TRANSITION - NOT SURE HOW THAT WOULD BE ACHIEVED THOUGHCHILDREN SKIN CARE ARE MORE IMPORTANT AS AT THE AGE OF 16 IS VERY EMBARRASSING FOR THEMChildren would feel more comfortable receiving treatment alongside other children, may feel scared if surrounded by adults.Children's and adults skin services should be separate because they're different. There's also long enough waiting times for an adult patient to see a dermatologist without making it longer.CHILDRENS SERVICES NEED A DIFFERENT APPROACH DUE TO NEEDING A CHAPERONE PLUS ALL THE BARRIERS OF FEAR ETC.WAITING TIMES FOR APPOINTMENTS/ PLUS CLINIC TIME COULD BE A LOT LONGERCLINICS TOO BUSY AS IS WITHOUT CHILDREN BEING INVOLVEDCOMBINING ADULT AND CHILDRENS SERVICES MAY MEAN LESS TARGETED CARE IS GIVENConsistence with consultant and treatment.CONSISTENCY OF CARE IS VALUED AND AT 16 YOU ARE NOT REALLY AN ADULTCONTINUITYContinuity and personal relationships are important in healthcare, especially for teenagers.Continuity is good in my opinion.Continuity of careContinuity of care is so importantContinuity of care.COULD BE, QUITE OFF PUTTING FOR YOUNGSTERS WHO COULD BE EXPERIENCING PROBLEMS COPING WITH OWN CONDITION, LESS INTIMIDATING IF WITH THEIR OWN PIER GROUPDifferent need. Environment and care should be different.DONT HAVE A CHILDDONT KNOW ENOUGH ABOUT ITDONT KNOW ENOUGH AS THIS IS MY ONLY VISIT WITH A SKIN PROBLEMDONT KNOW MUCH ABOUT ITDon't know what the benefit would be.DONT REALLY UNDERSTANDEASIER FOR THE PATIENTEasier to manage appointments/referrals.EASY FOR YOUNG PATIENTS TO FEEL MORE COMFORTABLE WITH THE STAFF AND SERVICES. MAY FEEL MORE SHY/VULNERABLE HAVING TO CHANGEEasy to continue treatment in friendly environment.Easy transition for the patient.Everything should be joined up in an attempt to keep notes and records easily accessable.Everything together.Feel keeping children and adults as two separate services is better for the child.For children to recieve a continuous service into adulthood and not slip through the system. FOR CONTINUITYFor continuity of care and for records to be complete and informative particularly for the patient. The continuity of care may help to identify a pattern to understanding of skin conditions. For me collaboration of the services reduces costs and increases the skills and effort made.Good idea.I don't have any experience of this but I feel that if a child has a chronic condition and attending hospital regularly they should be somewhere that caters for children's needs.I DONT KNOWI don't know enough details.I don't think children should see adults with skin problems. This could affect kids growing up thinking they might have skin problems til they reach adulthood.I FEEL CHILDREN SHOULD ALWAYS BE DEALTH WITH IN A CHILDRENS HOSPITAL WHENEVER POSSIBLEI FEEL THAT CHILDREN HAVE DEFFERENT NEEDS THAN ADULTS AND ARE BEST SERVED BY THOSE SPECIALISED IN CHILDCAREI feel that each doctor is different in their approach to patients and some are more sympathetic to the care of a child. I think joining up the services will have limitations.I FEEL THAT THE CHILDREN ARE MOSTLY SEEN BY THE SAME DOCTORSI have concerns about joining up and losing the service at Aintree which has an excellent clinic and worrying thoughts about moving the clinic due to travel expense, etc. How will OAPs cope?I have no experience of Childrens skin care services.I think dedicated children's services are tailored far better and are less intimidating for children. Also children can be annoying for older people.I think if you attend a hospital and your treatment is fine, why move to different one.I think this would give consistency in treatment provided, would reduce patients becoming lost in the system and save time on transition from child to adult services.IF IT MAKES THINGS EASIERIT IS DIFFERENT FOR CHILDREN TO CHANGE CONSULTANTS AS THEY HAVE BUILT UP TRUST IN THE ONE THEY ALREADY HAVEIt is difficult for adolescents to negotiate healthcare and whilst paediatric specialists build up good rapour with children and specialise in childhood diseases, it is often difficult to establish at what age a patient should be considered an adultKEEP SEEING THE SAME DOCTORLESS DISTRUCTIONMAKES IT EASIER FOR A CHILD TO TRANSITIONMakes more sense to have consistent medical records.Makes sense to have them all together.Makes the process quicker and less stressful.Many children with skin conditions will progress into adulthood with the same conditions, using community based services means they will have far more seamless care.Telemedicine would save time, and therefor money,for everyone, the GP, the dermatologist, but especially the patient who would not need to travel to a hospital for diagnosis, unless considered necessary at the next stage.More clinics to go to.More convenient.MY SON IS 15 YEARS OLD AND I FEEL HE NEEDS CONSISTANT CARE MANAGEMENTNo they move between services in every other speciality. That's like saying the doctor they are used to will never leave or retire and move on.No, think it should be left separate.Not applicable to me.Not sure of the implications--do these conditions or the possible treatments change with age? do staff need different expertise and training when dealing with children than adults? are there travel consequences if services are joined together?Obvious money saverOne Specialist who knows practically your life history is going to ask you on the feelings of possible draw backs on a medicine before prescribing itPROBABLY JUST FOR AN EASIER TRASITION FOR YOUNGER PEOPLE WITH SKIN CONDITIONS AS PEOPLE GET USED TO THEIR CLINICIANS SO IF THEY COULD SEE THE SAME PEOPLE, LESS ANXIETY WOULD BE INVOLVEDPROS AND CONS OF EACH.. FULL ANALYSIS HAS TO BE TAKEN BEFORE YOU CAN CONCLUDE DECISIONSEPERATING THEM ALLOWS THE CHILDREN TO FEEL MORE COMFORTABLE AMONGS THEIR PEERS WHEN THEY ARE YOUNGER; WHICH IS WHAT I WENT THROUGHServices should be provided equally but I am happy with service I have been given.SKIN IS SKIN, IT SHOULDNT BE DISCRIMINATED BY AGESkin services should be aimed towards age ranges as they are now.So continuity is kept, especially for special needs patients who need reassurance with the same doctor. Helps to keep things normal.So I can bring my child with me on the same appointment.SOMETIMES THERE ARE ADMINISTRATION DIFFICULTIRES WITH CHANGE OVERstreamline services, seamless care.THAT WAY THEY WOULD GET TO KEEP THE SAME DOCTOR AND NOT BE PASSED AROUNDThe environment that youngsters attend in their clinics are best made for them some adult conditions may frighten let alone scare our young people. Transitions are apart of life. When their the right age to cope they will make that transition. My grand daughter wishes she was still able to attend Alder Hey. So they have got to be doing things right.The same as the answer to question 8.Think easier if service joined. TO AVOID GAPS IN TREATMENT AND HELP CHILDREN MAKE SMOOTHER TRANSITIONSTo be able to stay with same consultant.TO ENSURE CONTINUITY IN IDENTIFYING AND TREATMENTWe have a specialist children's NHS Foundation Trust which provides hospital and community services. By definition it provides services to children not adults. Does the CCG want to abolish Alder Hey to have a children's and adults skin service?! Interestingly Whiston and Alder Hey, being skin specialists, understand that children's and adult dermatology is different so professionals specialise in one more than the other and work for the appropriate NHS trust. Children's and adult skin services can work together already by referring younger patients to the adult service.If you were able to receive information which helped you to better treat your's or your child’s skin condition yourself, would that appeal to you?What type of information would you find most helpful?Any kindAnything that makes my child better. Clear information on diet, different creams. Counselling available. Blogs/websites useful. Leaflets. Support groups.Diagnosis of condition, check if allergic to anything. Diet adviceDiet ideas, things to do in house (Cleaning, type of house etc), environmental factors that create problems, how to see a specialist. Diet, bathing cream, cleaning equipment, humidifiers - yes or noDiet, creams, as we're to seek further help from hospitalDifferences in creams, how they can work. Changes to diet. Different methods to treat, prevent and manage at home. How to cure baldness for free.How to maintain healthy skin and hair at home.InternetLeaflet on diet, different cream, what type of tests you can go for, a support group may offer weekly informal advice. Leaflets translated into own language. More information how to manage condition at home. More treatment options how to manage at home. On different cream. On how to treat at home, diet etc. On treatment, differences in cream. Regular appointments at a skin clinicTreat and manage condition at home, with diet, bathing, washing creams and heating. Treat child at home, examples of food to avoid and examples of cream to use. Treatment available. Types of treatment, new trials in treatment, info on going to a different hospital. Website on tests, new research, new creams etcWhere to get the best creams, etc.AdviceAdvise 1 to 1 not just a leaflet.AFTER CAREAll the leaflets i received were very helpful and reassuring. i felt informed and knew what to expectAny informationANY INFORMATION IS GOODAny information would, I'm sure, be helpful.Any.ANYTHING THAT HELPSAnything.Are the doctors being totally honest or as in my case I don't think it was or is Eczema The suffering that I am going through is having taken medicine unnecessary medicine for so long. Considrering I was healthy and the only reason I went to a Doctor was through getting a letter in the post recommending I go for a check up and the result was for suddenly having and being a sickly person with Eczema and of all the Doctors I have seen not one carried out their own tests everyone just went by the previousAs patient house bound don't think any better than district nurse. As stated l have no experience of attending a skin clinic. Better leaflets, especially with photographs of skin cancers, the words when describing skin cancer could relate to any minor skin changes, a variety of pictures for each type would be beneficial.Leaflets relating to care of conditions such as psoriasis would be of use.BookBy GP.CLEAR GUIDANCE NEW INFORMATION REGARDING NEW TREATMENTCommunication skills I'm receiving now which is very good. Great doctors and nurses.Diagnosis.Dietary information, some sort of advice clinic.DIETRYDONT KNOWEARLY DIAGNOSISEASILY ACCESSABLY. POSSIBLY MORE INTERNET MATERIALEasily accessible internet information.EASY TO UNDERSTAND COMMUNICATION RATHER THAN LETTERS DESCRIBING CONDITION AND STATSEMAILLEAFLETTRAININGEmailsExact name, nature of the conditionExplanation of condition. Treatment plan.Face to face with clinician preferred.FEEDBACK AND POSITIVE INFORMATION ON SUCCESSFUL CASES AND TREATMENTSGeneral info on the condition with treatment options.GENERAL INFORMATION ABOUT PREVENTION OF SKIN CANCERHow to avoid the condition reoccuring HOW TO MANAGE THE CONDITION - PREVENTATIVE MEASURESHow to spot symptoms (especially to recognise them) and how to apply medication effectively.HOW TO TREAT ITI prefer to get my information from the consultant. Then it is relevant to my specific condition and circumstances not generic.I THINK THE INFORMATION IS ALREADY OUT THERE (IE INTERNET, GP'S, HOSPITALS) IT'S JUST GETTING THE CORRECT DIAGNOSIS SO THEY CAN FIND THE CORRECT INFORMATIONI was given all information at my consultations.I would find more information on the treatment that are available to treat my ON POSSIBLE CASESInformation around creams/shower gels/fragrances/other substances that are known to be irritant to sensitive skin, information around whether there's anything in my diet that is contributing towards it and how I can prevent it, if there are any home treatments that can ease flare-RMATION LEAFLETInformation leaflet sent with appointment RMATION ON UNDERSTANDING YOUR CONDITION ONA MORE UNDERSTANDING MANNERInternet on particular problems.Just to try any new treatments that was available.LeafletLeafletsLeaflets on how to manage the condition when it flares upLeaflets, online info.LEAFLETS, TREATMENTS, REMEDIES, FACT SHEETS AND INFORMATIONLeaflets. Learning how to control.LIST OF ALL AVAILABLE TREATMENT OPTIONS / GREATER FLEXIBILITY IN TIMES OF APPOINTMENTS Managing I and treating it if possible.MORE EXAMPLESMore info on specific parts of body creams to be used.More information on condition rather than searching internet and getting conflicting messages.More leaflets/posters.NEW TREATMENT OPTIONSNo idea as yet.Not applicable although a counter solution to the harmful affects of toxic herbacides, pesticides and other chemicals would be useful. Not sure.Nursing/Medical practical demonstration and adviceOne on one sessions to teach me how to dress or treat my condition then maybe be able to go and try on my own but be able to contact the clinic if my complaint flares up. And get easy access to the clinic instead of waiting for your GP to try other creams or tablets etc to then be referred as they are not the ones in pain or suffering while they play around with your skinONLINE, EMAIL INFOPerhaps on line videos and patient information Pictures of treatment.Plain English Leaflets with diagramsPRODUCTS TO BUYRecommendations for reliable website info.Reminder letter regarding appointment.Self-care and medicines management - doctors, nurses and pharmacists helping people in person to apply creams correctly and tablets properly, and by giving them information leaflets (to read at home) about their condition and how to care for themselves at home.SIMPLE LEAFLETSSupport and understanding.SUPPORT GROUPS FUND RAISINGTalking to a professional.Telling me what the condition is.The information I received and was given at consultation was sufficient.THE REASON I HAVE MY SKIN CONDITION, AND OBVIOUSLY THE CUREThe type I am receiving right now, up close and personal by highly trained staff who specialise in my condition.Treatment that wouldn't require visiting GP.Treatment.WAYS TO KEEP SKIN UNDER CONTROL IN DIFFERENT WEATHER CONDITIONWEBSITE AND LEAFLETWEBSITES OR LEAFLETSwhat can I do to prevent the skin issues or at least manage it using both allopathic and complementary treatments What information to send.What my condition is, how to treat it, what make up products to use in the mean time.what the treatment should do and information on how long you think it would take to show an effectWhatever is appropriate.WHETHER OR NOT TO REPEAT OR EXTEND TREATMENT IF I DID NOT IMPROVE?Written information already supplied but maybe something recorded to watch in the waiting room.Written plan.How would you like to receive information about managing your/your child’s skin condition?Other (please specify)In a clear written report from consultant, with evidence of all tests that have been carried out and what other tests are available. Translated information. Everything is English nobody explain anything in own language, meaning we have to tell other people our problem. A LETTER AFTER THE CONSULTATION I would be interested in recieving information regarding the update of improved services in LiverpoolQUICKER AND LESS EASY TO AVOIDIt is possible for us to use technology to assist with diagnosing and managing skin conditions. For example, your GP could take a photo of your skin condition and send it to a consultant for their opinion. Do you think we should be offering this type of service?Please tell us why you have chosen this answer.Anything that can find an answer to my child's problem. Anything that helps you see a GP and consultant more quickly. As long as kept private, it may help find answer to the problem. Because it may bring different approach to care.Better treatment than GP advice. Don't like pictures.Don't like the thought of it.Good idea and far quicker than GP Choose & Book referral, just as long as system does not crash, etc.Good idea to get treatment more quickly. Good idea to help you see a specialist instead of waiting a long time for an appointment. Good idea to make things run fast. Good idea. Great choice of doctors would be available to diagnose Son's condition. I think it should be offered but not forced.I think it would be a good idea as long as private. I want a solution to my Daughter's condition. If in doubt about skin disorder.If it makes things go quickerIf it makes things quickerIf it offers more treatment optionsIf we get to the problemit may be a good idea to use Skype at home and are not frightened of new technology. It may enable a special consultant from London to treat my child on new research. Good idea. It may enable you to see different consultants across the country that give different opinions. It may help treat the problem more quickly. It may help with treatment. It might make process quickerMake things go faster. Make things quicker. Maybe help cut waiting timeMight be able to see different GPs or consultant with better idea for treatment. Might be better than GP advise. Might enable Son to see consultant faster. Might make process work faster and enable you to see a consultant faster. Might work. No problem if it can helpThis would help with faster diagnosis - plan for treatment.A 2dimensional picture may be helpful to triage an appointment with a specialist but I would be worried that this might be misused as an alternative to expert opinion. The consultant would need to review an image and have a face to face consultation. Surely timely referral is ideal. There are weaknesses in quality of image and scaling lesions on a photo. I would also like the opportunity to discuss my problem with an expert rather than via a GP. I have personal experience of a GP thinking that my melanoma was not one and delaying onward referral as he thought he could manage it himself. It was only my persistence in insisting on referral that resulted in an appropriate diagnosis.A photo is never the same as face to face.A photo might not always give a true indication.A PHOTOGRAPH WILL NOT TELL THE TRUE CONDITION OF THE AILMENTAgain - quicker diagnosis - the longer the diagnosis the worse the condition gets, the more stress and upset caused to the patient.ALLOWS FOR A MORE PRECISE DIAGNOSISANY AND ALL PROFESSIONAL OPTIONS OUGHT TO BE CONSIDERED AS EARLY AS POSSIBLE. IT WAS 2 AND A HALF YEARS BEFORE I FINALLY SAW A SPACIALIST THROUGH THE GPAny help for a GP is a good thing.ANYTHING THAT MAKES IT EASIER FOR THE CONSULTANTANYTHING THAT OFFERS FASTER DIAGNOSIS IS BETTERANYTHING TO HELP DISGNOSISAs different opinions one may have more knowledge, e.g. seen it before.As I said previously this seems an excellent method which would save everyone time, and money.As photographs can not show a true picture of the condition and wrong diagnosis may be givenAS THE SKIN CONDITION IS OFTEN IN REMISSION WHEN ATTENDING CLINICBecause I got refused my first appointment I don't think they fully understood how bad it was affecting me.BECAUSE IT MUST BE FAR BETTER TO SEE THE PROBLEM YOU'RE TRYING TO SOLVE, OPPOSED TO PEOPLE TRYING TO DESCRIBE IN Because l don't have enough knowledge of skin condition Because my skin which was not a mole, it was a pink circle, it didn't match the criteria but it would have turned into a melanoma.BECAUSE THERE IS NO RASH TO SEEBecause you can see what's wrong.Because you should have personal consultation and be able to personally discuss your condition and treatment that suits to you.BEING TOLD ABOUT A CONDITION IS OK BUT PHOTOS GIVE AN EXACT IDEA OF HOW BAD A CONDITION ISBETTER FOR ALLBETTER UESION BETWEEN GP AND CONSULTANTBut alongside other methods.Conditions need to be seen.Could be helpful not having to wait and attend outpatient appointment at hospital.Could possible save time and expense.Could save timeCould save time on other appointments by sending over picture, more patients could be seen.DEPENDS HOW QUICK IT WOUOLD WORKDONT SEE WHY NOTDONT THINK IT WOULD BE AFFECTIVE FROM LOOKING AT PIC, BUT NOT SUREdue to the fact that by seeing the person you can observe a clearer indication of the persons health and I feel that people can often really benefit from being seen by a real person EARLIER/QUICKER DIAGNOSISEASIER DIAGNOSISEASY FOR EVERYBODY. THE CAMERA DOES NOT LIFEefficiency and improving access to specialistsEmail - phone apps. Texts are quick and easy to access.Faster diagnosis but still having 1 to 1.For faster diagnosis.For myself it takes away the personal touch of the consultant seeing for themselves my problem as I don't see that a photo will help me in my stress of not knowing whether it will be seen or to be treated, it's bad enough having the condition without photographing it!Give advanced so treatment may be given via distance?GIVES REAL FACTUAL INFORMATION WHICH CAN BE REFERRED BACK TO DURING STAGES OF TREATMENT Good idea.GP are generally clueless about skin conditions and are far too quick to refer patient to hospitals saying 'they're the specialists'.GPs are already under pressure and I am not sure that this would work in a timely manner.I BELIEVE IT WOULD BE OF GREAT HELP TO DETERMINE HOW URGENT YOUR CONDITION IS BY A PHOTO BEING SENT AT THE TIME OF DOCS APPOINTMENTI don't think a phone could replace a 1:1 consultation. Concerns that some conditions could be missed.I don't think photographs can provide the level of detail required to do this. Is there any good quality evidence that it can?I feel seeing a consultant by referral would be better than sending pictures.I feel the consultant should see first hand.I HAVE TICKED YES AS NOT ALL GP'S ARE AWARE OF ALL SKIN CONDITIONS - MINE WAS GETTING TREATED WITH ALL DIFFERENT CREAMS UNTIL A LOCUM KNEW WHAT IT WAS AND REFFERED ME TO BROADGREENI LIKE TO TALK TO MY CONSULTANT FACE TO FACEI think it should be a biopsyI think it will speed up the process of diagnosing certain conditions helping to treat problems quicker.I THINK IT WILL SPEED UP THE WAITING TIME IN THE CONSULTANTS CAN SEE THE SEVERITY OF THE CONDITIONI think that would be really helpful and would free up gp appointments I think there is a risk that some conditions could be misdiagnosed.I think this would not only facilitate a more joined-up approach to skin services, but also it would mean that in many cases, patients may receive the right treatment faster. Obviously, you can't get all the information you need from a photo, but this is certainly a step in the right direction. I think yes because it would be better to get an expert's opinion in case you have to be referred.I TOOK A PICTURE OF MY LESION ON MY PERONSAL PHONE AND BOUGHT IT TO MY FIRST APPOINTMENT. IT WAS VERY USELFUL FOR THE CONSULTANT AS IT HAD CHANGED IN COLOUR ETC BY APPOINTMENTIdea of condition before seeing consultant.IF IMPERMENTED PROPERLY, IT CAN BE MANAGED EFFECTIVELY, I THINK IT SHOULD SURELY BE A MORE COST EFFECTIVE SYSTEM, THEREFORE LESS MONEY BEING SPENT ON THE NHS SERVICEIf it could help with black log issues and help the process move quicker then it would help all parties concerned . But I do believe you have to be careful that this system is not abused by GP's and the clinic doctors as some people need that one on one contact.If it helps with diagnosis.IF IT IS POSSIBLE TO SAVE TIME, IN CLINICS, TRAVELLING ETC.. HOWEVER THERE IS THE CHANCE THAT CONDITIONS CAN BE MISDIAGNOSED FROM JUST A PICTURE If uncertain, this can be revisited to ensure right diagnosis.INCREASED POOL OF KNOWLEDGEIS IT WOULD BE A QUICKER PROCESS IN DIAGNOSING THE CONDITION RATHER THAN HAVING TO WAIT A MINIMUM OF 3 MONTHS FOR A DERMAQTOLOGY APPOINTMENTIT ALLOWS YOU CHANCE TO MANAGE YOUR CONDITION WHILST WAITING TO SEE YOUR CONSULTANT IT COULD HELP REDUCE THE POSSIBLITY OF PATIENTS REQUIRING HOSPITAL CARE INSTEAD OF COMMUNITY CAREIT COULD HELP TO REDUCE ANXIETY IN WAITING FOR REFERRAL APPOINTMENT It could start the diagnosis earlier and prevent long term, drawn out symptoms.It gives clinician time to prepare before visit.It is not clear that a photo is sufficient. Personal contact conveys more info.It makes sense/is quicker.IT MAY AVOID UNNECESSARY APPOINTMENTSIF CONDITION COULD BE DIAGNOSED WITHOUT SEEING A CONSULTANTIT MAY GIVE A MORE SPECIFIC DIAGNOSISIt may help.It may save time.IT WOULD BE AN ADVANTAGE FOR A SPECIALIST CONSULTANT TO OFFER HELP AND ADVICE THOUGH LOOKING AT PHOTOGRAPHS OF CONDITIONIT WOULD BE QUICKERIt would be quicker.IT WOULD DEPENDS ON HOW GOOD THE TECHNOLOGY WOULD BE AND WHO WOULD REVIEW IT AND IT MUST NOT GET LOST!It would restrict waiting time and appointments.It would save a lot of time.It's convenient and makes waiting times quicker perhaps.Make it quicker.MAY ALLOW BENIGN SKIN ISSUES TO BE RULED OUT EARLY, PREVENTING STRESS TO PATIENTMay speed up diagnosis.Maybe sometimes this would suffice but in other instances would it miss out important aspects of service?MIGHT MAKE DIAGNOSIS MORE QUICKERMORE ACCURATE DIAGNOSIS WITH SLIGHTLY LONGER LEAD TIMEMORE EFFICIENT AND SAVES ME HAVING TO TRAVELMORE HELPFUL, SAVE TIMEMORE INSIGHT INTO THE PROBLEMS CAN BE BENIFICIAL TO PAITIENTS AND DOCTORSMore opinionsMost GP's do not have much knowledge or awareness of this condition so we will take any help we can.MY DOCTOR HAD NO IDEA THAT I HAD SKIN CANCER AND THAT THE MOLE I HAD REMOVED WAS CANCER HE THOUGHT IT WAS FINE ONLY THAT I ASKED FOR A SECOND OPINIONMy GP had no idea what my problem and treatment should be. I went back a second time and was given treatment (at a cost) that I don't believe provided a solution, guessing!My problem been ongoing over 2 years just getting told nothing can be done.Not happy with GP.ON THE SURFACE THIS SEEMS SENSIBLE TO ENSURE PATIENTS ARE BEING GIVERN THE CORRECT INITIAL DIAGNOSIS ASAP, BUT WHEN IT COMES TO ACTUAL TREATMENT AND MANAGEMENT OF THE CONDITION A FACE TO FACE OPINION SHOULD ALWAYS BE AVAILABLE FOR EVERY PATIENTOne consultant is enough, too much messing about.Photos can be very useful. As my mother's leg was bandaged I used photos of the wound when the nurses were tending the leg, to show the NHS homeopath so that he could see what he was treating when my mother attended the clinic. PHOTOS DO NOT ALWAYS GIVE A TRUE PICTUREPossibly could enable a faster diagnosis which would/could relieve anxiety etc. and make for speedy treatment.PREFER TO SEE A SPECIALIST RATHER THAN GENERALISTQUICKER DIAGNOSISQuicker service.Quicker.REDUCE WAITING TIMESSAVE TIME AND TRAVEL TO CONSULTANTSSave time at first clinic - to be forewarned is to be...SAVES ON APPOINTMENT WAITING TIMESaves time and having to visit several professionals if the GP needs a second opinion.See and speak with your Doctor in the morning and your consultant in the afternoon where any mis interpretations or assumptions can be rectified before any serious time is wasted Seeing a photo of my skin condition is nowhere near the reality of it, no I would not be interested in this service.SEEMS TO BE MORE TIME SAVING FOR HOSPITAL STAFFSKIN CONDITIONS ALL DIFFERENT. MY GP DIAGNOSED ME WITH SEVERAL DIFFERENT ONES BEFORE I DEMANDED A REFERAL. MR PARSHAW IDENTIFIED IT STRAIGH AWAYSo doctors can see condition at each stage, as changes can happen quite quickly.So more people can be helped.SO TOHER GOPS COULD SEE HOW SEVERE YOUR PROBLEM IS AND TAKE ACTIONSo you can receive better treatment.Sometimes a photo is not the full picture.SOMETIMES CONDITIOHN CAN DETERIORATE SOUNDS POSSIBLENOT SURE - COUNTING COSTSSPEED OF DIAGNOSIS WOULD INCREASESPEED UP THE PROCESSSPEED WAITING TIME UPTaking photos of skin conditions or any other medical condition may be helpful but it should not be relied upon to make a diagnosis and to determine treatment. Not everyone may want a photograph of a medical condition in circulation particularly in the ether of the internet.The CCG thus understands that GPs aren't specialists and need expertise of NHS hospital trust doctors and consultants, etc.The skin changes and some days better than others - some worse.There is no substitute for specialist opinion - that's why GP's are GP's and specialists are specialists There was a problem with my care in that i saw a gP for removal of skin lesion before a dermatologist to diagnose, resulting in my having a wide excision performed before the malignant melanoma had ever been disgnosed.Think it is a good idea.This detracts from other important aspects of making a clinical diagnosis, such as taking a detailed history which might highlight important background issues or factors.This is most definitely the future. We need to be embracing technology in an attempt to reduce waiting times, manage conditions and get prompt attention when required. Not all conditions require a consultation and if photos and emails can be used to improve patient service this should be. The world is changing, we need to embrace technology and move forward.This process would speed up the diagnostic process but an examination by a professional would confirm any doubts.This survey should be aimed at schools and other organisation that adults and young people attend who experience skin problemsThis would fast track treatment. As a patient I have created a photo journal tracking my skin condition on a daily basis.This would have been very useful.This would lead to diagnosis.Time & money saving - should be in use already.TO ALLOW HOSPITALS TO DEAL WITH MORE SERIOUS SKIN CONDITIONSTO SAVE TIME TRAVELLING TO AND FROM HOSPITAL AND USING A FULL DAY OFF WORK JUST FOR A FOLLOW UP APPOINTMENTTO SEE HOW TREATMENT IS WORKING To speed up diagnosis so as to begin treatment application, if necessary, more quickly. Especially for more serious conditions.WHEN I WAS 14 I HAD A PICTURE TAKEN AND SENT AWAY. THERE WAS A MIX UP AT THE TIME, BUT IT COULD AHVE SAVED ME WAITING OVER TWO YEARS TO RECEIVE A DIAGNOSISWHY NOT. IT SEEMS MORE EFFICIENTWhy not? Sooner diagnosed the better.WITH GUIDELINES IN PLACEWOULD HELP OTHER PATIENTS AND PROFESSIONALSWould make people with anxiety suffer less.WOULD SAVE LOTS OF EVERYBODYS TIMEWould save timeYes if it removes or lessens the need to attend hospital and takle time off work but such condition sare not purely physical. Will the GP's have the understanding of how the conditions can metally affect patients and how best to manage this? Yes this would hopefully help to prioritise appointments.Is there anything else that is important to you or your child when attending a clinic for a health appointment?Being seen on time of appointment. Staff seeing patients and not talking. Staff not inviting patients to be seen when no appointment (Alder Hey) pushing others back.Children only clinics. Choice of appointments near home. Clean environment and good quality care. Do not say you will grow out of it. Explain the treatment and conditionInformation about all services available to patients across the country on a rmation explained. Information on different treatment. Interpreter if needed. Knowing what to expect. Having a background on the child's condition before they attend the first clinic.Reminders if long time til appointment.See someone that can test for treatment, find answer and treat my child in long term. Times around school hours or after school, instead of rushing out to collect other children. TranslationTranslation and appointment after school hours, since I have children to pick up and could not leave them in school. Translation into own language, use of interpreter in GP consultation. Translation of informationTranslation. Waiting time.As part of the proposed improvements to dermatology services we are proposing that patients can attend clinics closer to their home. This would mean some patients (particularly children) who are usually seen in hospital, could be seen in these clinics by fully qualified staff and receive the same care they get at hospital. Do you think this is a good idea?Please tell us why you have answered ‘No’ to this question.(Not sure) Specific equipment is not going to be available at all the local services.I don't think you would get the same treatment you get at hospital.I think the care would suffer.I think you feel more secure in a hospital environmentIs there sufficient capital to fully equip these clinics?It would necessarily require dilution of expertise and only add to beaurocracy and increasing room for errorWhy change things that's working now.Will travel as GP is in a different area to where PT lives. Happy to travel.Do you have any suggestions as to how we could further improve skin services?Anything that makes things quick.Different children's hospitalFaster the betterHave more clinics and consultants to see children's conditions. Have more patients on the clinic. Start clinics before 9am and drop cancelling clinics (Alder Hey) for staff sickness, etc.Help parents get more advice from people that know about skin conditions. I would have liked to see hospital consultant quicker for first appointment waited 7 months.Make things more quicker as condition effects child's wellbeing.Make things move quickly. More clinicsMore consultants available to seeMore staff, better pay and less waiting time.More understanding of condition by GPMove clinicNeed quicker waiting timesNeeded as soon as possible. Quicker service is needed. Special clinics for mild eczemaSpecial monthly skin clinics. Drop In with nurses that can book you appointment at Hospital. GP knew very little about skin. Take them seriously not as a mild conditionYes, why not run clinics at pharmacies, that could refer to an clinic at the hospital. This is because often go to pharmacy for better advice than GP. A list of all the medicine you have ever been prescribed should stick out and every medical person should read it before seeing the patient APPOINTMENTS RUN ON TIMEAT MY AGE THE NEARER THE BETTER AS I REQUIRE HELP WITH TRANSPORTAvailability of appointments/a drop-in serviceBEING SEEN PROMPTLY AND ON TIMEBeing told the waiting time.CANT THINK OF ANYTHING ELSECHANGE TO CAR PARK COSTSConsistency in staff.CONTINUITY OF CARE - I.E. SEEING THE SAME CLINICIANS FOR FOLLOW-UPS NOT A NEW PERSON EVERY TIMECorrect appointment time adhered to.Disabled parking and access.DOCTOR AND NURSE AVAILABILITYERGONOMICS OF BUILDING AND PLEASANTNESS OF STAFFExpertise of the staff.FEEL SUPPORTED BEING KEPT INFORMED OF WAITING TIMES ETC.I have attended hospitals for over 30 years and found my care to be very good, I don't think a clinic would do the same thing.I think it a bit upsetting to both patients and parents alike if when you have arrived for an appointment and the doctor arrives late so the clinics all fall behind, some of those patients have traveled miles some with not lots of money to spear and if things run too late the children get hungry and that the parents are asking for drinks and something to eat we need to try and keep to appointments and doc's need to respect rmation on your condition.Keeping to timed appointments.Knowledge and skills of the staff most important after distance of the clinic from my home. A few of the numbers above are wrong as fault with survey.Most important is the waiting times that maybe long in case I have to be somewhere else.Most of the questions are not applicable although I had a skin condition as a child. I am completing this form as part of the Healthy Liverpool project.N/ANoNo.On time - no waiting.On time clinic.Privacy.REASSURABLE WAITING TIME BEFORE THE CONSULTATION AND TREATMENTREASSURANCESeeing a highly trained professional with years of experience and post graduate qualifications in dermatology: i.e. a dermatologist on the specialist register.Specialist NHS staff from various trusts should be doing these services not for-profit private companies nor professionals who provide general health services but aren't specialists. Understand that Aintree is a major hospital and community health organisation providing good services. Understand that town isn't everything.Staff - friendly, helpful, supportive.Staff :)tea/coffee/water in case of delayTHAT I AM SEEN AS CLOSE TO MY APPOINTMENT TIME THAT IS POSSIBLETHAT IM MADE TO FEEL I HAVE A SAY AND IT GETS HEARD, AND TOOK INTO CONSIDERATION, AS I KNOW MORE ABOUT IF/OR WHAT TREATMENT WORKS/WORKEDTHAT YOU SEE FAMILIAR FACES OF DOCTORSThe speed and availability of appointments. My appointment today has taken 4 months which I think is very poor.To see a health professional ASAP.Trying to keep as near to appointment times as possible.Very happy.warm comfortable and friendly environmentWould help to see familiar faces.Yes - To be treated promptly. Appendix Two: Skin Survey – Postcodes of respondentsPostcodeRespondentsL19L34L412L57L68L712L844L99L108L11 8L1214L1310L144L1545L1611L1732L1815L194L214L222L23 5L247L2512L264L272L282L306L315L325L351L368L471CH21CW81SY131WA51WA71WN51Total326Appendix Three: Social Value of the Engagement ProcessVCSEVolunteersEmployeesOutcomesValley Community Theatre35It brought inter-generational discussions, which added value and richness to the debate; breaking down perceived barriers.It allowed our ‘hard to reach’ young people to watch a quality piece of theatre that featured their teachers as two of the actors. It allowed one of our most challenging young people an opportunity to shine and receive positive feedback from staff, as he took the role of ‘running’ the microphone round the audience members when they spoke in the debate, and even got up on stage and acted at one point – something which he has always struggled with previously.As one of the actors appeared in a recent TV advert, we asked him if he could talk to our young people (as they all recognised him!) about becoming an actor. His talk was truly inspirational for our young people and we all valued his positive words and role-modelling.The event was a fantastic, creative and innovative training session for 2 of our Children In Need staff to use into their sessions and take forward.A member of staff and an actor in the show fed back to us that he really enjoyed the whole experience, as he felt it was good for his personal development to feel what its like to be in the young peoples shoes again as actors on stage taking direction. The engagement enabled community cohesion amongst several groups of ‘hard to reach’ people.It increased social contact.The dietary information increased participants’ self care awarenessWomen Reach Women3This was a real learning experience for the volunteers, the range of skin services in Liverpool explored during our in house training was proved valuable, also the different skin conditions was an eye opener for the volunteers, and also getting an insight into people’s life and how they are dealing with the different skin conditions was useful. The involvement in this engagement and the experience gained from previous LCCG engagements has been valuable for our volunteers, one volunteer who has been unemployed since leaving school (due to early year marriage and raising a family) has received a job as a lunch time supervisor at a local nursery. Another volunteer (who has no formal qualifications in this country) has secured a voluntary position with a local school to help out as a crèche worker.Participant involvement – as a result of this involvement, some participants commented on how they are now more aware of the whole system approach in Dermatology service and the diversity of the different services available, especially for parents of young children who are mostly familiar with Alder Hey hospital and their GP’s. It was made very clear from the outset that our volunteers/ sessional worker are not experts in this field/ nor qualified to give any advice and any medical advice will need to be sought from a qualified professional, however some participants from the South Asian community (especially those not familiar with the how the system works and where English was not their first language) did ask for advice and guidance.Chinese Wellbeing7Administrative and organisational skills employed and improvement in confidence. In addition to having the responsibility of informing community members of the proposed changes, they were able to learn themselves about the proposed model which will also affect them and their families as several staff live within the LCCG catchment area. From the demographic information provided, 18 respondents were aged 76+. From this group, 16 disclosed that they are living with long term chronic health conditions including diabetes. Social isolation is an issue for many in this group. The engagement provided quality time for social contact on a subject which has some relevance for them and that they can talk about with other members of the community or their family members. Also asking for their views is always well received as it can make the elderly feel valued community members. Elevate Potential42Confidence building, learning new skills, greater understanding of NHS services. Emmanuel Westly Foundation2It helped us develop a proper families support agency up, since we were engaging with a lot of families, that wanted to be involved in other projects. It became clear that families needed to listened to and their voice was not often heard by anyone.Kaalmo Youth Development4Staff involved in the engagement report a greater sense of team working and heightened awareness of the issues and how we as an organisation now need to respond.Volunteers report that they are gaining in confident out in the community talking to people, have more knowledge of the services available and are better-placed to signpost those needing help.Participant involvement continues to be one of our biggest learning outcomes. When the information is presented appropriately and the message delivered with the right level of force/directness, the impact is incredible and the quality of information shared higher. ................
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