The landscape of psoriasis provision in the UK

Psoriasis remains one of the commonest conditions seen in dermatological practice, and its treatment is one of the greatest cost burdens for the UK National Health Service. Treatment of psoriasis is complex, with numerous overlapping lines and therapies used in combination. This complexity reflects the underlying pathophysiology of the disease as well as the heterogeneous population that it affects. National Institute for Health and Care Excellence (NICE) guidance for the treatment of psoriasis has been available since 2013, and has been the subject of three national audits conducted by the British Association of Dermatologists. This report synthesizes the results of the most recent of those exercises and places it in the context of the NICE guidance and previous audits. It clearly shows the significant burden of disease, issues with provision of services and long waiting times and the marked shift in therapies towards targeted biologic therapies.

Psoriasis continues to be one of the most common diseases seen in hospital dermatology practice in the UK. 1 The emergence of biological targeted therapies in the past decade has revolutionized treatment of the disease, but it remains a lifelong chronic condition with significant morbidity and health economic impacts. 2 In 2011, the British Association of Dermatologists (BAD)-initiated Quality Standards for Dermatology was published, 3 which defines the expected provision of skin care services in the UK. In 2013, the National Institute for Health and Care Excellence (NICE) published a clinical guideline (CG153) setting out standards and guidance for the treatment of psoriasis. 4 Immediately following this, the BAD conducted an audit of the provision of psoriasis therapy in UK and Irish hospitals. 5 The primary actions arising from that audit were to have regular re-audits in order to assess uptake of the standards over time, and to provide centralized scoring tools (http://www.bad.org.uk/ ResourceListing.aspx?sitesectionid=678&itemid=250).

Report
In 2017-2018, a further national audit was conducted across the UK and Ireland to assess the uptake of the CG153 recommendations and standards and to assess the adherence to the Quality Standards for Dermatology; 100% adherence to the standards are expected in all cases. Data were collected by email using an Excel (Microsoft Corp., Redmond, WA, USA) spreadsheet with set fields completed by respondents (Data S1). Each spreadsheet was completed for five consecutive patients covering the work of one or more clinicians. The data collection period was February to May 2017 and analysis was conducted from June to October 2017. Analysis was performed using a novel and reproducible software program written in the R statistical language (http://www.R-project.org) (Data S2-S4).
The response to the audit was similar to that in the previous cycle; there were fewer overall respondents (254 respondents from 194 units in 2017 vs. 360 respondents from 170 units in 2013) but more patient data (1270 patients in 2017 vs. 1080 patients in 2013) recorded (as a result of using 5 rather than 3 sampled cases for each respondent). The regional spread of responses was also not significantly different from that in 2013 (Fig. 1). Similar proportions of psoriasis subtypes, balances of patient clinics and availability of services for those patients were recorded (Data S4). In 2013, the lack of availability of psychological services (standard 1 of the Quality Standards for Dermatology) was apparent, and action was suggested to increase them. However,  there was no evidence of an increase in the provision of psychological services reported in each clinical unit (Fig. 2).
Phototherapy remains an important therapy for the treatment of plaque psoriasis. 6 In this audit, a significant trend in waiting times for phototherapy services was seen, with a striking rise in the waiting times for both psoralen ultraviolet (UV)A and narrow-band UVB (Fig. 2). This may represent an increasing number of patients without a concomitant increase in provision of resources to the trusts providing the phototherapy to patients. Over the past decade, there has been a rapid rise in availability of targeted biologic therapies for the treatment of moderate to severe psoriasis. 7 In keeping with this, the audit data demonstrated that there has been a change in the balance of therapy types, with more patients now being prescribed biological therapies (Fig. 3). If this trend continues, the pressure on resources may be more acutely felt in future years.
There has been significant improvement in the recording of patient well-being since the publication of CG153 but little other positive change in the practice, with longer phototherapy waiting times and ongoing lack of psychological support for patients. A constrained economic landscape, restricted availability of other resources (e.g. staff, equipment) and competing clinical priorities are likely factors in this. The marked increase in use of biologic therapies is positive for patients with severe disease but carries potential financial consequences. There is no evidence of significant change in the patient population in this study (Data S4). An important question for clinicians and policymakers must therefore be whether the NICE standards and guidelines require review, or if an alternative approach to psoriasis management needs to be envisaged to alter UK practice.

Conflict of interest
The authors declare that they have no conflicts of interest.

Learning points
• Provision of care for patients with psoriasis continues to be challenging. • Provision of psychological support remains below the standards in NICE CG153. Figure 3 Balance of therapy types used for psoriasis. Type of therapy was not recorded in 2007, but between 2013 and 2017 there was a significant (P < 0.05, Fisher exact test) decrease in use of topical therapy alone and marginal (P> 0.05) decrease in phototherapy use, with concomitant increase in the use of biologic therapies. This reflects the increase in availability of biologics and possibly the increased confidence of clinicians in their use. The 'other' category comprised seven patients: three treated with apremilast, two with topical followed by nonsystemic biologic, and one with acitretin, while the remaining one had no information available.
• Phototherapy treatment waiting times are lengthening. • A greater proportion of patients are being treated with biologic therapies.