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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Psoriasis

Warning

Psoriasis: A common, chronic, inflammatory skin disorder that is characterized by scaly plaques affecting scalp, elbows, knees and sacrum but in more severe forms can affect any part of the body. Incidence up to 2% of the UK population. Nail changes including pitting, onycholysis and sub-ungual hyperkeratosis may be seen in 50% and an inflammatory polyarthritis in up to 14%. Palmoplantar pustulosis (PPP) is characterized by crops of sterile pustules on the palms and soles that erupt repeatedly over months or years and is strongly associated with smoking. Guttate psoriasis consists of a widespread eruption of many small scaly plaques and often follows a streptococcal throat infection. Generalised pustular psoriasis with background erythema studded with small pustules is a rare but severe form of psoriasis that may be life threatening. Psoriasis is a systemic disorder associated with an increased risk of cardiovascular disease; always assess cardiovascular risk factors. 

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Mild: localised plaques with limited impact on quality of life usually managed with topical treatment 

Assess lifestyle factors that may precipitate or aggravate psoriasis i.e. smoking, alcohol, obesity, certain medications and infections. 

 

Emollients – prescribe to soften scale (use fingertip measurement) 

 

Vitamin D with Steroid combined: 

  • Ointment, Cream, Gel, Foam: Apply OD for 4 weeks, review and repeat as necessary 

Calcipotriol with Betamethasone preparations:  

Non-branded ointment  

Dovobet®, Dalonev®, Dalbecal® ointments Dovobet® gel  

Wynzora® cream 

Enstilar® foam  

Useful for plaques on body and limbs. Not suitable for face or flexures. 

 

Vitamin D preparations: 

 

  • Calcipotriol (non-branded) ointment and l scalp solution apply OD/BD 

Calcipotriol (Dovonex®)  ointment apply OD/BD 

Calcitriol (Silkis®)  ointment apply BD 

Tacalcitol (Curatoderm®) ointment or  lotion apply BD. 

NB: Calcitriol and Tacalcitol may be less irritating than Calcipotriol and may be more suitable for sensitive areas like face and genitals. 

 

Topical Corticoteroids: 

  • Mild: OD facial psoriasis 

Moderately potent: OD face and flexural areas 

Potent:  OD trunk/limbs, BD palms/soles 

 

Coal Tar Preparations: 

  • Cream-Psoriderm® apply OD/BD 
  • Lotion-Exorex® apply OD/BD 
  • Shampoos: - Neutrogena T-Gel®, , Psoriderm® 

Polytar®, Capasal® (with salicylic acid), use up to OD 

 

Coal Tar + Salicylic acid and Sulfur:  

  • For scalp psoriasis mainly  

Cocois® ointment 100G apply up to OD 

Sebco® ointment 100G apply up to OD

Moderate psoriasis: Localised site or more widespread psoriasis > 10% body area 

Scalp psoriasis:  

  • Prescribe a regimen of coconut, tar and salicylic ointment (Sebco/Cocois) applied OD for an hour or overnight and wash off with tar-based shampoo to soften and remove thick scale. Reduce frequency as improves. 
  • Apply potent or very potent topical corticosteroid scalp solution / gel / foam (e.g. betamethasone +/- salicylic acid, clobetasol) OD after shampooing or, Vitamin D preparation, gel / foam OD, or corticosteroid + vitamin D (e.g. Dovobet® gel). 

 

Facial/Flexural psoriasis: 

  • Steroids: mild/moderate potency topical corticosteroid OD 

Vitamin D preparations: Calcitriol / Tacalcitol OD/BD may be used as less irritant than Calcipotriol 

Calcineurin inhibitors (e.g Protopic®) may be helpful but should be initiated by specialist. 

 

Nail psoriasis:  

  • Treatment difficult, keep trimmed, potent topical corticosteroid or Calcipotriol with Betamethasone combination OD may help 

 

PalmoPlantar Pustulosis: 

  • Associated with smoking.  

Steroids, potent or very potent topical corticosteroids OD/BD 

Calcipotriol with Betamethasone combination ointment OD 

 

Guttate Psoriasis: 

  • Widespread small plaques, self-limiting, often triggered 7-10 days after streptococcal URTI.  

Will often resolve spontaneously in weeks to months, useful treatments include: 

Mildly potent topical corticosteroid OD 

Vitamin D preparations OD 

Coal tar preparations OD 

 

  • Refer to secondary care for consideration of phototherapy and/or first line systemic therapy with Methotrexate, Ciclosporin or Acitretin for moderate to severe psoriasis failing to respond to treatment. 

 

Treatment failures with phototherapy and first line systemic therapies may require novel systemic therapy with phosphodiesterase type-4 inhibitor (Apremilast) or biologic therapies. 

Severe psoriasis: Widespread inflamed psoriasis or severe localised recalcitrant psoriasis (e.g. palms and soles) or affecting high impact sites like face or groin. 

Refer same day to dermatology/ emergency care for erythrodermic or generalised pustular psoriasis 

 

Refer to rheumatology if any evidence of psoriatic arthropathy. 

Referral Management

Mild: localised plaques with limited impact on quality of life usually managed with topical treatment 

  • Manage in primary care.  

Moderate psoriasis: Localised site or more widespread psoriasis > 10% body area 

  • Refer routinely to secondary care service if failure of appropriate topical treatment after 4 weeks  

Severe psoriasis: Widespread inflamed psoriasis or severe localised recalcitrant psoriasis (e.g. palms and soles) or affecting high impact sites like face or groin.

  • Consider referring urgently if psoriasis is very widespread and inflamed 
  • Emergency referral is indicated for erythrodermic or generalised pustular psoriasis. 
  • Refer to rheumatology if any evidence of psoriatic arthropathy. 

Clinical resources

Validated tools used to evaluate psoriasis include: 

DLQI 

PASI 

Skin Diversity descriptors 

Physician’s Global assessment tool 

Cardiovascular assessment  

Psoriatic Arthritis screening tool- PEST 

NICE CKS- Psoriasis 

PCDS- Psoriasis 

DermNet NZ- Psoriasis 

Clinical tips

  • Patient preference for type of topical preparation should guide effective treatment 
  • Psoriasis is a systemic disorder associated with an increased risk of cardiovascular disease; always assess cardiovascular risk factors. 
  • Excess alcohol, smoking and obesity can make psoriasis more difficult to control. 
  • Screen for arthritis and refer to rheumatology as needed. 

ICD search category(s)

Inflammatory 

ICD11 code - EA90.0          EA90.1

Editorial Information

Last reviewed: 23/05/2023

Next review date: 23/05/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society