Over the past 20 years of working as a specialist nurse, I have witnessed first-hand the changing face of care for people with Musculoskeletal conditions (MSK) – particularly Rheumatoid Arthritis – leading to better outcomes for patients.
This can, in part, be attributed to advances in treatment strategies, including biologic therapies, but is also a consequence of better access to care provided by a multi-disciplinary team (MDT) comprising consultant rheumatologists, specialist nurses, physiotherapists, occupational therapists and podiatrists as a core nucleus.
Data emerging from the second year of the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis provides further evidence of the importance of this team approach in achieving NICE Quality Standards for the management of RA and other MSK conditions.
In year one of the audit we found that higher numbers of consultants were associated with shorter waiting times to first appointment, facilitating early diagnosis and rapid access to care. Only 37% of patients were seen within three weeks of referral (NICE Quality Standard 2) and 25% of patients waited seven weeks or more for a specialist assessment.
The Royal College of Physicians recommend that one rheumatology consultant for every 86,000 people is needed to provide an adequate service, but this year’s audit found only one rheumatologist for every 116,000. Less is known about recommended workforce models for other members of the multi-disciplinary team.
This year we have undertaken additional analyses which demonstrate that higher numbers of specialist nurses are significantly associated with patients starting combination disease modifying drugs within six weeks (NICE Quality standard 3). Early access to combination treatment is crucial to improve pain, maintain function, aid work retention, and protect joints from irreversible damage in early disease.
Higher specialist nursing numbers are also associated with the prescription of short-term glucocorticoids which are used to bridge the gap whilst slow acting disease modifying drugs have chance to work, helping to control inflammation in the joints in the interim. Nurse led clinics facilitate treating to target and this data builds on existing evidence from RCTs demonstrating that specialist nurses provide high quality, cost-effective care for patients with inflammatory arthritis.
It is encouraging that we are starting to see successful business cases for additional consultant and specialist nurse staffing as a result of the year one audit findings.
Investment in additional specialist staff delivers improved outcomes for patients and has the potential to reduce the long term costs to the NHS and wider health economy. The reconfiguration of existing referral pathways, services and staffing through changes in referral pathways and organisational structure, such as the provision of early arthritis clinics, can also make improvements at no-cost.
Overall though, as in year one, there were many gaps in in access to the MDT: 72% of providers reported that their patients have access to specialist physiotherapy; 76% to specialist occupational therapy and 51% to specialist podiatry with marked regional variation. Despite the fact that 90% of people with RA experience foot problems, the provision of specialist podiatry remains markedly low indicating room for improvement.
Timely access to the specialist MDT is crucial not only in early RA but to support people living with a long term condition that is characterized by a fluctuating course. The added value of specialist nurses and allied health professionals working in rheumatology has long been recognised by our medical colleagues, primary care teams, patients and carers but we need to ensure that service managers and commissioners fully appreciate our worth to drive improvements in care. Only then can we work together to configure services that meet the needs of our patients with clear pathways and high quality cost effective care provided by appropriately trained and skilled workforce.
British Society Rheumatology is promoting a webinar as part of the MSK Network Series of webinars on 30 September 12.00-13.00: Coordinating a person-centred pathway to high quality care for people with rare autoimmune disorders
The webinar is presented by Ben Fisher from the University Hospitals Birmingham NHS Foundation Trust, who was British Society Rheumatology Best Practice Awards 2016 awards winner in the Outstanding Best Practice category
In this webinar we describe how we have set up a multidisciplinary clinic run by rheumatologists and attended by oral medicine and ophthalmology to streamline the diagnostic pathway and reduce frequency of visits. Key components are access to a slit lamp for eye examination, provision of a lip biopsy clinic, and standardised histopathological reporting following guidelines we have developed.
- The webinar is aimed at commissioners, clinicians and providers. Once you have Registered you will be sent a calendar invite containing details on how to join.
Dr Jill Firth is a Consultant Nurse in Rheumatalogy and Director for Service Improvement at the Pennine Musculoskeletal Partnership Ltd in Oldham and was elected President of the British Health Professionals in Rheumatology in 2016.
She has worked in rheumatology since 1997 including a period leading education and research at the University of Leeds (2004-2011) as Senior Research Fellow in Long Term Conditions and Lead Postgraduate Research Tutor for the School of Health care.
Jill has contributed to the development of specialist nursing nationally and internationally through education, research and publications.