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Debating the provision of rheumatology services

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Although there is widespread agreement on the need to improve patients’ access to rheumatol- ogy services, there is no consensus on which changes should be made to achieve this and there is much concern over...

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Debating the provision of rheumatology services

  1. 1. Meeting notes RHEUMATOLOGY IN PRACTICE 2007; Vol 5 No 3 10 Although there is widespread agreement on the need to improve patients’ access to rheumatol- ogy services, there is no consensus on which changes should be made to achieve this and there is much concern over the usefulness of relocating specialist medicine in general – and rheumatology in particular – into primary care. Some specialists think that this should, and could, be avoided through a reorganisation of secondary care services. This was the topic under discussion at the recent meeting of the multiprofessional West Midlands Rheumatology Forum, chaired by Dr Rainer Klocke, Chair of the Forum’s steering com- mittee and Consultant Rheumatologist at Dudley Group Hospitals NHS Trust, West Midlands. The meeting offered an in-depth assessment of how the delivery of rheumatology care within the NHS has recently evolved, and explored ways of ensur- ing that patients receive a better service and that the highest level of care is provided efficiently and close to home. Rheumatology at war Dr Andrew Bamji, Consultant Rheumatologist and Director at Queen Mary’s Hospital, Sidcup, Kent, and current President of the British Society for Rheumatology (BSR), was unable to be present, but started the event with a pre-recorded e-address. Dr Bamji briefed the audience on cur- rent and potential threats to rheumatology and outlined the essential principles for addressing such threats in the context of what he called ‘war’. According to Dr Bamji, there are four threats to rheumatology and specialist medicines in general. The government’s intention to move secondary care into the community and the creation of gen- eral practitioners with special interests (GPwSIs) are two such threats, partly because they mean withdrawing work from hospital departments, partly because there is uncertainty about whether services would indeed become more cost-effective and sustainable. Then, he said, there is the growth of integrated clinical assessment and treatment services (ICATS) and independent sector treatment centres (ISTCs). There are cases in which these have been intro- duced without any costing, for instance in Cumbria and Lancashire. There also appear to be legal issues in that the implementation process has bypassed the Health and Social Care Act 2001. There have also been difficulties in determining who was going to work there. The fourth and last threat is payment by results (PbR). This scheme is too expensive and, there- fore, unaffordable for private finance initiative (PFI) hospitals, which, in turn, ‘drives GPs to retain patients in their own care’, said Dr Bamji. All this is in addition to insufficient funds, staff cuts and an ever-decreasing number of referrals largely due to primary practitioners who either send patients elsewhere or do not refer them at all. There is also pressure to reduce the number of follow-ups, ‘clearly to save money’, he noted. How can these threats be countered? Dr Bamji recommended the following actions. ● Maintain an up-to-date database of prescribed drugs, patients’ follow-ups, new patient out- comes and expenses. Financial data are particu- larly important because, ‘You can use them to demonstrate your income–expenditure equa- tion and show your own trust the approximate number of patients you need to make a profit’. ● Find support from patients, colleagues, societies (Arthritis and Musculoskeletal Alliance and the National Rheumatoid Arthritis Society, for example), politicians and the press. Lorena Tonarelli MSc BSc(Hons) Independent Medical Writer, Henley-on- Thames Debating the provision of rheumatology services There are four threats to rheumatology and specialist medicines in general The forum votes on Dr Bamji’s assertion that rheumatology specialists are at war with the primary care trusts This picture has been removed due to copyright reasons.
  2. 2. RHEUMATOLOGY IN PRACTICE 2007; Vol 5 No 3 Meeting notes 11 ● Look at the BSR action plan, which describes ways to address the various problems facing rheumatology, and at the national guidelines. ● Promote your services: set up a website with information about your hospital and make sure GPs know about it, in order to increase the like- lihood of receiving referrals. Disease management in the community: lessons from diabetology An opposing view was expressed by Dr Felix Burden, Consultant Community Diabetologist at the Heart of Birmingham Teaching Primary Care Trust. According to him, the way to improve care is to bring secondary services into the commu- nity, with the overall aim of reducing the need for patients to be referred to a specialist, by means of a more effective system of disease prevention and management – as in diabetology. ‘My task is to try to make sure that no person with diabetes needs to see a consultant at all, and if we can get patients’ education right, we can achieve that. ‘Of course, we need specialists in acute settings but we also need them in primary care, to help lead on redesigning services and on teaching and to give specialist opinion,’ Dr Burden said. ‘To keep on looking at the number of referrals is not really what we are here for.’ In primary care, spe- cialists can help with the education of practice nurses and GPs, to whom they can provide practi- cal support. And they can go out in the commu- nity, doing clinics. Drawing on his experience in diabetology, he described how a system that brings the specialists into the community can lead to improvements for patients and the system alike. Such a system needs to focus on patients’ education, prompt interven- tion early on in the course of a disease, teamwork, fewer hospital follow-ups and cuts on unnecessary equipment, tests and medicines. The improve- ments include better screening and health out- comes, shorter waiting times and lower costs. Dr Burden said that, for example, the waiting times for a patient who needs to start insulin have decreased from at least three months in the past to just a few days or weeks today. In terms of savings as well, the change can be dramatic. ‘If you halt the follow-ups to have group education instead you can probably save nearly a million pounds,’ he said. Follow-ups should be largely done by primary care and community workers rather than in acute settings. Most importantly, patients should have a more active role in the management of their con- dition. Survey data show that people with long- term conditions prefer to be able to decide when, and if, they need advice from a specialist and don’t want to be forced into a treatment they consider unnecessary. Triage of musculoskeletal referrals as a new model of care Professor of Rheumatology Dr Peter Maddison, from the University of Bangor, Wales, also expressed disagreement with Dr Bamji’s view of rheumatology at war. ‘I don’t feel like a soldier in a battle, but a sort of a collaborator,’ he said, point- ing out that changes in musculoskeletal services are necessary given the numerous recent develop- ments and the fact that musculoskeletal disorders represent a leading cause of disability and a major source of expenditure, accounting for some £30 million spent weekly in disability benefits. A good example of this much-needed change, according to Professor Maddison, is the Targeted Early Access to Musculoskeletal Services (TEAMS) programme, which he developed – together with Dr Jeremy Jones (the pro- gramme’s leader) and a number of colleagues – to reduce unnec- essary referrals to hospitals in north-west Wales, particularly referrals to orthopaedics. ‘Musculoskeletal refer- rals to our services were totally disorganised,’ Professor Maddison explained. ‘An individual could be referred to any, and sometimes all clini- cal services. Waiting times to see a consultant were very long and, frequently, the patients were referred to the wrong specialty area.’ The key feature of the programme is a common access pathway for all GP musculoskeletal referrals (acute back pain, chronic back pain, osteoarthritis and arthritis), using a standardised referral letter. This is combined with clinical triage conducted by consultants and physiotherapists, which is done on the basis of demographic, clinical and occupa- tion information and ensures that patients are directed to the right specialist. ‘The TEAMs pro- gramme has had quite a dramatic effect, particu- larly on the accessibility of our services,’ Professor Maddison said. ‘Waiting times fell dramatically despite the fact that GP referrals more than dou- bled.’ This has been the case, for instance, for carpal tunnel syndrome. Following the imple- mentation of the TEAMS programme, patients were assessed more quickly and were immediately referred to a pre-op clinic if they needed surgery. The TEAMS programme has been a success because it involves primary and secondary clini- cians working together towards a common goal. And, within this pool of clinicians, GPwSIs and their interface musculoskeletal clinics play a piv- otal role. Professor Maddison said the TEAMS programme runs about 20 GPwSI clinics a month. I don’t feel like a soldier in a battle, but a sort of a collaborator
  3. 3. Meeting notes RHEUMATOLOGY IN PRACTICE 2007; Vol 5 No 3 12 These are mostly one-stop, with less than 10% of patients either referred or followed up. ‘The vast majority of patients rate this service as good or excellent,’ he said. ‘About three-quarters are totally satisfied and about the same number are perfectly happy not to see a consultant.’ What role for GPwSIs? This is also the experience of Dr Louise Warburton, a rheumatology GPwSI in Telford, Shropshire, and member of the Primary Care Rheumatology Society steering com- mittee. As a GPwSI she plays an important part in relieving some of the pressure on the local GPs and reducing the number of unnecessary referrals to secondary care. Most importantly, she helps hundreds of patients every year to receive a better service. This is not an easy task. A GPwSI needs to have a whole range of skills in addition to those that come from experience as GPs, said Dr Warburton. ‘We need to know about all kinds of things, not just musculoskeletal problems,’ she said. ‘And yet our skills are often overlooked in this debate.’ In fact, those who oppose the use of interface clinics are concerned about the competency of GPwSIs. But there is a system in place to make sure that they do have the necessary skills. These are outlined in a competency framework – a joint effort of several organisations, including the BSR and the British Institute of Musculoskeletal Medicine – offering primary practitioners who want to become GPwSIs guidance on what they need to learn. There is also a process of accredita- tion, usually by the primary care trust (PCT), which requires evidence that the GP actually has, and is capable of maintaining, the recommended skills. In addition, GPwSIs are encouraged to attend one of the annual Arthritis Research Campaign-funded symposia, which provide valu- able learning opportunities through a wide range of lectures and workshops. The service, of course, is not without problems, said Dr Warburton. ‘We still make mistakes and a number of patients are still failed by the NHS, unfortunately. Nevertheless, patients need a multi- disciplinary approach to optimise their care. Where this is delivered is not important. It is the quality of the care that matters. Instead of duplicat- ing services we should be combining them, and we should respect the abilities and contributions of our colleagues. This isn’t a war as far as I’m con- cerned. We should all try to embrace the changes and work together to optimise patients’ care to ensure that the standards remain high.’ Working smarter: the nursing perspective Indeed, changes are the way forward to working smarter, according to Susan Oliver, Nurse Consultant in Rheumatology and Chair of the Royal College of Nursing Rheumatology Nurses Forum, who offered an insight into nurses’ per- spectives on the issue of services redesign. Such changes should involve the whole nursing work- force, she said – outpatient nurses, ward nurses, specialist nurses and nurse practitioners. In particular, Mrs Oliver pointed out the need to develop the nurse’s role in order to meet patients’ needs more adequately. She highlighted the following points. ● Currently, much of the rheumatology nurse’s role is restricted to rheumatoid arthritis. Nurse specialists should look at ways to expand their field of intervention within musculoskeletal secondary care services. ● Caseloads should be reviewed in order ensure equity of access to services for all patients. ● More nurses should have their activity recorded. Careful gathering of information about what a nurse actually does within their organisation or team is important because it helps demonstrate that there is value in extend- ing their role. Yet, this is not done sufficiently often, or well enough. ● Costs should be reduced. ‘We have become quite expensive,’ said Mrs Oliver. ‘The nursing role is becoming unsustainable and we need to review our resources and decide how to make the most of them.’ Optimising care using inte- grated care pathways – which establish who has the competency to deliver a specific interven- tion to a certain patient at a particular point in time – is one way. Other possibilities include the Patients need a multidisciplinary approach to optimise their care Dr Felix Burden (pictured, left) makes the case for closer ties with the primary care trusts This picture has been removed due to copyright reasons.
  4. 4. RHEUMATOLOGY IN PRACTICE 2007; Vol 5 No 3 Meeting notes 13 implementation of new models of service provi- sion, like the social enterprise model, in which nurses – particularly in foundation hospitals – are taken out of the PCTs to deliver care in the community. Nurse telephone triage can also contribute to substantial savings by reducing the number of unnecessary admissions to hospital. ● Nurses should have more opportunities for con- tinued education and training. ● There should be more collaboration with other long-term condition groups. ‘We really have to work with these changes. If we don’t, a lot of independent contractors will take services out of the PCT,’ said Mrs Oliver. ‘Nurses need to evaluate what they are providing and how to optimise their contribution. They must also demonstrate what they add to patients’ outcomes and show how they add value to the organisation, particularly in PCT.’ Panel discussion Dr Deva Situnayake, Consultant Rheumatologist and Deputy Medical Director of the Combined Sandwell and West Birmingham Hospitals Trust, chaired the panel discussion. In addition to the meeting’s speakers, the debate also featured Chan Ghordan, who has been managing the Birmingham Arthritis Resource Centre – a walk- in service for people with arthritis and their carers – for the past six years. Dr Situnayake expressed concern about how the changes affecting the ser- vices may make it difficult to continue to engage con- structively with the PCTs. He then called for a show of hands on whether or not the audience agreed with Dr Bamji’s idea of being at war with the PCTs. The audience voted against almost unanimously, with only one dissenting vote. The discussion covered the key areas of how to effectively engage with PCTs, education and models of care. It raised a number of important issues. The current redesign of the services involves the creation of new, smaller practices that operate independently, sometimes almost in competition with each other. There is concern that this system might be neither easy to manage nor efficient. Reducing follow-ups may not be possible if GPs send patients with long-term conditions to the hospital for monitoring. Dr Burden suggested that one way to address this would be to have input from pharmacists looking after patients who need ongoing monitoring of their drug treatment. Shifting care into the community would improve the service offered to patients, but many GPs apparently show little interest. Mrs Gordhan said that seven out of ten patients with arthritis who attend the BARC complain that they are not getting adequate help, information and support from their GP. Some members of the audience expressed doubts about the sustainability of a system that provides free care at the point of delivery. In Mrs Oliver’s view, the obvious alternative would be to have people pay for some of the services. However, by 2020 the number of chronic diseases affecting the elderly will have doubled. Many of them will not be able to contribute and this will result in a huge burden on the workforce. A more realistic option would be to deconstruct the existing facilities and create smaller, healthier systems, closer to the patients and with self-management programmes. Education is paramount. Providing nurses with more opportunities for education would reduce primary and secondary care work and, done appropriately, would help the patients as well. A telephone helpline service for healthcare profes- sionals as well as patients is particularly helpful. GPsWIs could be an important resource ■ Acknowledgement The WMRF meetings are supported by Pfizer UK. ● There is concern over the relocation of rheumatology medicine into primary care. ● By 2020 the number of chronic diseases affecting the elderly will have doubled, putting an even greater strain on resources. ● Although moving care into the community has benefits, it is not certain that GPs are keen. Key points Providing nurses with more opportunities for education would reduce primary and secondary care work From left to right: Dr Rainer Klocke, Dr Felix Burden, Dr Louise Warburton, Susan Oliver and Professor Peter Maddison This picture has been removed due to copyright reasons.

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