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2 Specialties RheumatologyRheumatology ∗Dr Ian Rowe FRCP MA MD Consultant rheumatologistDr Neil Snowden FRCP Consultant rheumatologistDr Ruth Richmond FRCP Consultant rheumatologistDr Marwan Bukhari FRCP PhD Consultant rheumatologist1 Description of the specialtyRheumatology deals with the investigation, diagnosisand management of patients with arthritis and othermusculoskeletal conditions. This incorporates morethan 200 disorders affecting joints, bones, muscles andsoft tissues, including inflammatory arthritis and othersystemic autoimmune disorders, vasculitis, soft-tissueconditions, spinal pain and metabolic bone disease. Asignificant number of musculoskeletal conditions alsoaffect other organ systems.Rheumatology is a multidisciplinary specialty and therheumatologist works in close liaison with othermedical specialists and healthcare professionals.Accredited training for paediatric and adolescentrheumatology is based within paediatrics, althoughadult rheumatologists should be aware of the spectrumof conditions that affect children in order to take part inthe transitional care of older adolescents and youngadults. Specific training is available in sports andrehabilitation medicine.Who are the patients?The burden of musculoskeletal disease in the UK issignificant (Table 1), with 10 million working days lostin 2006–7 due to musculoskeletal conditions, which issecond only to stress, depression and anxiety. 1 Theestimated cost to society is £5.7 billion per year.2 Organisation of the service and patternsof referralUp to 30% of people who consult their GPs and 40% ofthose who attend NHS walk-in centres do so with amusculoskeletal complaint. 10 Those with inflammatoryarthritis or autoimmune connective tissue diseaserequire input from a rheumatologist. Early referral forpatients with inflammatory disease is vital to minimisejoint damage and is cost-effective. Treatment is mosteffective if started within 3 months of symptom onset. 5Referral to secondary care via a rapid-access system isappropriate for patients with ‘red flags’, includingsystemic disorders such as malignancy or complexmultisystem disease. Most self-limitingnon-inflammatory disorders and exacerbations ofchronic degenerative disease such as osteoarthritis andback pain are managed in primary care.The NHS white paper 11 for England will giverheumatologists more opportunities to work directlywith frontline colleagues in primary care. Thecommissioning proposals should lead to improvedintegration with primary care and increased access tosupport and advice for GPs to manage musculoskeletaldisease in the community. Integral involvement ofrheumatologists will ensure the appropriateformulation of quality and outcome measures in linewith national standards and guidance.The Department of Health (DH) in England’s bestpractice guidance document The musculoskeletal servicesframework (MSF) 10 has emphasised the role of triage,assessment, diagnosis and treatment by practitionerswith special interests (GPs, therapists and specialists)and the establishment of intermediate services betweenprimary and secondary care known as clinicalassessment and treatment services (CATS). The CATShave been proposed in order to improve the efficiencyand appropriateness of referrals. In order to besuccessful, the CATS must work in close liaison withrheumatologists and primary care specialists and shouldbe integrated with regard to continuing professionaldevelopment (CPD) programmes, audit and teaching ofspecialist staff and students, rather than beingstand-alone entities.∗ Please see an appendix to this chapter, which has been written for the revised 5th edition 2013 (p. 249). The rest of the text has been reproduced fromthe 2011 edition.C○ Royal College of Physicians 2013 235
Consultant physicians working with patientsTable 1 Estimated numbers of people with rheumatic disease in the UKCondition Estimated number of people SourceAll musculoskeletal conditions 10 million people Arthritis Research UK 1Osteoarthritis-related joint pain 8.5 million National Institute for Health and CareExcellence 2Osteoporosis 2.1 million minimum European Vertebral Osteoporosis Study 3Back pain: GP consultations 2.6 million/year Royal College of General Practitioners 1991statistics applied to year 2000 population 4Rheumatoid arthritisIncidence 26,000/yearPrevalence 580,000National Audit Office, 2009 5Ankylosing spondylitis 200,000 Royal College of General Practitioners 1991statistics applied to year 2000 population 4Systemic lupus erythematosus 10,000 Epidemiological survey in Leicester 6Scleroderma 1,500 Epidemiological survey in the West Midlands 7Gout 250,000 Royal College of General Practitioners 1991statistics applied to year 2000 population 4Regional pain syndromes (eg shoulderpain)Chronic widespread pain(eg fibromyalgia)20% of adult population Epidemiological studies in north-west England(unpublished)11.2% of adult population Croft P, et al, 1993 8Juvenile idiopathic arthritis (JIA)Incidence: 10 per 100,000 (children upto 16 years)Estimated 12,000 children withJIA in UKSymmons DP, et al, 1996 9Secondary careThe core work of secondary care rheumatology servicesprovided by consultant rheumatologists and themultidisciplinary team (MDT) is the treatment ofinflammatory arthritis, autoimmune connective tissuedisease and vasculitis. The availability of powerfulbiologic disease-modifying and immunosuppressivetreatmentshasmadeitpossibleforrheumatologyMDTs to develop care pathways with the aim ofachieving clinical remission or very low disease activityfor patients with inflammatory arthritis. Theseaims are reflected in the recent NICE guidance forrheumatoid arthritis (http://guidance.nice.org.uk/CG79) and the National Audit Office’s report fromJuly 2009 on Services for people with rheumatoidarthritis. 5Tertiary careTertiary care can provide specialised services that coverthe needs of small groups of patients with rare orcomplex conditions, who may require specialisedinvestigation or management not available in a localhospital. Examples of these include complexautoimmune connective tissue diseases and raremetabolic bone diseases. These services may includespecialised surgery, such as neurosurgery and handsurgery, and specialist rheumatology MDTs includingrehabilitation therapists.Paediatric rheumatologyTertiary care services in paediatrics include specialistpaediatric and adolescent rheumatology services in allmajor children’s centres covering every region. Thesecentres provide outreach services that include workingwith adult rheumatologists as part of a managed clinicalnetwork. It is good practice for adult rheumatologists toprovide paediatric rheumatology care within localpaediatric services and within a regional paediatricrheumatology network. 12236 C○ Royal College of Physicians 2013
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