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2 Specialties RheumatologyTable 3 How to ensure that the service is of high qualityGuidelinesCommentsSpecialist society guidelinesThe BSR commissions and produces its own guidelines, which are available on thewebsite (www.rheumatology.org.uk) and in the journal Rheumatology.The BSR’s standards, guidelines and audit group keep guidelines up to date andcommission new guidelines and audit toolkits.NICE guidanceNICE has produced a number of appraisals and guidelines of importance torheumatology services (www.nice.org.uk/).Importantly, in February 2009, NICE published guidance on the management ofrheumatoid arthritis in adults (http://guidance.nice.org.uk/CG79). 16 The documentemphasised the importance of early referral to a rheumatologist for patients withthis common condition. It defined the need for close and regular monitoring ofpatients with rheumatoid arthritis to enable tight control of disease activity usingdisease-modifying and biologic drugs.National Audit Office reportIn July 2009, the National Audit Office published the report Services for people withrheumatoid arthritis (www.nao.org.uk/publications/0809/services for peoplewith rheum.aspx). 5 This supported the NICE guidelines and explained the long-termcost benefits of investing in these standards of care.ARMA standards of care projectARMA has produced a series of publications defining reasonable expectations of careand services for all people with musculoskeletal conditions; these are accompaniedby audit toolkits (www.arma.uk.net/).ARMA has recently published two documents Joint working? An audit of theDepartment of Health’s musculoskeletal services framework 19 (www.arma.uk.net/pdfs/MSF%20Review FINAL1.pdf) and The musculoskeletal map of England 20(www.arma.uk.net/pdfs/Musculoskeletal%20map%20FINAL%202.pdf). Thesedocuments highlight the significant variations in response to the MSF and in thequality of NHS musculoskeletal services across England.Inflammatory arthritis care pathwayIn 2009, the DH published a Commissioning pathway for inflammatory arthritis(www.nras.org.uk/includes/documents/cm docs/2010/i/ia pathway.pdf). 21 Thepathway encouraged commissioners and GPs to work with rheumatologists toredesign and deliver better services for patients with inflammatory arthritis.Peer reviewPeer review is a clinical governance tool that facilitates improvement in the qualityof clinical service. The BSR promotes this and published new guidance 22(www.rheumatology.org.uk/includes/documents/cm docs/2010/p/2 peer reviewguidance 6 sept 2010.pdf) and a proforma 23 (www.rheumatology.org.uk/includes/documents/cm docs/2010/p/peer review proforma aug 2010.doc) for thescheme in 2010.The recommended workload is as follows: new patients: 6–7 new patients per clinic dependingon casemix, with one slot for urgent cases(approximately 30 minutes per patient) review clinics: 10–15 patients per clinic(10–15 minutes per patient) mixed clinics: one new patient takes the time of tworeview patients, but this depends on the casemix specialised clinics for patients with complexdisorders eg early rheumatoid arthritis, systemiclupus erythematosus, vasculitis and paediatricrheumatology: numbers of patients seen in clinicsneed to be reduced from recommendations above number of patients seen in consultant clinics needtobereducedfromrecommendationsaboveiftheconsultant is supporting and training junior staff (byabout 20%) number of patients seen in consultant clinics needtobereducedfromrecommendationsaboveiftheconsultant is undertaking undergraduate andpostgraduate teaching: the Royal College ofPhysicians (RCP) recommends a reduction of 25% number of patients seen in consultant clinicsneed to be reduced from recommendations above ifthe consultant is supervising nurse-ledclinics.C○ Royal College of Physicians 2013 239
Consultant physicians working with patientsTable 4 Recent NICE, BSR and ARMA publications relevant to rheumatologyCompleted NICE musculoskeletalguidance 24 Current BSR guidelines 36 ARMA 53Rheumatoid arthritis 16Osteoarthritis 25Arthritis (juvenile idiopathic) –etanercept 26Osteoarthritis and rheumatoidarthritis – cyclooxygenase-2 (COX-2)inhibitors 27Psoriatic arthritis – etanercept,infliximab and adalimumab 28Rheumatoid arthritis – adalimumab,etanercept and infliximab 29Rheumatoid arthritis – certolizumabpegol 30Rheumatoid arthritis – drugs fortreatment after failure of a tumournecrosis factor (TNF) inhibitor 31Rheumatoid arthritis – tocilizumab 32Hyperuricaemia – febuxostat 33Osteoporosis – primary prevention 34Osteoporosis – secondaryGuidelines on safety of anti-TNFtherapies in RA 37Management of giant cell arteritis38Guidelines on eligibility criteria for thefirst biologic therapy in rheumatoidarthritis39Quick reference guide for monitoringof disease-modifying anti-rheumaticdrug (DMARD) therapy40Management of polymyalgiarheumatica41Management of rheumatoid arthritisafterfirst2years 42DMARD therapy 43Metoject44Management of adults withanti-neutrophil cytoplasmic antibody(ANCA)-associated vasculitis 45Management of gout46Management of rheumatoid arthritisprevention 35 (first 2 years)47Management of hot swollen joints inadults48Anti-TNF α therapy in psoriaticarthritis49Prescribing TNF blockers in adults withrheumatoid arthritis50Standards of care for persons withrheumatoid arthritis51Prescribing TNF α blockers in adultswith ankylosing spondylitis 52Standards of careBack pain 54Inflammatory arthritis 55Osteoarthritis 56Connective tissue diseases 57Metabolic bone disease 58Regional musculoskeletal pain 59Overarching principles 60Musculoskeletal foot healthproblems 61Other publicationsJoint working 19The musculoskeletal map ofEngland 20Charter for work for people affectedby musculoskeletal disorders in theUK 62Table 6 shows the patient allocation for non-consultantstaff.Casemix and ratio of new patients tofollow-up patientsThe ratio of new patients to follow-up patients variesconsiderably, with a national mean of 1:3.9(interquartile range 1:1.3 to 1:7.8). 66 Anumberofvariables are important, particularly casemix (which isinfluenced by the provision of local CATS and specialistservices) and the quality of GP services, including thecapacity for shared care. A casemix study from theMidlands identified that the major influence on theratio of new patients to follow-up patients was theproportion of patients with inflammatory conditions. 67Their mean ratio was 1:4.9, with a range of 1:3.0to 1:7.3.Primary care trusts (PCTs) in England tried to imposeratios for new patients to follow-up patients in anattempt to devolve follow-up care into the community.However, NICE guidelines on rheumatoid arthritisrecommend more frequent follow-up for patients withactive disease, as well as rapid access and annual review.It is therefore important that rheumatology units areactively involved in discussions with PCTs and futureGP consortia (health boards in Wales) about developingappropriate care pathways and community services.Community servicesAn increasing number of consultant rheumatologistsare now working in community-based clinics, includingpolyclinics and CATS. Appropriate MDTs shouldprovide support at these peripheral sites. Furtherintegration with primary care services is likely in the240 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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