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2 Specialties RheumatologyTable 10 Full-time academic clinical rheumatologistActivity Workload Programmed activities (PAs)Direct clinical careAcute trustSpecialist patient clinics plus associatedadministration (administration approximately0.25 sessions per clinic)1.5Ward round and inpatient referrals 1Research academic sessions – universityTotal number of direct clinical care andacademic PAsSupporting professional activities (SPAs)Work to maintain and improve the quality ofhealthcareOther NHS responsibilitiesExternal dutiesFull academic sessions (this is an example; theexact work balance will vary considerably fromone individual to the next)Teaching and training, appraisal, audit, clinicalgovernance, CPD, revalidation, some aspects ofacademic work.eg medical director/clinical director/leadconsultant in specialty/clinical tutoreg work for deaneries/royal colleges/specialistsocieties/DH or other government bodies, etc57.5 (average)2.5 (average)Local agreement with trustLocal agreement with trust10 Key points for commissioners1 Commissioning for rheumatic diseases mustensure that patients’ needs are at the centre ofservice planning and support the concept of ‘nodecision about me without me’.2 Consultants, as well as all other key healthcareprofessionals, such as specialist nurses,physiotherapists and occupationaltherapists, should be involved incommissioning of rheumatology services ata local level.3 Many rheumatic diseases are complex,chronic, disabling and life shortening.Successful commissioning must includelong-term planning, with integrated pathwaysbetween primary and secondary care, includingsocial support.4 Commissioning must involve patientrepresentation through organisations such as localARMA networks, National Rheumatoid ArthritisSociety (NRAS) and Arthritis Care.5 The introduction of competition in commissioningof services brings a risk of fragmentation of existinggood-quality clinical networks, which are essentialfor management of rheumatic diseases.6 Commissioning must focus on quality andoutcome measures (including the ability to work)rather than on targets that may not be clinicallyrelevant.7 Quality of services should be assessed by qualitymetrics and by (multicentre or national) auditsagainst national standards produced by bodies suchas NICE, the BSR and the RCP.8 Commissioning must conform to NICE clinicalguidance and technology appraisals but should alsobe flexible enough to recognise that some patientswith severe progressive rheumatic diseases shouldnot be disadvantaged because their condition hasnot been assessed by NICE.9 Commissioning must recognise the clinicalimportance and potential cost benefit of earlyreferral and specialist treatment for rheumaticdiseases, as highlighted by NICE guidance, the18-week commissioning pathway for inflammatoryarthritis and the National Audit Office’s report onservices for rheumatoid arthritis. 510 Crude ratios of new patients to follow-up patientsdo not reflect service quality in rheumatology unitsand must be analysed in the context of the localclinical casemix, staffing and model of serviceprovision.C○ Royal College of Physicians 2013 245
Consultant physicians working with patientsReferences1 Arthritis Research UK. Arthritis – data and statistics.London: Arthritis Research UK, 2010. www.arthritisresearchuk.org/arthritis information/arthritisdata and statistic.aspx [Accessed 1 July 2011].2 National Institute for Health and Care Excellence.Osteoarthritis – background information. London: NICE,2010. www.cks.nhs.uk/osteoarthritis/backgroundinformation/prevalence [Accessed 1 July 2011].3 O’Neill TW, Felsenberg D, Varlow J, et al. The prevalenceof vertebral deformity in European men and women: theEuropean Vertebral Osteoporosis Study. JBoneMinerRes1996;11:1010–8.4 McCormick A, Fleming D, Charlton J. Morbidity statisticsfrom general practice, fourth national study 1991–1992.RCGP 1991 statistics applied to year 2000 population.London: Stationery Office, 1995.5 National Audit Office. Services for people with rheumatoidarthritis. London: NAO, 2009. www.nao.org.uk/publications/0809/services for people with rheum.aspx[Accessed 1 July 2011].6 Samanta A, Roy S, Feehally J, Symmons DP. Theprevalence of diagnosed systemic lupus erythematosus inWhites and Indian Asian migrants in Leicester city, UK.Br J Rheum 1992;31:679–82.7 Silman A, Jannini S, Symmons D, Bacon P. Anepidemiological study of scleroderma in the WestMidlands. Br J Rheum 1988;27:286–90.8 Croft P, Rigby AS, Boswell R, et al. The prevalence ofchronic widespread pain in the general population. JRheumatol 1993;20:710–3.9 Symmons DP, Jones M, Osborne J, et al.Paediatricrheumatology in the United Kingdom: data from theBritish Paediatric Rheumatology National GroupDiagnostic Register. J Rheumatol 1996;23:1975–88.10 Department of Health. The musculoskeletal servicesframework. London: DH, 2006.11 Department of Health. Equity and excellence: liberatingthe NHS. London: DH, 2010. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 117353 [Accessed 1July 2011].12 British Society for Paediatric and AdolescentRheumatology. BSPAR position statement on professionalsworking in paediatric rheumatology. Birmingham:BSPAR: 2007. www.bspar.org.uk/downloads/clinicalguidelines/Final BSPAR Position Statement onProfessionals working in Paediatric RheumatologyTeams.pdf13 British Society for Rheumatology. Musculoskeletaldisorders: providing for the patient’s needs. No. 1. Therole of rheumatology departments. London: BSR,1992.14 British Society for Rheumatology. Guidelines on themanagement of rheumatoid arthritis. London: BSR,2006.15 Arthritis and Musculoskeletal Alliance. Standards ofcare – care documents. London: ARMA, 2006. www.arma.uk.net/care.html [Accessed 1 July 2011].16 National Institute for Health and Care Excellence. Themanagement of rheumatoid arthritis in adults.London:NICE, 2010. www.nice.org.uk/CG79 [Accessed 1 July2011].17 Carr A. Defining the extended clinical role for alliedhealth professionals in rheumatology. In: ARC conferenceproceedings. No 12. Chesterfield: Arthritis ResearchCampaign, 2001.18 Hay EM, Campbell A, Linney S, et al. Development of acompetency framework for general practitioners with aspecial interest in musculoskeletal/rheumatologypractice. Rheumatology 2007;46:360–2.19 Arthritis and Musculoskeletal Alliance. Joint working? Anaudit of the Department of Health’s musculoskeletalservices framework. Exeter: ARMA, 2009. www.arma.uk.net/pdfs/MSF%20Review FINAL1.pdf [Accessed 4July 2011].20 Arthritis and Musculoskeletal Alliance. Themusculoskeletal map of England. Exeter: ARMA, 2010.www.arma.uk.net/pdfs/Musculoskeletal%20map%20FINAL%202.pdf [Accessed 4 July 2011].21 Department of Health. 18 week commissioning pathwayinflammatory arthritis (joint pain). London: DH, 2009.www.nras.org.uk/includes/documents/cm docs/2010/i/ia pathway.pdf [Accessed 4 July 2011].22 British Society for Rheumatology. British Society forRheumatology and British Health Professionals inRheumatology peer review scheme. London: BSR, 2010.www.rheumatology.org.uk/includes/documents/cmdocs/2010/p/2 peer review guidance 6 sept 2010.pdf[Accessed 4 July 2011].23 British Society for Rheumatology. British Society forRheumatology and British Health Professionals inRheumatology peer review scheme: peer review visitproforma. London: BSR, 2010. www.rheumatology.org.uk/includes/documents/cm docs/2010/p/peerreview proforma aug 2010.doc [Accessed 4 July 2011].24 National Institute for Health and Care Excellence.Musculoskeletal. London: NICE, 2011. http://guidance.nice.org.uk/Topic/Musculoskeletal [Accessed 4 July2011].25 National Institute for Health and Care Excellence. Thecare and management of osteoarthritis in adults. London:NICE, 2008. http://guidance.nice.org.uk/CG59 [Accessed4 July 2011].26 National Institute for Health and Care Excellence.Etanercept for the treatment of juvenile idiopathic arthritis.London: NICE, 2002. http://guidance.nice.org.uk/TA35[Accessed 4 July 2011].246 C○ Royal College of Physicians 2013
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