Primary care

Each year about 20% of the population (opens PDF, 505KB) consult their GP with musculoskeletal symptoms, and these consultations account for around 30% of GP appointments and attendances at NHS walk-in centres. Most self-limiting non-inflammatory disorders (eg exacerbations of chronic degenerative disease such as osteoarthritis, back and neck pain, and regional problems such as tennis elbow) are managed in primary care, although some require onward referral to therapy services, orthopaedics or rheumatology.

Referral pathways

Given the high burden and wide spectrum of people with RMD problems in primary care, it is crucial that any onward referral is directed to the most appropriate destination in the shortest possible time. Different health economies deal with this in different ways. Some allow primary care physicians to make the decision whether a patient with an RMD problem is referred to rheumatology, physiotherapy, orthopaedics or other services. Local rheumatology services may develop referral guidelines to facilitate this process. However, many areas have developed more structured systems for the triage and signposting of MSK referrals, sometimes involving a single portal of entry into specialist MSK services including rheumatology. The British Society for Rheumatology has awards for best practice.

The Department of Health’s musculoskeletal services framework published in 2006 introduced a model of triage, assessment, diagnosis and treatment by practitioners with MSK competencies (GPs, therapists and specialists) working in intermediate services between primary and secondary care, known as clinical assessment and treatment services (CATS). In order to be successful, CATS must work in close liaison with rheumatologists and primary care specialists, with integrated governance and education programmes, rather than being standalone entities. Integrated rheumatology and MSK services have been introduced in some areas, for example stroke.

Rheumatologists can make a useful contribution to the diagnosis and management of most MSK conditions, whether this is a generalised or regional RMD problem. However, those with potential inflammatory arthritis and systemic autoimmune disease will benefit from rheumatological input, and this needs to be provided in a timely, and often urgent, manner.

Urgent and non-urgent access

Most rheumatological referrals can be dealt with in an outpatient or ambulatory setting, with a varying degree of urgency. Some referrals, for example with known or suspected systemic autoimmune diseases, will need assessment within 1–2 days. Patients with suspected inflammatory arthritis should be seen within 3 weeks of referral – as specified in NICE quality standards for rheumatoid arthritis. Data from the National Clinical Audit for rheumatoid and early inflammatory arthritis shows that in 2015 only 17% of patients were referred within 3 days of presentation and a quarter waited more than 3 months for referral. A smaller number of patients with acute rheumatological emergencies (eg suspected septic arthritis or severe multi-organ disease) will need acute admission to hospital, usually organised via the general medical take. Even non-urgent rheumatological referrals should be seen within a small number of weeks given the personal and social impact of musculoskeletal disorders.



Secondary care

Secondary care clinicians access rheumatology specialist advice via outpatient clinics, inpatient consultations or via discussion with a colleague.

Combined clinics provide an opportunity to coordinate care for complex patients (eg with dermatology, respiratory and renal medicine), run dedicated clinics for paediatric and adolescent (transitional) patients and enable access to orthopaedic surgery. Specialist advice should be available throughout antenatal and postnatal care for individuals with diseases such as lupus and antiphospholipid syndrome.

Tertiary specialised services care for patients with rare or complex conditions, who may require specialised investigation or management not available in a local hospital. Examples include complex autoimmune connective tissue diseases and rare metabolic bone diseases. These services may include close working with other branches of specialised medicine (eg renal, respiratory, cardiology, dermatology or genetics), specialised surgery (eg neurosurgery and hand surgery), and specialist rheumatology MDTs including rehabilitation therapists. Regional networks have been promoted in order to ensure coordination of care. This is exemplified by Eastern Network for Rare Autoimmune Diseases (ENRAD) where monthly regional video virtual MDT clinics of specialists from different hospitals take place, and where regular meetings of specialists occur and NHSE Specialist Services policies are implemented equally and promptly across a large area of secondary care providers.   

Tertiary specialist paediatric and adolescent rheumatology services are provided in most NHS regions. These centres provide outreach services that include working with adult rheumatologists as part of a managed clinical network. It is good practice for adult rheumatologists to provide paediatric rheumatology care within local paediatric services and within a regional paediatric rheumatology network. The British Society for Paediatric and Adolescent Rheumatology has published Standards of Care for children with arthritis and professionals working in paediatric rheumatology teams.