The patient population

As described elsewhere in this resource, the health and social burdens of rheumatic and musculoskeletal diseases are enormous. Rheumatology has a unique role in the assessment and management of people who have inflammatory rheumatological disorders (which affect 1–2% of the population), but also has some contribution to make to almost every aspect of musculoskeletal disease. Many musculoskeletal problems are dealt with in primary care or are self-managed. Beyond primary care, signposting and coordination of musculoskeletal problems is complex, and arguably underdeveloped. We need better pathways to ensure that the right patient is seen at the right time by the right healthcare professional. This is a challenge for both commissioners and providers of rheumatological care.

Prevention of disease

Health promotion and disease prevention are now recognised to be of increasing importance in the management of rheumatological conditions. The importance of weight reduction in patients with knee osteoarthritis has been demonstrated in studies. Smoking is an important risk factor in the development of rheumatoid arthritis and response to treatment. The increased risk of cardiovascular disease is well recognised in patients with rheumatoid arthritis, and the importance of addressing modifiable risk factors was highlighted when it was included in the Quality Outcomes Framework for GPs – although unfortunately this indicator has subsequently been removed. The increased cardiovascular risk is also well recognised in patients with systemic lupus erythematosus (SLE). Cardiovascular risk and, in addition, advice about alcohol intake are important considerations in patients with gout.

Many rheumatology departments now have a formalised annual review process for patients with inflammatory arthritis. This will include a review of modifiable cardiovascular risk factors. Rheumatologists will typically work in collaboration with GPs to address these risk factors. In other conditions such as gout, the importance of addressing modifiable cardiovascular risk factors will be highlighted to the GP.

It is important that rheumatology departments understand how to signpost patients to community-based services such as stop smoking and healthy lifestyle services. Many of these services allow patients to self-refer, so it is important that literature is made available to patients where appropriate.

Planning effective services

As noted in the section on patient population above, the burden of musculoskeletal disease is considerable and the systems for provision of care for these disorders are complex. Historically, it has also been difficult to demonstrate the outcomes of many rheumatological disorders, which are often lifelong conditions with gradual accumulation of disability and reduction in quality of life. Some outcome data are now becoming available, for example from the Early Inflammatory Arthritis national audit, which shows that there are significant shortfalls in care across the NHS, coupled with considerable variability in care at a local level. Despite the burdens of musculoskeletal disease, and the emerging evidence of suboptimal outcomes, needs assessment and planning of service provision at a public health level has been limited. Fortunately, a variety of resources are now becoming available to support providers and commissioners to provide services appropriate to the needs of their populations. For example, Versus Arthritis has launched a musculoskeletal calculator and other tools to enable an assessment of need. The British Society for Rheumatology has also developed resources to support evidence-based commissioning of high-quality rheumatology services.

Getting It Right First Time in rheumatology

Getting It Right First Time (GIRFT) is a clinically-led programme to identify variation in practice, with the aim of improving quality and cost-efficacy of services across the NHS in England. When Professor Tim Briggs was president of the British Orthopaedic Association, he brought together all the available data sources about orthopaedic practice, and visited every NHS orthopaedic department, working with clinicians and managers to identify opportunities for service quality improvement and cost reduction. This resulted in potential for £60 million of savings. As a partnership between the Royal National Orthopaedic Hospital and NHS Improvement, the programme has developed to include over 35 specialties and cross-cutting themes. The British Society for Rheumatology is supporting the implementation of GIRFT across the specialty, seeing this as a major opportunity to use data to drive improvement and priority setting in rheumatology services.

The GIRFT process encompasses several stages:

  • Bringing together available national data about rheumatology services to produce a data-pack for each department, with information provided by departments to give context
  • Each department will be visited by a national clinical lead for rheumatology with the GIRFT team, to help clinicians and managers identify areas of good practice to share, and priorities for improvement
  • A national report written by the national clinical leads will identify themes for further work and development
  • GIRFT regional hubs will help departments share their good practice and implement improvements identified in the national report and in the departmental action plans.

Departmental visits are planned to start in early 2019. Further information is available from BSR via [email protected]