Maintaining quality | Medical Care - Guidance for Desiging Services and Developing Physicians for Specialties

Designing services

Specialties

Rheumatology

Maintaining quality

Standards of care

A definition of good-quality care in rheumatology is complex. Life expectancy is reduced by many rheumatic diseases (for example, by an average of 7 years in people with rheumatoid arthritis) but mortality alone will not give an adequate measure of good rheumatology care. Chronic rheumatic diseases impinge on every aspect of life: physical health, psychological wellbeing, relationships and sexuality and work capacity. Standards of care in rheumatology need to reflect all these, and a complex triangulation of outcomes and experience is required. Rheumatology should clearly also be underpinned by the ethical and legal framework laid down by the GMC in the various components of Good Medical Practice, by the CQC, by the Francis Report and by overarching NICE quality standards, such as those on patient experience. Some units also benchmark the quality of their service with national schemes such as customer service excellence and those provided by BSI/ISO.

There is potential in the future for developing a system for accreditation of rheumatology units around this framework of quality and standards.

High-quality rheumatology services should be person-centred, accessible and multidisciplinary:

Person-centred – rheumatology services should maximise quality of life, including preserving the ability to stay in work, and should ensure people have a positive experience of care
Accessible – care should be timely, provided equitably and in an environment suited to those with disability
Multidisciplinary – care must be collaborative and integrated across all sectors of health care. A strong MDT is pivotal for this.

The key standards for the practice of rheumatology are laid down in the following:

Guidance	Comments
Specialist society and patient organisation standards and guidelines	The British Society for Rheumatology (BSR) commissions and produces its own guidelines, which are available via the BSR website and are published in Rheumatology BSR guidelines are accredited by NICE, involving an evidence-based process Other specialist societies and patient organisations have also produced guidance and standards (eg NOS, BSPAR, NRAS, EULAR) Choosing Wisely UK recommendations
NICE guidance and quality standards	NICE has produced a large number of technology appraisals, clinical guidelines and quality standards relevant to rheumatology
ARMA standards of care project	The UK Arthritis and Musculoskeletal Alliance (ARMA) has produced a series of documents, covering a wide range of MSK conditions, defining reasonable expectations of care and services. These are accompanied by audit toolkits
Other NHS standards specific to rheumatology	The former National Patient Safety Agency set out important principles for the safe use of methotrexate, and defined some misuses of methotrexate as NHS ’never events’ Specialist commissioning policies
Other local standards for rheumatology	Many providers and CCGs have developed frameworks for high-quality safe rheumatological practice, for example around the shared care of DMARDs

Evaluation of standards of care

Standards and guidelines should always include a framework for audit and evaluation. A number of national and local approaches to audit and evaluation have been taken within rheumatology. Evaluations driven within the specialty have also been supplemented by the publication of reports produced by outside bodies.

Evaluation	Comments
National audit of early inflammatory arthritis	The national audit ran from 2014–15 and reports are in the public domain The second national audit commenced in 2018 Audit against NICE RA quality standards and measures of patient outcome Sponsored by HQIP and part of NCAPOP and NHS quality accounts
BSR biologics register	Although primarily a research tool, effectively provides a rolling national audit of biologics usage against NICE technology appraisals and clinical guidelines
Other national audit	BSR has developed other national audits eg Gout 2013/SLE multi-regional audit 2018
National disease registries	Under the auspices of specialised commissioning, national registries of rarer disease will be developed, including systemic lupus erythematosus (SLE) and ANCA-associated vasculitis (AAV). These will effectively act as a rolling national audit, particularly of the use of complex and expensive treatments
Local audit	Most rheumatology units will have local audit programmes looking at both national guidance and local guidelines (eg shared care)
Local and national peer review	Rheumatological peer review is well established in many parts of the UK. BSR is developing a national framework and unified documentation to support this
Other national reports	In 2009, the National Audit Office produced a report reviewing national performance against certain NICE standards, and importantly included an economic analysis In 2012, the LSE produced a pan-European comparison of access to biologics, noting poor access in the UK
Medical appraisal and revalidation	Participation in quality improvement and patient surveys are key requirements for revalidation
Internal governance processes	Most trusts have rigorous internal governance structures for reporting and investigation of complaints and clinical incidents, and review of mortality
Other measures of patient outcome	Some services systematically collect PROM (patient reported outcome measure) data. An overarching MSK PROM (MSK-HQ) has been developed
Other measures of patient experience	Most NHS organisations systematically collect patient satisfaction surveys, friends and family surveys and other PREMs (patient reported experience measures)
Other measures of staff experience	Most NHS organisations collect data on staff satisfaction, and surrogate data is available in terms of sickness rates and recruitment and retention
CQC inspection	All healthcare providers may be subject to inspection, although these will rarely be rheumatology specific

Many mechanisms exist to translate the results of audit and evaluation into improvements in practice at the levels of individual clinicians, rheumatology units, provider trusts and commissioners. There has also been an attempt to incentivise one aspect of good-quality care with the development of a best practice tariff for early inflammatory arthritis. This funding mechanism has entered its second year but remains under evaluation.

Accessing data for quality improvement

The National Clinical Audit for rheumatoid and early inflammatory arthritis ran from 2014–15 to examine the assessment and early secondary care management of all forms of peripheral joint early inflammatory arthritis in NHS secondary care settings in England and Wales. The second national audit began data collection in 2018. These audits include performance against NICE quality standards, and a range of patient outcome and experience measures, along with organisational data such as staffing levels and service configuration. The audit is intended to help clinicians improve their quality of care for patients, and facilitate negotiations with their employers and commissioners to improve services. As with the BSR registries, researchers and academics can apply to access the dataset in order to undertake further research.

The annual reports from the first national audit were published in January 2016. They show that only one-third of patients with inflammatory arthritis are not seen within the NICE quality standard of 3 weeks of referral from primary care, and that this leads to delays in treatment. The audit also demonstrated huge variation in practice between individual units across the NHS in England and Wales. This was the first systematic benchmarking of rheumatology units across the NHS. The report provided a breakdown of performance at trust level, and trusts can also access their detailed data for local analysis. This local data provided detailed information about treatment and patient experience beyond that included in the national report.

The BSR has details of the registers for biological therapies. Other smaller national audits supported by BSR have been carried out, including an audit of gout management and a follow-up in 2014 looking at treatment targeting uric acid levels. Most centres undertake local service and quality improvement projects to drive up the standard of care for rheumatology patients, examples of which are provided here.

Last reviewed:13/08/2018