As part of the Connect Health Change webinar series, we present the Q&A summary from our panel who discussed Community rheumatology services – now essential for 2022/23.
Connect Health “Change” brings you the latest in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
Rheumatology departments in secondary care are under pressure and frequently not meeting quality standards due to increasing referrals and a shortage of consultant rheumatologists and supporting professionals in hospital services. This is evidenced for example, in the national early inflammatory Arthritis Audit where 52% of patients don’t have an annual review and assessment of Early Arthritis targets are often missed.
Rheumatology services continue to be inundated with non-inflammatory patients who should be managing non-inflammatory Community MSK services leaving rheumatology expertise to assess and initiate treatment in Early Inflammatory clinics. Reviews of stable patients with inflammatory arthritis can be well managed in community settings but many still attend the hospital. Recently to add to the debate, the British Society for Rheumatology referral guidance Oct 21 has made clear suggestions of clinical scenarios where patients should not be referred to Tier-3 specialist (hospital-based) services, including uncomplicated gout, polymyalgia rheumatica and fibromyalgia.
In this webinar our panel debated how troubled NHS Rheumatology pathways could be improved through development or expansion of community-based rheumatology services thus reducing the burden for hospitals and improving patient care where EIA and other targets are met – clearly beneficial to patient care. How far can community delivery go? Is there a line that shouldn’t be crossed that would affect patient safety?
Delegate feedback included:
- A broad range of speakers from different perspectives
- Really enjoyed the patient perspective, raised awareness of PMR ddx and workup in FCP
- Factual information about Rheum services and how they might change
Watch the Webinar in Full
Chaired by:
Dr Benjamin Ellis, from Imperial College NHS Trust and adviser to Versus Arthritis
Q&A
Dr Elizabeth MacPhie, Consultant Rheumatologist & Clinical Lead for Central Lancashire Moving Well, Lancashire and South Cumbria NHS Foundation Trust. Former Chair of Clinical Affairs Committee at the British Society for Rheumatology
Question 1: What challenges have you faced both internally within service and externally from general practice to get your service set up?
Answer: I’m very fortunate, I work in a community based service and I’m part of an integrated MSK service. We were fortunate that our commissioners locally recognised that there were huge benefits to be had by commissioning a rheumatology service. I would strongly advocate if you can avoid going down being recommissioned or retendered, as to do so is very stressful for the team not knowing where you’re going to be working, who you’re going to be working for. It does create a lot of uncertainty but what it did allow us to do was to shape the service, to put our cards on the table.
Working together in partnership has helped us to think about the importance of clinical discussions right across the patient pathway. At the point when patients are referred, we’ve got the opportunity at triage to discuss where this patient is best placed. We’ve also had a lot of opportunities to speak to primary care colleagues that have programmed educational events for GPs and primary care, it’s allowed us a really good forum to be able to work with primary care and raise awareness about how this service is working differently
Question 2: Is there a solution on its way to convert University Hospitals Morecambe Bay (UHMB) A&G to an eReferral?
Answer: I’ve just been on the ICB referral optimisation group and the functionality of converting an A&G query to a referral on the UHMB system is on the “to do list” for the IT developers. There is quite a lot of work to do to map this through as will need to flow through to eRS but it will happen.
Question 3: Do you support MSK interface services with any triage support or community consultant clinics to manage tricky referrals or where the outcome is not clear?
Answer: I would definitely support MSK triaging clinicians having a means to discuss “tricky” referrals with a rheumatologist. We are able to do this within our service due to how we are commissioned and it’s been hugely beneficial. We can also prevent multiple referrals through to different services about the same problem and we know this happens. How you set this up will need some thinking through, we divert referrals through eRS to a different triaging queue and if it’s really tricky send a message through EMIS or simply email or message colleagues.
Question 4: Do you think the funding for the provision of rheumatology might be more or less favourable as some elements (non-inflammatory) move to community MSK services?
Answer: Mindful that many departments are set up on a PBR model (though covid changed funding streams) and therefore referrals numbers = finance. However, we’re aware many departments are struggling with volume of referrals and I have no doubt would benefit hugely from being provided with the opportunity to reduce the non-inflammatory workload. We need to work with commissioners and across ICBs on metrics that focus more on quality and protect our funding. Our models of care and funding streams should not focus on referral numbers.
Question 5: You’re just moving the problem elsewhere?
Answer: We are a hospital service that moved into the community, so we provide everything that’s needed in a hospital setting. It’s not any cheaper to move people out of the hospital, but what it does allow us to do is to really de-medicalise long term conditions because people are being seen outside of a hospital environment. They feel a lot more relaxed coming to clinic and it’s a lot more accessible for patients. Being part of an integrated model has been the really big journey for us because it’s empowered us to be able to provide a different offer to patients.
One of the biggest drivers for us is the fact that we’re based at a football stadium, so there is loads of free and ample parking and that’s often the biggest thing that patients emphasise, as well as our team. I think sometimes we underestimate the stresses of going to hospital, particularly on patients with long term conditions and how many appointments they need to attend at the hospital.
Michael Dare, Rheumatology APP Essex and Kent Community Rheumatology services and National Rheumatology Lead for Connect Health
Question 1: Should everything be filtered through community?
Answer: No, not everything should be filtered through a community service. There are some conditions which are very serious conditions, emergency conditions, so there should be specific fast track pathways for those conditions to specialised services. Conditions that would fall into that category would be things like GCA, multi system connective tissue, disease and a hot swollen joint that could be a septic joint. There may be some others but for those conditions there should be specific pathways that can bypass the community service. And obviously there should be EIA pathway for your early inflammatory arthritis, whether that comes through a community service and is triaged directly onto the EIA pathway or whether that’s referred directly from primary care onto the pathway is neither here nor there. However, the vast majority of your arthralgia aches and pains, joint pain for several months or years, those are bread and butter for a community service and should come through a single point of access. Those patients can then be filtered out so that the ones that really need to go to the hospital can be referred to the hospital and the ones that can be managed by a MSK MDT team can be managed by the community based service.
The benefits for the patients are endless. They can be seen quickly. They can be redirected to the hospital if needed, or they can be managed in the community if needed and the long term benefits for that is improved.
Question 2: How can we use this learning to improve patient journeys from primary care?
Answer: The results can be used across the spectrum of rheumatic diseases. There are some exclusions which this is not appropriate for, but across rheumatic diseases whether we are talking about possible rheumatoid, gout, polymyalgia or psoriatic arthritis, it does need a specialised clinician review and work up. We need to ensure that every patient that walks into a consultants door in secondary care really needs to be there.
Benjamin: And I can follow that up. I think one of the things that people sometimes ask is whether this creates additional delays for people who, let’s say do have early rheumatoid arthritis of going through another service first. Do you have any data on that or any reflections?
We don’t have any data on that as per se, but due to the nature of the triage process that we employ, the triage is done in such a way that very obvious early inflammatory arthritis patients are triaged directly to the hospital anyway so we would never see someone with several swollen joints, raised inflammatory markers, new onset of inflammatory joint pain in a community service. I don’t think there’s really a delay to diagnosis, if anything there’s a positive benefit for the patient because something that was referred routinely should be picked up as inflammatory arthritis in a community and escalated on an EIA pathway in secondary care. We have several examples of that in our Community service where we have escalated to the significant benefit of our patients.
Benjamin: So in fact, they’re probably a lot of patients that some of us at the moment might be rejecting outright, saying there’s not enough evidence to meet the threshold to come to rheumatology but actually, if there was a proper community pathway people could be seen anyway and then get the support they need.
Exactly, and I think when patients are referred often, colleagues in primary care are asking for assistance to help diagnose or manage the patient. So a lot of the time the patient not being seen is not beneficial for all of our colleagues in primary care or for the patient themselves, a community service, that’s multidisciplinary staff is a perfect solution for that problem.
Question 3: How sensitive is the Spade Tool?
Answer: The study from Dr Raj Sengupta and Dr Shabina Habibi suggested a 88% Specificity and 70% Sensitivity with a 4 threshold. Sensitivity and specificity decreased with lower thresholds unfortunately.
Question 4: 92% conversion rate is fantastic Mike, did you MR scan and/or HLA-B27 test in your community service in this extended triage; and if so who funded this? (any concerns from community service contract re: increased investigations?)
Answer: We have a fully functional Community rheumatology service in South Essex. We have access to HLA-B27 and whole spine MRI and requested these when guided to perform further investigation by SPADE tool and using clinical reasoning.
Prof Bhaskar Dasgupta, Rheumatology Lead Consultant, Connect Health
Question 1: [Polymyalgia rheumatica] Why is it, that it’s the only systemic disease that primary care should be managing? Where does it come from?
Answer: It’s a historic legacy. It’s a legacy of the times when all the rheumatology patients were just treated with steroids and aspirin. Polymyalgia rheumatica like any other inflammatory condition, does respond to steroids so it’s a historic hangover and therefore GPs have been given the task of treating these patients because it does to an extent respond to steroids up front. We now recognise that there are complexities within the diagnosis and I’d really agree that these patients need to have stratification. What might be simple PMR, what might be PMR presentation of other connective tissue diseases, what might be the polymyalgia presentation of large vessel vasculitis? I totally agree that diagnostic complexity needs to be addressed and needs to be addressed now.
Benjamin: Makes me wonder if part of it’s because we think of it as something that mainly effects older people? I can’t help thinking there’s some age discrimination here, if it was something that affected younger people, we wouldn’t be saying to GPs, no you just manage it.
Absolutely, I mean it’s sister condition, the sight loss in GCA. No one bats an eyelid because it is occurring in older people. If younger people went blind with sight loss in one eye, I bet your bottom dollar we would have a totally different healthcare system for GCA.
Question 2: The recommendation for PMR support to be managed in a community rheumatology service – would this recommendation be for consultant input? ANP? GP with special interest?
Answer: Community Rheumatology services by Connect Health has an excellent MDT so you get opinion from the whole team.
Question 3: Given the workforce and skill shortages, productivity and efficiency are even more important. There are many ways to address this challenge, especially around the visibility of performance through live dashboards which require excellent systems. Is/has anyone done some benchmarking with other services and could you share the lessons, please?
Answer: By Dr Graeme Wilkes: We have been operating a live database with dashboards since 2017 at Connect and in February moved from PROMS data collected by clinicians with the patients to e-PROMS collected remotely before during and after episode of care. We are on a steep learning curve currently on this – we have 21,000 completed datasets already across with a wide range of data – demographics, PROMS PREMS etc. Happy to share and we are willing to help any NHS partner with that technology and our experience. We are benchmarking with a couple of NHS Trusts but it’s hard to find others who have developed to a similar degree
Dr Lesley Perkins, Joint MSK Lead for Waltham Forest, Tower Hamlets and Newham
Question 1: Given the demands and plans to move care out of hospitals added to the development of PCNs – do you think GPs have an appetite to become GPwER and on today’s topic – should we be training more GPs to GPwER level in Rheumatology or should this develop out of FCPs in Primary Care or both?
Answer: I think there is scope for both. I personally would love this and I think like all things this would allow for PCNs to encourage fibromyalgia diagnosis in general practice. I think it would also give patients more confidence. Advice and guidance, moving forward visioning for dealing with this within PCNs.
Question 2: What could people be doing right now that would make a difference to patients without collapsing the system?
Answer: Advice and referrals is one area where we could be more quickly communicating to support our patients without having to wait months for a clinic appointment, whether that’s telephone or face to face. Moving forward we need to be thinking about visioning and delivering more of this within PCNs and within general practice to support patients closer to home. But for now, just trying to set up those relationships is super important when it comes to delivering care better.
Tim Atkinson, Surviving pain advocate
Question 1: Do you think for most people, do you think people have strong feelings about who sees them or where they are seen? Or is it do they get the care and attention they need?
Answer: It’s do they get the care and attention they need and however that could be provided. Clearly anything that’s embedded in the community is an advantage, but I had a rheumatology consultation on the phone this morning with my consultant. I haven’t seen him in person for nearly three years, largely because of the pandemic. It would be nice to have some sort of face to face contact with somebody, not necessarily him, because I realise he’s snowed under with new referrals, but perhaps with one of the community nurses who again are massively overworked given the needs we patients place on them. Some people occasionally at least need that face to face contact.
Summary question for speakers
What is the one thing you would change to improve Community Rheumatology services?
Michael: I think I would change the perception and hostility towards the establishment and running of community-based services. There are more than enough patients to keep everyone very busy and we are all working towards a common goal of ensuring the patient sees the right person first time. This goal further feeds into the BSR and NHS GIRFT guidelines and aspiring to this goal ensures that those patients with new onset of disease can be seen quickly and initiated on treatment quickly and reach remission quickly in Tier 3 services. This goal saves joints, saves money, and saves livelihoods.
Tim: From a patient’s perspective all I want is consistency, as far as possible – seeing the same team playing by the same rules and, where there are necessary changes, having them (and the rationale for them) explained.
Prof Dasgupta: Upskill the FCPs with Ultrasonography skills – vital to sort out inflammatory from non inflammatory.
Watch the webinar again, which includes further insight from the speakers including a full Q&A session, and read more about the speakers here:
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