Scottish Public Health Network publishes its Health Care Needs Assessment of Services for Adults with Rheumatoid Arthritis

The National Rheumatoid Arthritis Society (NRAS) welcomes the publication of the Scottish Public Health Network’s Health Care Needs Assessment of Services for Adults with Rheumatoid Arthritis, a report that NRAS contributed to through consultation and referenced publications. 

The purpose of this report is to review and update the epidemiological data about Rheumatoid Arthritis (RA) in Scotland and use the views of all those involved in RA services to identify gaps, highlight priority areas for change and make recommendations that will assist NHS Boards to plan and develop future services. This Needs Assessment updates the findings of the last Public Health Institute for Scotland exercise, which was conducted in 2002.

The value of this report is revealed by the identification of RA as one of the major chronic diseases in Scotland. Approximately 37,000 people live with the condition and an estimated 1,851 new cases diagnosed each year. This is the first time detailed figures for the prevalence of RA in Scotland have been published.

One of the key findings was the need for early diagnosis and referral, something that is so often lacking at the moment. Scotland is not unique in this however, the pattern is the same all across the UK. The report confirms that “early treatment of RA improves outcomes” and this is something that NRAS fully endorses and hopes all parties can work towards achieving.

“We welcome this report as it demonstrates the urgent need to raise public awareness and promote early diagnosis of rheumatoid arthritis, as well as the need to improve the services for those already suffering from the disease in Scotland. We now hope the Scottish Government will take action to implement the report’s recommendations” said Ailsa Bosworth.

The important role the voluntary sector plays when it comes to employment and the societal impact of RA was also highlighted in the report. A third of people with RA are forced to stop working within 5 years of diagnosis and the report claims that agencies such as NRAS provide a wealth of support to patients on employment and social issues, helping to raise awareness and empower patients to manage their employability and job retention problems.

The report concluded that “there is no reason why Scotland cannot be a world leader in RA health if there is a collective desire to attain the best we can for all who suffer this condition.” NRAS would welcome the chance to work with the Directorate for Health and Social Care to try and make this happen.

Key issues & recommendations

The report identifies seven key issues that give cause for concern and these are:

•    The need to shift practice towards early diagnosis and treatment;
•    Ensuring the appropriate management of chronic disease;
•    Access to the multidisciplinary team (MDT);
•    Managing the cost pressures associated with RA drug prescribing;
•    Reducing work disability due to RA;
•    Meeting training and staffing needs; and
•    Auditing and improving outcomes.

These seven issues and the subsequent recommendations are outlined below:

•    The need to shift practice towards early diagnosis and treatment. Although there have been improvements in recent years, there is still considerable delay in diagnosis. A particular concern was raised that the development of new triage pathways for musculoskeletal diseases may inadvertently lead to further delays.

The report recommends that referral guidelines with clear referral routes should be agreed with GPs and that public awareness should be raised to limit the delay in patients first visiting their GP. Referral protocols for physiotherapy triage services should also be developed to redirect patients more appropriately and rheumatology units should give rapid access appointments for people with suspected RA. All Boards should ensure that Early RA clinics or similar service arrangements are in place to deliver ‘intensive, treat to target’ management of patients with newly diagnosed RA.

•    Ensuring appropriate management of chronic disease. The number of DMARD and biologic therapies has increased substantially and will continue to do so, but many enhanced service agreements have failed to keep pace with this.

The report recommends that assessment tools should be applied from the outset to enable monitoring of progress and treatment to target. Imaging facilities for ultrasound examination by a clinician or technician with experience in musculoskeletal ultrasound scanning of inflammatory arthritis should be made available. A management plan should be put in place for all RA patients to address co-morbidities (this could take place in an annual review), self-management should be made the ‘cornerstone’ of chronic disease management and RA patients should be given access to the rheumatology team between scheduled appointments when required.

•    Access to the multidisciplinary team (MDT). Most rheumatology departments in Scotland now have at least some elements of a MDT but provision is patchy and most units do not have all professions attached to their Unit.

The report recommends that all patients with RA should have access to assessment by a full MDT, via clear referral pathways and members of the MDT must have specialist training in Rheumatology and should preferably be attached to the Rheumatology Unit.

•    Managing the cost pressures associated with RA drug prescribing. £22.5 million is spent in Scotland each year on biologic drugs for the treatment of RA and Boards expect the budget to grow by around 10% per annum.

The report recommends the development of a National Biologics Database to assist Boards to predict future spending and infrastructure requirements. It recommends that each rheumatology unit should have access to an infusion facility, with adequate capacity, staffing, equipment and protected from seasonal closures. Each Board should also have local protocols in place for the monitoring of DMARDs, including parenteral methotrexate, by GPs. An annual review of drug therapy should also take place in primary or secondary care.

•    Reducing work disability due to RA. Work disability is a common consequence of RA, with 1 in 3 having stopped working within five years of diagnosis and that screening patients at diagnosis and providing access to Vocational Rehabilitation and Occupational Therapy can be effective at improving work outcomes. However, capacity for such interventions is limited, with further clarification required over referral routes, and audit of the process and outcome.

The report recommends that early use of DMARD therapy should be employed to minimise work disability and all patients should be asked ‘the work question’ regularly by a healthcare professional and referred on for Vocational Rehabilitation/Occupational Therapy as necessary. Rheumatology units should have a pathway for referral to local employability networks, or similar.

•    Meeting training and staffing needs. Some rheumatology units do not currently have dedicated support from Allied Health Professionals (AHP), with small numbers of experienced AHPs learning on the job and no provision of training for their successors. The report also notes problems with consultant staffing levels falling short of recommendations made by the British Society for Rheumatology, with variation in levels across Scotland and limited succession planning.

The report recommends the development of rheumatology training programmes for nurses and AHPs should be encouraged through links with universities. The current and future staffing needs for AHPs should also be determined and succession planning for AHPs should be addressed as a matter of urgency. A review of the adequacy of medical staffing levels for RA services should be undertaken.

•    Auditing and improving outcomes. Many rheumatology units carry out local audit and there has been a coordinated system of national audit since 2006. However, recent audit results have shown considerable geographical variation in case mix and outcomes. There is an opportunity to build upon the existing network and strengthen national audit of outcomes in RA in Scotland and to use this as a tool to improve quality and reduce variation in clinical care.

The report recommends that key national agencies should support Scotland wide audit. This should focus on evidence based practice and the three domains in the NHS Scotland Quality Strategy. Rheumatology Units should collaborate on a national basis when developing local disease registers so that opportunities to facilitate audit, research and national data collection are maximised.

The National Rheumatoid Arthritis Society provides support, information and advocacy for people with rheumatoid arthritis and their families, friends and carers. They provide a resource for health professionals with an interest in rheumatology and work closely with rheumatology teams across the UK. For further advice or information on rheumatoid arthritis, visit the NRAS website at www.nras.org.uk or phone 0845 4583969.

ENDS

For further information on this please contact the NRAS PR & Press Officer – Andrew Scott – at andrew@nras.org.uk / 0845 4583969 / 07703 026974.

Notes:

•    RA primarily affects women who are approximately three times more likely to get it than men and can occur at any age, although onset is more common after the age of 40.
•    The mission of NRAS is ‘working for a better life for people living with rheumatoid arthritis’ by providing information, education, support and advocacy; raising public and government awareness of RA; campaigning for equity of access to best treatment and care; and facilitating the networking of people with RA and encouraging self-help.