Patients in Focus - Runner Up 2004

25/01/04 : Dr Michelle Sinclair GP, Richmond Surgery, Fleet, Hampshire

Background

Richmond Surgery is a six-doctor practice with 11,000 patients, situated in the suburbs of Fleet, Hampshire. We have a mixed population, but have a significant, affluent, commuter belt population. The practice was a first-wave fundholder and is now a Personal Medical Services (PMS) practice. We are forward-thinking and for many years have attempted to blur the primary care/secondary care interface. This meets with the current Government's definition of intermediate care.

I became interested in anti-TNF therapy, when a young patient of mine became housebound due to her rheumatoid arthritis. A colleague had recently joined a pharmaceutical company and we were discussing the role of infliximab in severe rheumatoid arthritis.

I contacted our local rheumatologist to discuss the possibility of this patient receiving anti-TNF therapy. Unfortunately his experience had been marred by the death of one of his first patients, but he agreed to try my patient on the drug nonetheless. It was a resounding success and having become housebound in recent months, my patient returned to work. Six months later she walked, unaided, down the aisle and has recently taken up cycling with her semi-professional cyclist husband.

Having sparked my interest in this fascinating area of Rheumatology, I attended several national meetings on anti-TNF therapy. The message seemed always the same, this was a wonder treatment, but the logistics required for the growing need could pose a problem and the necessity for patients to indefinitely travel miles to receive hospital treatment was less than satisfactory. Our local rheumatologists at both North Hampshire Hospital and Frimley Park Hospital confirmed this. I raised the question as to whether it was a viable prospect to consider infusing infliximab in primary care, as a solution to the capacity and access issues that presented both hospitals. Both nationally and locally, opinions seemed to be the same. In theory, it could be done, but what about in practice!

Stakeholders

The first step in the long and sometimes arduous process was to identify the stakeholders involved in developing such a project. This included GPs, rheumatologists, patients, the PCT, the Local Medical Committee and the Medical Defence bodies.

Question 1 had already been identified. Was there a need? The answer was obviously yes.

We have three district general hospitals that we refer to locally and all have capacity issues. At the time of developing the project, the rheumatology department at North Hampshire Hospital was facing the prospect of losing its site for infusion completely. They were using the chemotherapy day unit for infliximab infusion and due to their own logistical problems, this seemed unlikely to continue. Frimley Park Hospital uses the Haematology Day Unit for infusion, but the numbers of patients being started on anti-TNF therapy was being restricted by the capacity of the day unit to infuse.

Consensus of opinion seemed to be that anti-TNF therapy use would also dramatically rise over the coming years. If we had capacity issues now, these would certainly worsen in the future. Initially used by rheumatologists, suggested anti-TNF drug indications seemed to be growing almost monthly. The gastroenterologists were already infusing the drug and nationally this use was being extended to dermatology and possibly other specialities.

Consultation Process

We then entered a long period of discussion with the various stakeholders. The list seemed endless.

• GP/Industry - Initial funding to develop the clinic until PCT funding started.
• GP/rheumatologists, both local and national - Practicalities of infusion, including safety issues, clinical governance, prescribing issues, responsibility and ownership.
• GP/PCT - To undertake to fund the clinic after its initial set-up and to further develop the concept of intermediate care.
• GP/LMC - Agreement as to the clinic/intermediate care acceptability within primary care.
• GP/medical defence body - medico-legal safety and acceptability.
• GP/pharmaceutical advisers - safety issues surrounding infusion and monitoring and development of a Shared Care Agreement.
• GP/hospital pharmacy and finance departments - logistics of practice reimbursement for the costs of the drug.
• GP/pharmaceutical distributor - logistics of drug delivery.

Shared Care Agreement

The next stage of the process was to develop a shared care agreement between the practice and the rheumatology departments, which dealt with communication, safety and monitoring. This needed to be ratified by the rheumatologists themselves, the pharmaceutical advisers at the PCT, the LMC, the Medical Defence body and the PCT itself. The outreach clinic would infuse patients who had been stabilised on infliximab and who would continue to be seen by their consultant for regular follow up, prescribing and monitoring. The practicalities next needed to be considered.

Practicalities

We required infusion nurses, equipment, cold storage drug delivery, GP presence, a communication link between the hospitals/surgery/patient’s general practitioner and a system of invoicing the hospital departments. Above all, the clinic set-up had to be to the highest standard.

This was not a cheap option, but a viable and, most importantly, a more accessible alternative. In order to set up a clinic we had to identify those patients who would be suitable to attend. This meant those patients in the immediate locality, though not necessarily in the Fleet area per se. The rheumatologists, the Haematology Day Unit and ourselves liased with patients to seek their agreement for their care to be transferred to ourselves, for infusion. Finally we had to bring all the logistical issues together to tally with the patient infusion timetables.

D-day

The clinic started on 9th October 2003 and we began with 10 patients from Frimley Park Hospital, all from the rheumatology department. We have received support from all of them in the development of this service and I include letters from some of them as patient endorsement.

Audit

It is our intention in March (six months after the start date) to audit the clinic. We will audit patient satisfaction, consultant satisfaction, adverse/significant events and cost.

Conclusion

As is so often the case in medicine, an individual patient case prompted a succession of events that has led to the development of the community based infusion clinic.

It has been a great success in terms of patient satisfaction, access and personal development. We hope that we have developed a formula that can be applied nationally, not only for Rheumatology, but also for other specialties.

Intermediate care is an exciting development in general practice. To bring low-intensity secondary care work into the community is not a new concept, but with the advent of PMS and the new GMS contract we should be able to bridge the gap between secondary and primary care.

At the end of the day, patient care should be delivered in an environment both suitable and acceptable to the patient, whether in secondary care or primary care. Although there has been a steep learning curve, this project has been hugely exciting and rewarding and I hope it will herald further developments in intermediate care. It has demonstrated that Primary Care, Secondary Care and Primary Care Trusts can work in partnership to develop and re-shape services in innovative ways to benefit patient care.