Fife Rheumatic Disease Unit

04/04/06 : Dr Jane Gibson, Consultant Rheumatologist, FRDU

Where is Fife?

The kingdom of Fife lies north of Edinburgh and south of Dundee on the East coast of Scotland. It has a population of 350,000 which is mainly rural but with three main towns; Kirkcaldy, Dunfermline and St.Andrews. The ‘East Neuk’ of Fife is famous for its fishing villages and beautiful beaches.

The Department

Fife Rheumatic Diseases Unit (FRDU) covers all of Fife and provides care for patients with any rheumatic disease. We have a central department at Cameron Hospital where all the team is based but most of our work is either within the patients home or in hospital outpatient clinics Most rheumatology units nowadays are ‘team-based’ but few are lucky enough to employ their own physiotherapists, podiatrists, occupational therapists, specialist nurses and psychologists. We do! Not only that but the team members share offices so that they can easily discuss patients together in order to improve their overall care. The consultants offices are next door so that we can pop in and out of each others’ rooms very easily. This may sound too cosy for some doctors but it really works for us and helps us share information easily. We divide the unit into area teams; West, Central and North-East Fife. This means that patients can get to know their own ‘team’ and know who to call if they need help. Another difference in our department is that all aspects of patient care is planned by agreement. Instead of being led from ‘top down’ by the medical consultants, all members of the team are equal and are responsible for the ethos and structure of the Department. Planning for the Department as a whole takes place at regular business meetings and annual, goal-setting, ‘away days’.

Where do we see patients with Rheumatoid Arthritis? Outpatient clinics are held at 4 sites across Fife, all with full appropriate facilities. All new patients are seen by a Consultant Rheumatologist or Associate Specialist (equivalent to consultant). If RA is diagnosed, patients receive an information pack regarding the team, their disease, their new drugs, blood monitoring sheet, telephone helpline number and details of the ‘drop-in’ clinic. They will then be referred to the team who will arrange to see them individually at home. All members of the team except the doctors and podiatrist see the patient in their own home. Of great importance is the addition of patient representatives to our team over the last few years. Our patient representatives take part in departmental planning, assist us in preparing patient information and act as a support for patients with inflammatory arthritis. In this respect they are very much like the expert patients that NRAS are currently training.

The team approach to patient care

The aim of what we do is to provide high quality medical care but also to‘empower’ the patient. This means giving the individual the skills to enable them to have some control over their own disease. Without these skills and knowledge, it is harder for them to take an active part in their management. It is our firm belief that the patient should lie at the centre of all our efforts and should have a say in their treatment. That is why we feel that seeing the person at home is important. People are more relaxed and able to take in information when in their own surroundings. Carers, family and friends can also take an active part in the sessions if wanted. From our point of view we get a much better understanding of what is important to each person if they are seen at home rather than in the sterile atmosphere of an outpatient clinic room. In particular, those who see the patient at home are often able to bring important social information back to the doctors who are relatively isolated from this aspect of a patients’ life. Greater understanding of the individual, their priorities and goals can improve our efforts to involve the patient in their care.

The team approach to education

Patient education is the key to successful management of chronic disease. Education starts in the clinic when the diagnosis is made but it is recognised that most patients are unable to remember most of what is explained at that appointment. Within four weeks therefore the specialist nurse will see them at home with their carers to discuss in detail their diagnosis, its implications, drug therapy and self-help techniques. This will usually take three visits. The physiotherapist is usually next out and the OT after that. Podiatry appointments are in local clinics all over Fife. “I am more likely to do my exercises at home because that’s where I was taught them”
The team approach to pain management

Early aggressive intervention with Disease Modifying Anti Rheumatic Drugs (DMARDs), regular exercise, joint protection techniques, preventative podiatry strategies and thorough patient education are all aimed at reducing disability by maintaining function and reducing pain. We are also able to prescribe anti-TNFalpha therapy when required but despite all these measures, many patients continue to experience significant pain and stiffness. This can lead to sleep disorders, loss of social interaction and confidence, depression and loss of employment. The team members consider these aspects at every interaction and have strategies for dealing with them. Some of the other special services that we provide are:

    * Specialist nurses skilled in management of sleep disturbance.
    * A joint protection course for all appropriate new patients with inflammatory arthritis
    * A fatigue management course for those suffering intolerable fatigue.
    * Special expertise in pain management using complementary therapies, relaxation techniques and T’ai Chi.
    * A bath lift loan service for those unable to get in and out of the bath
    * A drop-in clinic. Patients do not need an appointment but if they are having a flare-up can ‘drop-in’ and get their joints injected or intramuscular injection of steroid

What are we most proud of?

The strength and dedication of the whole team working for the welfare of the patient. What should we do next? We are always looking for ways to improve what we do. NRAS have offered to help us with an audit of our practice to see if there are areas where we ‘could do better’. We will take these results and use them with all the new therapies available to make sure that patients get the care they deserve.