Queen's Hospital Foundation Trust, Burton

The Burton Hospital Foundation Trust serves a population of about 250,000. This semi rural community is centered around the historic town of Burton on Trent located south of the peak district. The town is surrounded by large conurbations including Birmingham to the south, Derby to the north, Stoke on Trent to the west and Nottingham and Leicester to the east. Despite the catchment’s population, Burton and nearby towns such as Uttoxeter and local villages had no specialist rheumatology services until the arrival of Dr Mohamed Nisar in 1995.

Previously patients had to either endure long and uncomfortable journeys to specialist units in the larger cities or were managed by non-specialist physicians and orthopaedic surgeons locally or by their own general practitioners. It was during the last period of local commissioning in the form of GP fund holding that the need for a specialist in rheumatology based in Burton was recognised.

In appointing Dr Mohamed Nisar from the Sheffield Centre for Rheumatic Diseases, The Queen’s Hospital in Burton on Trent gained an enthusiastic rheumatologist committed to the delivery of modern, multidisciplinary rheumatology care. Senior physiotherapists with an interest in musculoskeletal medicine and rheumatology and a clinical nurse were identified and recruited to the fledgling department within a year. Formal and consistent inclusion of occupational therapy proved more difficult but was eventually added incrementally from 1998.

Rheumatology TeamReferrals to the new department grew rapidly reflecting not only the well recognised iceberg of musculoskeletal pathology in the community but also the need for specialist assessment and ongoing care for a significant proportion of cases. To cope with the influx of referrals Dr Nisar and his team adopted a two pronged strategy. First, the multidisciplinary team functions were integrated to ensure efficient and timely input from the team which operated as a mutually supportive unit. Second, autoimmune connective tissue and inflammatory joint diseases were considered department priorities. To this day well over 80% of the workload falls within these categories.

Dr Nisar has developed an interest in the treatment of inflammatory joint diseases including rheumatoid arthritis and the assessment and care of patients with a wide range of multi-system connective tissue diseases including systemic lupus erythematosus and scleroderma. In addition, a longstanding interest in multidisciplinary team care has been harnessed to assemble and develop a team of specialist therapists and nurses capable of delivering patient care equivalent to best practice and beyond.

Despite the immediate success and obvious value of the rheumatology service to the local population, 11 years lapsed before the appointment of Dr Ramsharan Laxminarayan as the second consultant rheumatologist. Dr Laxminarayan is trained in Osteoporosis and musculoskeletal ultrasound. The department has recently acquired a state of the art portable Toshiba ultrasound scanner mainly for use in the diagnosis of early inflammatory arthritis. Osteoporosis services have been established as a staged process and significant further development has been proposed.

The consultants are ably supported by Dr Subha Arthanari, associate specialist in rheumatology who has an interest in pregnancy in rheumatic diseases as well as musculoskeletal ultrasound. The team have presented findings of a variety of clinical and observational research projects at the both the BSR and EULAR annual conferences. The department actively participates in national and west midlands regional audit projects the results of which have confirmed consistently high standards of care throughout the department.

The nurse specialist team has grown from a single post in 1996 to 3.5 whole time equivalent nurses including a part time research nurse added recently, funded by the local research network. All nurses undertake traditional nurse specialist roles including patient education, introduction of medication, monitoring and metrology but also undertake added-value tasks such as annual review of inflammatory arthritis patients along with co-morbidity screening. The importance of annual nurse and therapy review were first proposed by the team at Burton in a presentation to the BSR in 2002. As part of the step-wise development of the department, Sr Jane Whitmore has been in post for 5 yrs with primary responsibility for patients on biologic drugs. Sr Denise Tilley provides care and support for a challenging and complex cohort of patients with multi-system connective tissue diseases.  Srs Julie Leggett and Clare Williams complete the nurse team and provide traditional clinical nurse and research functions respectively.

Physical therapy includes Physiotherapy and Occupational Therapists who share their treatment and office areas ensuring a seamless service for their patients. The core team includes physiotherapists Allison Dean, Hilary Smith and Helen Nutland, and Occupational Therapists Alison Holmes and Nicola Briggs, and they have worked together for over 10 years. OT and physiotherapy trainees and students from Derby, Birmingham and Keele universities regularly rotate through the department.
The mission of the OTs and Physios is to support their consultant and nurse colleagues to provide comprehensive full packages of care for Rheumatoid arthritis and other complex rheumatological conditions, truly demonstrating multi-disciplinary team work.
This includes performing combined OT and physio assessments of patients, and patient education.

Team round TableTreatment is targeted to the needs of the patient, whether this is flare management, understanding how to protect joints, returning to work or learning to communicate with their health care professionals and families’ about their problem. Periodically, group education sessions for inflammatory joint disease, osteoporosis and knee arthritis are held. These present an opportunity for the team to remind patients how to manage their condition, and reinforce the importance of attending regularly for reviews and monitoring. The role of the whole team is reinforced.  A ‘fast access’ clinic is held weekly for Rheumatology colleagues to access, on behalf of patients who may be in a flare. Patients known to the department may refer themselves if they have concerns they wish to discuss with the dedicated therapists.

A therapy annual review is offered to all patients with Inflammatory Arthritis, to ensure that they understand how to physically manage any changes in their condition. Selected patients such as those in remission or with low disease activity and particularly those on biologic therapies are encouraged to progress to more advanced levels of fitness and even supported to attend local gyms.  Many people also receive expert advice regarding return to work or claiming benefits. Other innovations have included developing a model of care for therapy involvement in multi-system and connective tissue diseases. Recently an audit of the use of the popular games console, ‘Wii-fit’ for advanced foot deformity in RA was presented at EULAR 2010 and BHPR 2011.
      
The Burton Hospitals dept of rheumatology has participated in all major recent surveys and audits including the BSR early inflammatory arthritis audit and the King’s Fund survey of provision for patients with rheumatoid arthritis. In each of these assessments the dept has performed extremely well despite local constraints and limitations resulting from its small size, for example in the establishment of an early arthritis clinic. These findings merely confirmed the results of a detailed audit of care of patients with inflammatory arthritis against the ARMA guidelines conducted by the West Midlands Rheumatology Services and Training Committee in 2006.

In December, 2009, the rheumatology dept at Burton was peer-reviewed by a team of senior colleagues for various hospitals in the West Midlands as part of the West Midlands Rheumatology Services and Training Committee cyclical peer review of rheumatology services. After a detailed inspection the committee concluded “The Rheumatology Dept at Queen’s Hospital Foundation Trust, Burton offers a high quality rheumatology service with a number of examples of best practice. The Trust should be proud of this department…. a jewel within the Burton Hospital services…” The committee also encouraged investment in an already well established culture of research and innovation in the department as well as selected expansion in services to address local needs. The former is underway with the recent appointment of a research nurse; the latter however, is now inevitably subject to local and national health economics.

In the last decade, the department has been instrumental in forming patient support groups allied to national patient organisations within the musculoskeletal alliance. These include Arthritis Care, Raynauds and Scleroderma Association, National Ankylosing Spondylitis Society and of course, NRAS. In the uncertain times ahead for the NHS as a whole but particularly for patients with challenging, complex and chronic conditions like those needing the expertise of a multidisciplinary rheumatology team, departments across the country like the one at Burton Hospitals Foundation Trust will need steadfast and vocal support from local patient groups and their parent national organisations to ensure rheumatology services are not just protected but nurtured.