Commissioning a service for the diagnosis and management of rheumatoid arthritis in adults

Rheumatoid arthritis (RA) is an inflammatory disease. It typically affects the small joints of the hands and feet, and usually both sides equally and symmetrically. RA is associated with a range of comorbidities, including increased risk of cardiovascular disease, infection and osteoporosis. In addition, people with RA often experience feelings of isolation and depression^[1][2]. The diagnosis and treatment of RA is led primarily by consultant rheumatologists based in acute hospitals. Currently, follow-up appointments (every 3-6 months) for people with RA can account for up to 75% of a rheumatologist's workload. These are often booked in advance and make it difficult to accommodate urgent reviews for flare-ups^[3]. NICE clinical guideline CG79 on rheumatoid arthritis recommends early treatment in recent-onset active RA and during a flare-up, access to a multidisciplinary team and offering review appointments to people with satisfactorily controlled established RA at a frequency and location suitable to their needs.

There are approximately 400,000 people with RA in the UK. The incidence of the condition is low, with around 1.5 men and 3.6 women developing RA per 10,000 people per year. This translates into approximately 12,000 people developing RA per year in the UK. The overall occurrence of RA is two to four times greater in women than men. The peak age of incidence in the UK for both genders is the 70s, but people of all ages can develop the disease. Around three quarters of people with RA are first diagnosed when of working age^[4].

Approximately one third of people stop work because of the disease within 2 years of onset, and this proportion increases thereafter. The total costs of RA in the UK, including indirect costs and work-related disability, have been estimated at between £3.8 and £4.75 billion per year. Clearly this disease is costly to the UK economy and to individuals. It has been estimated that RA costs the NHS around £560 million a year, with the majority of the cost occurring in the acute sector^[4].

The National Audit Office (NAO) report Services for people with rheumatoid arthritis has identified that:

• not all people with RA have access to multidisciplinary services
• 14% of trusts provide access to psychological services
• 15% of trusts offer routine monthly monitoring to people with active disease
• support or information to help people with RA self-manage their condition, and remain in or return to work is not consistently provided.

Economic modelling by the NAO suggests that increasing the proportion of people with RA who receive earlier treatment could initially increase the costs to the NHS by £11 million over 5 years due to higher expenditure on drugs and the associated costs of monitoring people with the disease. However, after 9 years earlier treatment could become cost neutral to the NHS^[4]. See also specifying a service for the diagnosis and management of rheumatoid arthritis in adults.

Despite recent advances in medical management of RA leading to a reduction in the requirement for surgery, significant numbers of people with the disease still go on to develop irreversible damage to joints and tendons. The NAO report Services for people with rheumatoid arthritis identifies that around 11% of people with RA on conventional drug therapy (not biologics) will need large or small joint surgery within 5 years of presentation, the need for surgery is linked to disease severity.

Benefits

The potential benefits of robustly commissioning an effective RA service include:

• early diagnosis and treatment with effective therapies reducing surgery rates and disability^[1]
• early treatment resulting in productivity gains due to reduced sick leave and people with RA remaining in work longer
• improving the quality of life and outcomes for people with RA
• reducing inequalities through improving access to the multidisciplinary (MDT) team and treatment during flare-ups^[4], and providing patient education to meet the needs of the local population^[5]
• increasing patient choice and improving partnership working, patient experience and engagement
• better use of resources by providing annual reviews and follow-up appointments based on individual need rather than at fixed intervals, which may release resources so that services are more able to meet the needs of people with RA during flare-ups
• better value for money could be achieved through increasing early diagnosis and treatment^[1], which could become cost-neutral to the NHS after around 9 years^[4].

Key clinical issues

Key clinical issues in providing an effective RA service are:

• early identification and referral for specialist treatment, improving diagnosis and the suppression of inflammation in the early stages of the disease^[1]
• minimising disease activity through the use of disease-modifying anti-rheumatic drugs (DMARDS) to optimise the chances of preventing progressive damage to joints with subsequent disability and reducing the need for surgery^[1]
• relief of pain and fatigue are very important to people with RA, therefore drug management should also aim to relieve pain
• reducing anxiety and depression which are associated with fatigue and pain^[1], however only 14% of trusts provide access to psychological services^[4]
• assessing the risk of heart conditions which are more common in people with RA and result in premature death for many patients
• providing personal care plans, patient self management and annual reviews can improve appropriate and timely access to treatment for people with RA during flare-ups
• providing the best possible outcomes for individual patients, their carers and local communities including supporting people with RA to remain in work
• providing a quality assured service.

National drivers

National priorities and initiatives relevant to commissioning an RA service include:

• Equity and excellence: liberating the NHS: Transparency in outcomes - a framework for the NHS (draft for consultation).
• Revision to the Operating Framework for the NHS in England 2010/11
• Procurement guide for commissioners of NHS funded services 2010.
• Quality, innovation, productivity and prevention
• Commissioning for quality and innovation makes a proportion of providers' income conditional on quality and innovation
• The national service framework for long-term conditions sets clear quality standards and pathways for people with long-term conditions.
• The musculoskeletal services framework makes recommendations for offering more care closer to home including rheumatology services.
• The National Audit Office: Services for people with rheumatoid arthritis
• Supporting people with long term conditions: An NHS and social care model to support local innovation and integration identifies key aspects of care for people with long-term conditions including case management, disease-specific management and supported self-care.
• Supporting people with long term conditions: commissioning personalised care planning - a guide for commissioners. A guide to developing services, which promotes individualised care and self-management to achieve improved outcomes for people with long-term conditions such as RA.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. National Collaborating Centre for Chronic Conditions (2009) Rheumatoid arthritis. National clinical guideline for management and treatment in adults. London: Royal College of Physicians.
2. Luqmani R, Hennell S, Estrach C et al. (2009) British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Oxford University Press.
3. Kirwan JR, Mitchell K, Hewlett S et al. (2003) Clinical and psychological outcome from a randomized controlled trial of patient-initiated direct-access hospital follow-up for rheumatoid arthritis extended to 4 years. Rheumatology 42: 422-6.
4. National Audit Office (2009) Services for people with rheumatoid arthritis. London: The Stationery Office.
5. Adebajo A, Benkiron L, Dieppe P (2004) Patient education for diverse populations. Rheumatology 43:1321-2.