Queen Mary's Hospital, Sidcup, Kent DA14 6LT
Service review:
Department of rheumatology:
September 2006
Dr Andrew Bamji FRCP
Lead clinician
Introduction
What is Rheumatology?
A subspecialty of internal medicine that involves the non-surgical evaluation
and treatment of the rheumatic diseases and conditions. Rheumatic diseases
and conditions are characterised by symptoms involving the musculoskeletal
system. Many of the rheumatic diseases and conditions feature immune
system abnormalities. Therefore, rheumatology also involves the study of the
immune system.
What is a Rheumatologist?
A rheumatologist is a physician who is qualified by additional training and
experience in the diagnosis and treatment of arthritis and other diseases of
the joints, muscles and bones. Many rheumatologists conduct research to
determine the cause and better treatments for these disabling and sometimes
fatal diseases.
What kind of training do rheumatologists have?
After four or five years of medical school and three years of training in either
internal medicine, rheumatologists devote an additional four years to
specialized rheumatology training.
What do rheumatologists treat?
Rheumatologists treat arthritis, certain autoimmune diseases, musculoskeletal
pain disorders and osteoporosis. There are more than 100 types of these
diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus, back pain,
osteoporosis, fibromyalgia and tendonitis. Some of these are very serious
diseases that can be difficult to diagnose and treat.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Injection of the carpal tunnel
When should you see a rheumatologist?
If musculoskeletal pains are not severe or disabling and last just a few days, it
makes sense to give the problem a reasonable chance to be resolved. But
sometimes, pain in the joints, muscles or bones is severe or persists for more
than a few days. At that point, you should see your physician.
Many types of rheumatic diseases are not easily identified in the early stages.
Rheumatologists are specially trained to do the detective work necessary to
discover the cause of swelling and pain. It's important to determine a correct
diagnosis early so that appropriate treatment can begin early. Some
musculoskeletal disorders respond best to treatment in the early stages of the
disease.
Because some rheumatic diseases are complex, one visit to a rheumatologist
may not be enough to determine a diagnosis and course of treatment. These
diseases often change or evolve over time. Rheumatologists work closely with
patients to identify the problem and design an individualized treatment
program.
Children are not immune to arthritis
How does the rheumatologist work with other health care professionals?
The role the rheumatologist plays in health care depends on several factors
and needs. Typically the rheumatologist works with other physicians,
sometimes acting as a consultant to advise another physician about a specific
diagnosis and treatment plan. In other situations, the rheumatologist acts as a
a manager, relying upon the help of many skilled professionals including
nurses, physical and occupational therapists, psychologists and social
workers. Team work is important, since musculoskeletal disorders are chronic.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Health care professionals can help people with musculoskeletal diseases and
their families cope with the changes the diseases cause in their lives.
Rheumatologists also work closely with orthopaedic surgeons, who perform
joint replacements, soft tissue reconstruction and repair and nerve
decompression, and with radiologists who report on X-rays, CT, MRI and
ultrasound scans. They may also call upon neurosurgeons (in particular for
neck and back problems).
Population needs
Current RCP guidelines for Consultant Rheumatologist numbers suggest a
norm of 1 consultant to 85,000 population. Based on a local population of
220,000 for Bexley Borough that represents a requirement of 2.6 wte posts.
QMH has 1.75.
The Rheumatology unit at Queen Mary's Hospital
See “Hospital Doctor” Team of the Year submission, 2005 (appendix 1).
The department sees all rheumatological problems and runs clinics both at
QMH and Erith. An emergency access system is available for patients with an
acute flare-up of one or more joints. Dr Bamji sees children with arthritis. The
back pain triage service has significantly reduced inappropriate referrals to
orthopaedics and the Pain Clinic and has had an enormous impact on the
waiting time to first appointment in these and the rheumatology departments.
Staffing
The department has acquired associated staff who have helped to achieve the
current ARMA Standards of Care (specialist nurse – essential for biologics
monitoring and the helpline; specialist physiotherapist(s) for back and knee
pain and a specialist OT for hand work. These latter are also important for the
orthopaedic team).
The specialist nurse post has been the subject of review and was put “at risk”
as part of the Fit for Future programme. The department’s response was
robust – see Appendix 2. It is now accepted that a specialist nurse (or more
than one) is essential to the management of patients with chronic rheumatic
diseases and this is acknowledged both in Royal College and Arthritis &
Musculoskeletal Alliance (ARMA) guidelines as well as in the new
Musculoskeletal Framework document published this year (see
www.18weeks.nhs.uk/public/default.aspx?load=ArticleViewer&ArticleId=449). The
nurse provides emergency clinics, a telephone helpline, direction of the new
rheumatoid arthritis patient group and monitoring of RA patients on biologic
agents. The appendix outlines the cost implications of withdrawing the post;
even without a mechanism to charge for telephone consultations there would
be a net loss of income from withdrawal of the post, as the consultants would
have to abandon new patient clinics to provide the intensive follow-up care
required. This is further addressed in proposals for change at the end of this
paper.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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The other AHP departmental members are not directly funded under
rheumatology but are recharged as an overhead in the Trading Account, as
are the HCAs. We are exploring the charging system for the Back Pain Triage
service.
Secretarial cover was previously provided by 2 secretaries who worked solely
in rheumatology. This has been changed, and they now have to cover
neurology in addition and the typing support time is now completely
inadequate. The current arrangements are entirely unsatisfactory; the
secretaries are diverted from rheumatology care and as a result
communication with local GPs and patients is suffering. In the context of the
drugs used in rheumatology this is creating a serious clinical risk.
The potential problems were identified before the introduction of the new
system (Appendix 3), but the views of the clinicians were overruled. We
continue to monitor the situation carefully but as it appears that some
secretarial redeployment has led to underutilisation we believe that the
original status quo should be restored, not least because the neurologists are
largely off site and the secretaries are therefore carrying an unreasonable
clinical responsibility in an unfamiliar area.
Departmental achievements





Runner-up, “Hospital Doctor” Rheumatology Team of the Year, 2005
Catriona Howse (RSN) is one of 20 national Healthcare Champions
chosen by the National Rheumatoid Arthritis Society (NRAS) for 2006.
Dr Bamji is President of the British Society for Rheumatology (2006-8),
is a Regional Advisor for NRAS and a member of Council of RCP
(London). He has judged the HD competition this year and lectures
nationwide on rheumatology topics in particular relation to service
delivery
The department has an unrivalled digital image bank for teaching
The Back Pain Triage service and the departmental website are
included on the ARMA website as examples of good practice
Throughput
The unit has one of the highest throughputs of patients per doctor in the UK
(see Table 1). Inpatients are minimal. Day case drug administration
(infliximab) is performed on the Elmstead Unit.
The Musculoskeletal Framework underpins the need for a secondary care
rheumatology service for the management of inflammatory arthritis (IA)
Current Payment by Results tariffs are £230 for a new patient, £90 for a
follow-up. High cost drugs are excluded.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Table 1. Departmental statistics
2000-2001
Dr Bamji
Dr Cheung
Attended
Cancelled
Cancelled
by patient
by hospital
DNA
685
87
9
0
Follow-up
2214
400
70
0
Total
2899
487
79
0
New
764
108
26
0
Follow-up
1061
192
24
0
Total
1825
300
50
0
New
656
71
12
0
Follow-up
2490
244
64
0
Total
3146
315
76
0
New
2001-2002
Dr Bamji
Dr Cheung
734
97
21
0
Follow-up
1161
145
39
0
Total
1895
242
60
0
New
584
70
20
1
Follow-up
2662
285
73
37
Total
3246
355
93
38
New
2002-2003
Dr Bamji
Dr Cheung
734
91
5
3
Follow-up
1226
155
25
5
Total
1960
246
30
8
New
2003-2004
Dr Bamji
Dr Cheung
522
48
5
4
Follow-up
2695
252
75
20
Total
3217
300
80
24
New
722
103
12
14
Follow-up
1311
165
41
16
Total
2033
268
53
30
New
2004-2005
Dr Bamji
Dr Cheung
543
35
14
0
Follow-up
2836
279
69
32
Total
3379
314
83
32
New
777
58
11
6
Follow-up
1260
177
55
10
Total
2037
235
66
16
New
497
45
10
2
Follow-up
1833
198
38
11
Total
2330
243
48
13
New
478
35
12
3
792
117
17
1
1270
152
29
4
New
1/424/11/2005
Dr Bamji
Dr Cheung
Follow-up
Total
Casemix
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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A large proportion of new patients have non-inflammatory musculoskeletal
problems which can be dealt with on a “one-stop” basis. Of the first 123
patients analysed since June 2006, 67 were not offered a further appointment.
Of those that were, 23 had newly diagnosed inflammatory joint disease or
were transfers from other units with inflammatory arthritis. The remainder
required assessment of the results of treatment. Thus we have a robust
approach to discharging patients and given the pressure on clinics we are not
keen to hold on to patients unnecessarily. However in response to a request
from the PCT we have agreed an approach to reducing follow-up numbers
(see Appendix 4).
Follow-up patients are predominantly suffering from inflammatory joint
disease. They may need frequent monitoring in the early stages to stabilise
treatment and require at a minimum a yearly review (ARMA Standards of
Care). Dr Bamji currently has 589 RA patients and 411 other IA patients on
the books. Of 141 “other” patients, 42 have PMR and 5 have GCA – which in
many units are counted as non-RA IA
164 patients in total are on biologic agents. The cost implications are outlined
below.
The department runs spreadsheets for patient listing and currently uses a
commercial program, RheDAS, for monitoring RA patients
Monitoring
Shared-care monitoring is not formalised and many local practices,
particularly those from outside Bexley, are unhappy to monitor if they are not
prescribing. All Biologics monitoring and submissions of data to BSRBR are
coordinated by the RSN
Website
The URL is www.sidcuprheum.org.uk. The Introduction is taken from the site.
We established the site to improve communication in the then absence of a
hospital site. The site is being submitted as an innovation in the Health and
Social Care Awards round, 2006. It provides a wealth of information for
patients, GPs and specialists and is highly regarded. It also provides an
alternative contact portal.
Costs
The department has a small budget which is largely in balance. We
understand that this review was requested because the deficit showing in the
first 2 months of the financial year 2006-7 was in the order of £140,000.
The rheumatology nurse post was initially funded from a grant but on the
understanding that funding would be taken over by the Trust after the first
year. The overall cost is less than expected because the postholder has
chosen to work part-time, but as outlined above the loss of revenue
consequent upon disestablishment of the post outweighs any savings, so it
makes no economic sense. Furthermore my presidency of the British Society
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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for Rheumatology was conditional on the establishment of the post, and its
removal would break a verbal undertaking from the previous Chief Executive
and Medical Director which I was given in February 2005.
MRI costs are above budget. In the financial year 2005-6 the “overspend”
against notional allocation was in the order of £16,000. Analysis of this
showed that a substantial proportion were shoulder and back scans. The
former cannot be reduced on clinical grounds (although offering open access
to GPs, clinically suspect as this is, may transfer this cost). Shoulder scans
could be reduced by making orthopaedic referrals without scans, but this
would burden that department with unnecessary referrals (often a scan
identifies a problem that will require medical rather than surgical intervention)
and would transfer any spend to that department. The inadequacy of the
allocation represents a failure in our view to uprate with changes in clinical
practice. The use of ultrasound is being discussed; however this requires a
capital outlay for a machine, though it would undoubtedly produce a revenue
saving on MRI and has major advantages in the investigation and monitoring
of small joint and other soft tissue problems such as carpal tunnel syndrome –
thus additionally saving on electromyography.. Pathology costs are generally
low. Use of anti-CCP testing may enable us to target treatment more
effectively.
The hospital does not have a DEXA scanner. This is because a detailed
analysis undertaken some 10 years ago indicated that the convenience of
local scanning was outweighed by the capital and revenue consequences of
maintaining and running the machine. As there is no waiting list of
consequence at neighbouring sites (QE and Guy’s) the cost per scan using
these units is significantly lower than providing an in-house service.
However, changes in screening policy may make it cost-effective to provide
scanning that accrues GP income.
High cost drugs
Biologics cost £10,000 per year per patient. These are currently licensed for
rheumatoid arthritis and psoriatic arthritis; we await a decision on ankylosing
spondylitis, but the clinical effects are little short of amazing in the small
eligible group we have commenced. We have 165 patients currently on
biologics. A breakdown by PCT will follow. We are thus spending over £1.5m
on them The available drugs are etanercept (Enbrel), infliximab (Remicade)
and adalimumab (Humira) – they are collectively known as TNF-α blockers.
More recently a B-cell depletion drug, rituximab, has been licensed for TNF-α
failures; the cost per cycle is approximately half that of a year’s TNF-α
blockade, but holds the prospect of inducing remission after 2-3 courses.
Further research evidence is awaited. Analysis of invoices suggests that over
90% of the 2006 overspend is attributable to this expenditure alone and our
advice from the Accounts department confirms this. The problem is twofold –
a failure to recharge to host PCTs and an inadequate allocation from Bexley
(or both). Bromley, Greenwich and Kent agree patients on a cost per case
basis and so all invoices should automatically be paid when presented.
However the total allocation for NICE approved high cost drugs from Bexley
CT is simply insufficient. They claim a statutory duty to stay within budget, but
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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we have a statutory duty to provide NICE-approved drugs. In this context it
should be noted that the Bexley CT HSS return shows that they claim
compliance with section 5a (the section covering this) – but in view of the
current problems this is untrue, and I have notified the Department of Health
of this. In my capacity as President, British Society for Rheumatology I have
also been invited to discuss matters of moment with the Healthcare
Commission, who have specifically asked to cover problems on NICE HTAs,
so I will be notifying them of our local problem as well as the many others
around the country.
The impact of biologic drugs could be reduced by the introduction of
subcutaneous methotrexate. Use of oral MTX is limited by its absorption and
the development of side-effects. S/C administration allows higher doses
without concomitant higher toxicity. MTX failure is a precondition for biologics
administration; thus, enabling more effective use of MTX may delay or avoid
the need for biologic agents. S/C MTX costs, on home delivery, about £75
monthly compared to £710 for a biologic agent. There is resistance from the
Pharmacy on this; further discussions will be held later in the year.
Problems
The unit is struggling to cope with the pressures of cuts. Continuing threats to
staff posts have caused damage morale-wise. That said we believe that we
provide an excellent service, and this is underpinned by the comments of
patients, relatives and GPs – indeed we attract a substantial number of
referrals from all the surrounding PCTs.
Compared to other units we are grossly underprovided with specialist nurses
and as noted are short on consultants. We have some support from a
rehabilitation SpR but problems in the rotation have led to long gaps, and this
is anyway a supernumerary post.
Pressures on us to reduce follow-ups have been unreasonable, but this issue
is being addressed; however, hard data on reduction will not be available for
at least 6 months.
Proposals

Restructure of the Choose & Book clinics to reflect GP and patient
need, and bring the Back Pain Triage service into the system as a
rheumatology assessment clinic. (Note: this will be delayed as the
national keyword/clinic type lists have been modified without
consultation with the British Society for Rheumatology and are now
inappropriate and incorrect)

The Specialist Nurse post must be agreed as a permanent post. Its
costs are outweighed by the income it brings in; it is essential for
monitoring and audit as required by specialist standards of care; and
without it the withdrawal of biologic drugs from patients who are not
responding will be delayed
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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
The secretarial service must be restored to its previous level to avoid
delays in communication and thereby patient risk. We do not feel that
our clinical concerns at the time of re-organisation were taken
sufficiently seriously, and regret that our fears have been entirely
justified. This impacts on neurology as well as on rheumatology. The
secretaries are under enormous and unacceptable pressure, while
other secretaries appear under-employed. We propose that the
neurology secretary post be re-established immediately and the work
returned to its previous (excellent) incumbent.

A managed reduction of follow-up patients is possible but limited by the
needs to provide a high quality service as recommended in
professional standards of care. We may be able to reduce some RA
follow-ups from 6 months to one year if stable; however it is possible
that this will generate additional urgent appointments. Removing some
other groups (such as chronic pain patients) may result in rapid rereferral. We believe, given the pressure on our clinics, that we should
be allowed to manage this process without interference; it is in our own
interests to reduce our follow-up burden but clinical need is paramount.

Introduction of S/C MTX is a priority and will save money – if two
patients yearly are deferred by one year then the overall saving is
about £18,000.

Recharging for biologics must be tightened up. Negotiations are
urgently needed over the high-cost drug allocation from Bexley CT,
which is woefully inadequate and will accordingly lead to rationing
and/or breach of our statutory duty to provide the drugs for eligible
patients. Sorting this out will solve the financial issues

Anti-CCP antibody testing was agreed in a business case at the end of
2005 and has not yet been introduced. This is a priority and may
enable advance screening for disease severity – thus targeting therapy
more effectively.

Consideration should be given to a financial analysis of provision of a
DEXA scanner to be sited in the Erith Hospital X-ray department

A business case for musculoskeletal ultrasound should be developed
to enable savings on MRI and electromyography

The Musculoskeletal Framework requires the development of a CATS
(Clinical Treatment and Assessment Centre). We believe this is best
provided by a triage service comprising rheumatology (including our
GP(SI)), orthopaedics and physiotherapy. Any other proposal will
cause chaos with Choose & Book and will duplicate work at
unnecessary expense.

I am concerned that continuing threats to the department’s staffing will
cause medical and medicolegal risks or result in unfavourable or
unwelcome publicity. It is well recognised that the patient lobby in
chronic diseases is both vocal and influential and has already
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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intervened locally; this has resulted in pressure from patient groups and
MPs, press reports and culminated in a visit from the All-Party
parliamentary group for Rheumatoid Arthritis. I hope that this
document indicates our understanding of the problems facing us and
the willingness to explore innovative solutions, but clinical integrity and
avoidance of risk remain paramount
If the hospital configuration remains the same, then these proposals will
suffice. However, if the development of an on-site ISTC and proposals for
changing the configuration of acute hospitals lead to the withdrawal of A&E
then I propose that serious consideration be given to a network arrangement
for musculoskeletal services using Queen Mary's as a hub for both outpatient
and inpatient work as well as diagnostic facilities, and drawing in the
appropriate departments from the QE and Princess Royal.
Another possibility would be to adopt the Stoke model where musculoskeletal
outpatient (and this includes rheumatology inpatient and day case work) are
moved, managerially, into the PCT.
I will be pleased to appear before the Board to discuss this document.
Dr Andrew Bamji FRCP
18th September 2006
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Appendix 1
Queen Mary's Sidcup rheumatology department:
Submission for “Hospital Doctor” Team of the Year
The Hospital and the Department
Queen Mary's Hospital Sidcup serves a base population of 215,000 and
provides a rheumatology service to four PCT areas – Bexley, Greenwich,
Bromley and Dartford – a total catchment population of about 260,000. It
does so with a consultant base that is well below the recommended level of
1:85,000, with 1.75 whole time equivalent sessions.
The population is mixed, with a relatively small number of ethnic minority
patients.
The Department is based within the therapies area of the hospital and has its
own dedicated consulting rooms which double as offices. This offers the
opportunity of immediate liaison with the therapists; furthermore the waiting
area is shared additionally with the orthopaedic clinics. Thus all the staff can
consult rapidly and informally with each other. In addition the team do clinics
at the cottage hospital 6 miles away in Erith.
The Department deals with all rheumatology problems (including children) and
has a large follow-up population of patients with inflammatory joint disease.
Where possible a “one-stop” service is provided for new patients. 127
patients are currently on TNF- blockade. Services are almost exclusively
provided on an outpatient basis. New patient clinic appointments are
prioritised by the consultants. Concordance with the half-hour waiting time in
outpatients is over 95% in all clinics.
The team
Until the last two years the rheumatology service was entirely consultantbased but in that time a competent and compact multidisciplinary team has
been developed. Its philosophy is simple – to provide timely and appropriate
care for the whole range of musculoskeletal conditions. It now comprises
Dr Andrew Bamji (Lead Clinician) – Consultant in rheumatology (7.5
sessions) and rehabilitation (2.5 sessions) and Director, Elmstead
Rehabilitation Unit
Appointed 1983 and full-time at Sidcup from 1987. President-Elect of the
British Society for Rheumatology and Curator of the hospital archives;
previous Associate Medical Director and Clinical Tutor
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Dr Nap Cheung – Consultant in rheumatology (full-time)
Appointed 1999. College Tutor 2005-. Joint Hand Clinic with Mr G. Mani
(orthopaedics)
Dr Shanti Mendonça – GP with Special Interest
Appointed 2002
Dr Bijay Sinha – SpR in rehabilitation medicine
On rotation with Medway Maritime Hospital (to July 2005)
Catriona Howse – Rheumatology Nurse Specialist
Appointed 2004; previous experience as a renal medicine Specialist Nurse
Elaine Willett – Physiotherapy Specialist Practitioner
Appointed 2001. Co-ordinator of the Back Pain triage service
Chris Boyles – Extended Scope physiotherapist (Knee Pain)
Appointed 2004
Sara Glassberg – Occupational Therapist (Hand specialist) – Locum
Appointed 2005
Stuart Rickman – Occupational therapy Technician
Appointed 1988
Karen Brickenden – Secretary
Appointed 2001. Hospital Audit Co-ordinator 1992-2000
Wendy Dyke – Secretary
Appointed 2000
The department works closely with the Orthopaedic service and has direct
access to specialists in knee replacement, shoulder problems, hand and foot
surgery as well as to general services. It is supported by an excellent
radiology department with ultrasound, spiral CT and MRI (routine waiting time
about 8 weeks) and by an efficient Appliance Department. There are also
close working relationships with the Pain service.
The department runs several databases but these are self-developed due to
lack of funding.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Special services
The department provides the following special services
Helpline (intended for rheumatoid arthritis patients and carers, to provide
support and advice relating to any aspects of their disease)
Information service. A number of patient information leaflets are locally
produced (for example on osteoporosis, diet and methotrexate treatment).
Several protocols for use by generalists are on the hospital’s intranet
database, including a management algorithm for the acute hot joint
Specialist Biologics Clinics. These have been established to provide
relevant information for patients prior to starting treatment, so that they are
able to make a fully informed choice about their Anti-TNF treatment. They also
ensure that patients are monitored for any adverse events, and long term
efficacy.
Nurse-led follow-up Clinics provide:
support and education to newly diagnosed RA patients
long term follow up, with the aim of empowering patients with information
about their disease, thus enabling them to take responsibility for their own
health care needs.
Innovations
Emergency Access slots (for A&E referrals, flare-ups, acute hot joints,
diagnostic appointments; appointments can usually be made within 24 hours
of request). Patients for whom emergency appointments may be needed are
issued with an information sheet giving weekday contact numbers. Patients
may be seen outside clinic times. The system provides timely expert
treatment but in particular is key to the diagnosis of intermittent problems –
such as crystal synovitis or palindromic rheumatism – in which acute episodes
may have settled before a standard appointment can be obtained. Indeed the
service provides quicker access to care than is available in general practice.
Back pain service. This triage service ensures that all patients with back
pain are assessed within two weeks and are triaged to physiotherapy,
rheumatology or the Pain Clinic. It was established in 2001 and was initially
developed to control the waiting list for the Pain Clinic, which had reached 18
months. The orthopaedic surgeons at Sidcup do not perform back surgery
and so no back pain referrals now go to that department. Development of the
service was undertaken in liaison with local GPs and resulted in major
reductions in waiting times for routine rheumatology outpatient appointments
(from an average of 21 weeks to 10 weeks) as well as a significant drop in the
routine orthopaedic clinic waiting time. Referral is by protocol on a form which
enables “red flag” signs to be identified and the triage team liaise closely with
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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the rheumatology consultants in difficult cases. The triage physiotherapists
can order MRI scans.
Figures for the triage service are appended below. Prior to start-up about
40% of referrals came to physiotherapy, 30% to rheumatology, 20% to
orthopaedics, with the remaining 10% to the Pain Clinic; many of these latter
three would be referred back for physiotherapy. Thus over 200 “unnecessary”
referrals per year to rheumatology have been avoided yearly.
Knee pain service. This new service, commenced in 2005, is designed to
reduce the numbers of non-surgical knee consultations within the Orthopaedic
department, but sits more naturally in management terms within the
rheumatology department and so has been subsumed. Chris Boyles, the ESP,
performs joint injections, can make direct referrals for MRI scans and can add
patients directly to surgical waiting lists. In addition he is training the A&E
nursing staff in back pain triage
Hand service. Apart from the Combined clinic (see above) the OT
department offer a responsive care and splinting programme with a particular
focus on rheumatoid arthritis.
Extended roles. Our secretaries have an excellent reputation for patient
liaison and their success in this culminated in the award of hospital “Team of
the Month” to the outpatient secretaries in March 2005.
Special treatments
Intensive lobbying on a local basis has ensured that the department has no
problems with the administration or supply of TNF- blockade, either in
rheumatoid arthritis or in ankylosing spondylitis or psoriatic arthritis (see
figures appended).
Viscosupplementation injections are also performed; this is not confined to
the knee but includes injection of shoulders, ankles and elbows. In particular,
elbow injection in secondary osteoarthritis of the elbow following RA can be
highly successful in relieving symptoms.
Dr Cheung performs epidural injections for discogenic pain and sciatica
Research
Dr Cheung is a participant in a number of multicentre clinical trials
Audit
The Back Pain Triage service undertakes a rolling audit of workload and last
year assessed outcomes. Catriona Howse has commenced an audit of TNF-
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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 patients. The department participates in the sub-regional rheumatology
audit group.
Management and budget
The multidisciplinary team has a monthly meeting to discuss problems,
strategy and finance
What is special about the Queen Mary's department
We excel in providing patient focussed service that is readily accessible,
comprehensive, friendly and flexible. Seamless teamwork by the team
ensures a quality and responsiveness that is an exemplar for the Trust.
The department’s workload is heavy but waiting times for new appointments
are low. Follow-up appointments are flexible; some patients only attend
yearly, or less frequently, but all have the opportunity to arrange an early
appointment directly with the department. We take special pride in the
management of acute inflammatory disease activity with our emergency
access service; this is vital to avoid both diagnostic delays, and the
inappropriate attendance of our patients either in orthopaedic clinics or in the
A&E department. The Back Pain Triage service is a particular example of
successful multidisciplinary working which has not only streamlined the
management of rheumatology patients (and reduced waiting times
accordingly) but removed a large tranche of unnecessary referrals from the
orthopaedic surgeons.
All this adds up to a service that meets the needs of the users whilst also
operating in an effective and efficient way.
Acknowledgement to
Schering-Plough (start-up money for specialist nurse post) 2002
Wyeth (grant for database development) 2004
Butterfly Appeal (Mayor’s fund – for computer/educational equipment) 2005
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Appendix 1.1
Department statistics
Total patients with rheumatoid arthritis in long-term follow-up: 927
Disease breakdown of follow-up patients (%):
RA
55
Seronegative arthritis (inc reactive
arthritis, spondarthritis, psoriatic
arthritis)
21
SLE and other connective tissue
disease
10
PMR/GCA
5
Osteoarthritis
5
JIA
1
Crystal arthropathy
1
Chronic pain
1
Osteoporosis
1
TNF- patients:
Total
127; approximately half from outside
Bexley PCT
RA
109
AS
13
Psoriatic arthritis
4
Other
1
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Back pain triage statistics
Sept 20012
2002-3
2003-4
2004- May
2005
835
1023
1406
1016
Physiotherapy
75.9
75.2
76
84.5
Orthopaedics
4.8
0
0
0
Rheumatology 8.1
8.1
6.5
2.9
Pain Clinic
4.2
2.2
5.7
4.0
Returned to
GP*
5.9
14.3
10.8
8.2
Total
referrals
Triaged to (%)
*Proforma not appended to referral, or incomplete
Rheumatology Helpline
This service was established at Queen Mary’s Hospital in December 2004 to provide patients
with greater access to advice and information about their condition, medication, and reduce
the number of emergency telephone calls and appointments with the Consultant
Rheumatologists or secretaries. The helpline was also established to provide information and
advice to general practitioners, and district and practice nurses. The service has resulted in:
Patients being provided with additional advice and information between appointments.
Patients and carers being provided with an additional support resource between
appointments.
Provision of a screening service by a qualified health care professional for patients requesting
emergency appointments to prevent inappropriate use of resources.
Reduction of the number of telephone calls from patients dealt with by Consultants and the
departmental secretaries.
Nature of patients and callers using helpline
Helpline calls were made for a variety of reasons, principally:
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
17
Medication query
Medication side-effect
Blood test query
General exacerbation of disease
Exacerbation of disease – specific joint involvement
Request for emergency or earlier Outpatient appointment
Requesting outpatient appointment
Requesting change of outpatient appointment
(Note: the helpline is now taking nearly 200 calls monthly. We are looking at
how these may be converted into face-to-face appointments)
Appendix 2: Business case for rheumatology specialist nurse post
This post has been operational since November 2004. Its establishment
followed advice from a Departmental Peer Review (see attached appendix 1)
and a visit from the All-Party Parliamentary Group on rheumatoid arthritis,
both of which emphasized the need for the post. At the time of establishment
Queen Mary’s was the only local hospital without such a post.
Start-up funding was available following a substantial grant from ScheringPlough pharmaceuticals, who provided approximately £19,000 towards the
first year’s salary. There was subsequent agreement with Trust management
that the post would remain funded as part of the requirement to provide the
necessary infrastructure for administration of biologic agents.
The Department, having established the post, was successful in being
nominated for the “Hospital Doctor” rheumatology Team of the Year Award in
2005, and was runner-up in the category; the other shortlisted departments
were Southampton and King’s College Hospital, both large teaching centres.
This achievement underpinned the transformation of a small department
unable to fully manage biologics to one which is recognized nationally as a
centre of excellence. It should also be pointed out that the number of
consultant sessions is well short of recommendation of the Royal College of
Physicians and the British Society for Rheumatology (BSR); we have 1.75wte
compared to an expected level of 2.5. The nurse post goes a considerable
way to meeting the shortfall and as a result of the establishment of the post
we have put on hold our outstanding request for additional consultant
sessions.
The importance of rheumatology specialist nurses is outlined in the Standards
of Care document produced by the Arthritis and Musculoskeletal Alliance
(ARMA). Many of the information functions now expected by government are
covered by the post but, most importantly, NICE guidance on the
administration of biologic agents places a statutory duty on funding both of the
drugs and of the necessary infrastructure for doing this. Thus it is expected
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
18
that the costs and personnel needed to manage registration and monitoring
are met. This was underlined by a letter to me, in my capacity as a member
of the External Relations Committee of the British Society for Rheumatology,
from the Department of Health which gave specific direction on the issue (see
appendix 2).
Regardless of national directives there is also a local issue. Dr Bamji is the
next President of the British Society for Rheumatology. He discussed the
implications of this to his own Job Plan with the Medical Director before
agreeing to do it (in January 2005), indicating that it was only possible to
proceed on the basis that the department had a specialist nurse in post.
There has been no subsequent discussion indicating that there would be any
problem with maintaining the post.
It should also be noted that the RCP recommendations on consultant
workload are for 4-5 clinics weekly (for a full-time equivalent) with either 6 new
or 12 follow-ups per clinic. Dr Bamji (who is only 0.75wte in rheumatology)
does 4-6 rheumatology clinics, and occasionally 7 weekly notwithstanding his
outside commitments, with 8-12 new or 17-25 follow-up patients on each.
This is grossly in excess of the recommended numbers and is only
sustainable because of the specialist nurse support.
Workload of the post
The specialist nurse now manages all patients on biologic agents. She runs
her own clinics for monitoring and for acute disease flares. She also operates
the Department’s Helpline and is setting up the monitoring database
(RheDAS) for RA patients. Work on this was commenced at the beginning of
March 2006. The numbers of patients seen are substantial; 190 patients were
seen in the nurse clinics in the last 3 months (this includes TNF monitoring
patients, other RA patients and emergency consultations).
Implications of withdrawal /failure to fund
Problem
Failure to meet NICE guidelines on
prescribing and monitoring of biologic
agents
Loss of rheumatology helpline
Implication
Postcode prescribing which is
unacceptable to the DoH and
government; without the nurse our
capacity to mange new start-ups in a
timely fashion is zero. Two separate
government ministers have stated
that there should be no impediment to
patients who are eligible for
treatment; thus any patients who fulfil
NICE criteria for the prescription of
biologic agents but who cannot
receive them due to funding issues
will be told to contact their Members
of Parliament.
Ongoing monitoring requires a
clinician.
The Helpline has taken 172 calls from
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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January 2006 to date. See Table 2
for the breakdown. Without it there
will be increased pressure on the
Department’s secretaries, and further
pressure on urgent consultant
appointments.
Failure to set up database
Loss of audit capacity
Loss of coordination for patient
information and education
Increased pressure on consultant
follow-up clinics
The helpline is an essential part of
any rheumatology department and is
a recommended service both in BSR
guidelines and in the “Consultant
Physicians Working with Patients”
guidelines from the Royal College of
Physicians (in which there is a
specific recommendation that a senior
nurse specialist runs it.).
Failure to meet NICE guidelines on
monitoring. Failure to monitor serially
in a timely fashion resulting in patients
staying on biologic agents for longer
than is appropriate.
At present the specialist nurse is
conducting an ongoing audit of
biologic agents. This includes
patients with conditions other than RA
and patients started on etanercept for
whom there is no longer a
requirement to enter data on the BSR
Biologics Register. This function
would be unsupportable at consultant
level due to pressure of work.
A first Study Day for RA patients has
been arranged under the auspices on
the National Rheumatoid Arthritis
Society in line with government
aspirations for patient education and
the development of an Expert Patient
network. This and any future days
will be lost.
Most are already full. Adding back
those patients currently under review
by the specialist nurse will have a
catastrophic effect on new patient
throughput, as the only way to
manage inflammatory joint disease
will be to cancel new patient clinics.
This runs counter to the Trust’s wish
(and need) to attract more new
patients into the system to maintain
income. The loss of one new clinic a
week (8-12 patients per consultant)
produces a substantial income loss
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
20
which is greater than the cost of the
nurse post. As noted above the nurse
uses the new database to do serial
assessments and judge treatment
failure; if patients return to ad hoc
consultant clinics this will necessarily
be assessed less often, and so
unnecessary drug expenditure will be
incurred. See Table 1.
The DoH has made it clear that it will
condone job losses where clinical
services are not affected. By
implication it will not agree damaging
cuts to clinical services. Removal of
the rheumatology specialist nurse is
unquestionably damaging to patient
care and safety
If patients are not being properly
monitored, and if GPs have to be told
that their access to new patient slots
is being curtailed, it will generate
significant adverse publicity for the
Trust. “Patient power” may also
generate negative publicity in the
local press. That is a high-risk
strategy, as it may encourage a belief
that the hospital is unsustainable.
Political repercussions
Local implications
Table 1: Capacity of nurse-led clinic
Monday AM
Tuesday AM
Tuesday PM QMS
Weekly
Capacity
10
10
10
4 Week
Capacity
40
40
20
Tuesday PM EDH
8
8
Wednesday AM
Thursday AM
6
6
24
12
Comments
Alternate
Weeks
Alternate
Weeks
Alternate
Weeks
Total
40
80
100
108
132
144
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
21
Table 2: Rheumatology helpline calls
Rheumatology Helpline Calls
Dec 1st 2004 - March 29th 2006
80
70
60
Number of 50
Calls Per 40
Month
30
20
10
0
75
70
55
35 38
55
41
37
18 21
Feb
28
Oct
Dec
13
3
Dec
26
Apr
Jun
0 0
Aug
Feb
Month
Funding
The bottom line is that we are expected, indeed required, to meet NICE
guidelines for the prescribing of biologic agents and this is impossible without
specialist nurse input. The cost of the nurse post should be met from the
overall cost of biologic agents. In comparison to the total cost and given the
costs of failure to monitor (Table 3 below shows the breakdown) the nurse
post effectively pays for itself.
Number Of Patients
Anti - TNF Patients March 2006
N = 156
120
100
80
60
40
20
0
97
24
Etanercept
Infliximab
23
Adalimumab
7
5
Rituximab
Suspended
Drug Type
Furthermore the loss of the post has a direct impact on costs. The Payment
by Results tariff has been re-published. This indicates that a new patient will
be chargeable at £219 and a follow-up at £97 (adults). On the assumption
that the nurse specialist workload would have to be subsumed by the
consultants a total of 760 consultant appointments would be lost annually
(source: nurse specialist clinic figures for November 2005 - February 2006).
Given the follow-up burden this could only be achieved by losing new patient
slots; clinics are currently full on the follow-up side and indeed overbooked.
This would mean a loss of new patient income of £92,720 annually.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
22
From a financial viewpoint, given that we are trying to increase income, this is
ridiculous – and indeed such a sum would pay for three specialist nurses.
Thus there are two ways forward for agreeing continued funding for the post.
The cost of lost income leaves the Trust with a sensible fall-back position of
continuing to fund the post on the basis that its continuation costs one-third of
the potential lost income from its disestablishment.
The Care Trust, which directly funds biologics and must continue to do so
under PbR, be asked to allocate, on an ongoing basis, a specific sum from the
biologics budget to cover the salary of the rheumatology specialist nurse, or it
will effectively breach its statutory responsibility.
Dr Andrew Bamji FRCP
Clinical lead, Department of Rheumatology
Queen Mary's Hospital, Sidcup, Kent DA14 6LT
28th March 2006
Appendix 2.1: Report of Peer Review visit 2001
BRITISH SOCIETY FOR RHEUMATOLOGY PEER REVIEW SCHEME
REVIEW OF RHEUMATOLOGY UNIT AT QUEEN MARY’S HOSPITAL,
SIDCUP
28th September, 2001
Reviewers:
Professor DL Scott (King’s College Hospital, London)
Dr J Wojtulewski (Eastbourne General Hospital, Eastbourne)
SUMMARY AND RECOMMENDATIONS
The rheumatology unit at Queen Mary’s Hospital, Sidcup is providing high
quality clinical opinions on newly referred patients with rheumatic disorders.
The service is organised by dedicated and highly motivated staff and operates
in a pleasant and highly suitable environment.
We have identified the following resource issues that need consideration by
the Trust:
There is no provision for the long-term management of patients with
inflammatory arthritis. The most cost-effective method of providing this is to
appoint a full-time rheumatology specialist nurse. This action is urgent and
needs to be undertaken within the next 6 months. National recommendations
from the British Society for Rheumatology are that each rheumatology unit
should have one specialist nurse.
There is insufficient medical secretarial input for the workload. National
recommendations from the British Society for Rheumatology are that each full
time consultant rheumatologist should have one full-time rheumatology
secretary. We estimate the shortfall in medical secretaries is approximately 7
hours/week. This shortfall needs to be addressed in the next 12 months.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
23
There are too few consultant sessions in rheumatology for the population
served by this Trust. Currently there are 18.5 consultant sessions for a
population of 220,000; this represents one session per 12,000 population.
National recommendations from the British Society for Rheumatology are for
one consultant session per 8,500. This shortfall needs addressing in the longterm but it is not a matter of immediate concern.
GENERAL INFORMATION
Queen Mary’s Hospital Sidcup is a District General Hospital serving a
population of 220,000. It has a busy acute medical service involving 10
consultant physicians. Two consultants provide rheumatology services and
one of these consultants also provides rehabilitation services.
RHEUMATOLOGY STAFF
Consultants
Dr A Bamji (Maximum part-time)
8.5 sessions rheumatology and 1.5 sessions rehabilitation
Dr N Cheung (Maximum part-time)
10 sessions rheumatology
Medical Secretaries 2 posts
28 hours with Dr Bamji
25 hours with Dr Cheung
Junior Staff
None
Specialist Nurses
None
Other Professionals Reasonable levels of support from
physiotherapy/occupational therapy
FACILITIES
Clinics
Dedicated rheumatology clinics that operate full time
High quality facilities that are well designed for people
with arthritis
Day-Care
No special facilities
Access to space on rehabilitation unit
Functionally adequate for current needs
In-patients
No special facilities
Access to general medical beds
Functionally adequate for current needs
OUTPATIENT ACTIVITY
Overview
The unit provides high quality clinical opinions on patients referred for
specialist advice. As the workload is relatively high for a unit with only 18.5
consultant sessions it is unsurprising that the wait for appointments slightly
exceeds the 13 week NHS target. With an adjustment in the unit staffing
levels this target should be met. It is unlikely that any other unit in the country
provides higher quality specialist opinions on the assessment of new referrals.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
24
By contrast there is a significant problem with the long-term specialist follow
up of patients with rheumatoid arthritis and other forms of inflammatory
arthritis and connective tissue diseases. As the unit has no specialist nurse,
no day care facilities and no dedicated in-patient beds the needs of these
patients are being ignored. The consultant rheumatologists are fully aware of
the extent of the problem, but cannot do more within their current resources.
This matter needs urgent attention from the Trust.
Data from NHS Statistics
(http://www.doh.gov.uk/hospitalactivity/statistics)
Year
1996/7
1997/8
1998/9
1999/2000
New
1241
1280
953
1064
Follow-up
3038
3273
2372
2720
Ratio
2.4
2.6
2.5
2.6
Waiting Times from NHS Statistics
(http://www.doh.gov.uk/waitingtimes/)
2000/1
GP
Referrals
293
335
First Quarter
Second
Quarter
Third Quarter
306
Fourth Quarter 389
Waiting over
13 weeks
97
131
Percent Waiting
Over 13 weeks
33%
39%
103
107
34%
28%
Outpatient Clinics
Clinics held each week
Patients seen by consultant
Average wait for new patient
Wait for urgent new patients
Average wait for follow-up patients
Wait for urgent follow-up patients
12
100%
16 weeks
0-2 weeks
12 weeks
0-2 weeks
Facilities for Clinics
Present
Appropriate clinic environment
Good support from receptionists
and health care assistants
Access to pathology and imaging
services
Support from physiotherapy,
occupational therapy and surgical
Absent
No specialist rheumatology nurse
No system for monitoring DMARD
therapy in rheumatoid arthritis
Limited combined clinics with
other specialists
No junior staff
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
25
appliances
INPATIENT AND DAY CASE ACTIVITY
Patients with acute medical problems can be admitted as and when the need
arises. There are sufficient junior medical staff to meet this need, though the
arrangements are not ideal.
There is some access to day care facilities on the rehabilitation unit, but no
dedicated day care access or support.
OTHER ASPECTS OF UNIT
Continuing Professional Development
Consultants in the unit are involved with national and local schemes for
education within rheumatology and are well informed on all aspects of the
speciality.
Audit
The unit participates in local and regional audits.
Research
The unit is involved in regional research initiatives and would wish to increase
its activity in this arena. Dr Cheung has considerable research expertise in
rheumatoid arthritis. The unit should be attracting sufficient NHS R&D income
to the Trust to fund at least part of a rheumatology nurse, though it is unclear
that the Trust is actually claiming this income.
Teaching
The unit has little opportunity for undergraduate or postgraduate teaching and
this is an area for potential development.
National Activities
Dr Bamji has taken a leading national role in setting standards and clinical
affairs. He continues to hold responsibilities in these areas.
Secretarial Support
The unit has two dedicated medical secretaries, who work part-time (28 and
25 hours/week). The amount of secretarial work exceeds the time available
and at least one of the secretaries is putting in additional hours on a voluntary
basis to maintain a high quality service.
Regional Context
The changes in the NHS in the next 5 years, with the introduction of primary
care trusts and the formation of new strategic health authorities for London,
will change the context in which specialist rheumatology services are
delivered. We do not believe that rheumatology services should be
centralised, as they need to be delivered locally to meet the needs of people
with arthritis. Nevertheless the interactions with other local Trusts could
change in this new environment. Therefore recommendations about junior
medical support and consultant staff should be deferred until more information
is known about the general pattern of specialist services in South East
London.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
26
Appendix 2.2: Letter from the Department of Health: 9th June 2004
Thank you for your recent email to Rosie Winterton about NHS funding for
treatments recommended by National Institute for Clinical Excellence (NICE)
appraisals. Due to her busy schedule Ms Winterton cannot respond to all of
her correspondence personally, therefore I have been asked to reply.
Having spoken to policy officials I can confirm that the costs for drugs are
dependent on the specific appraisal, on the whole drugs are fairly cheap to
administer and facilitate but if a drug has an administration cost then this will
be factored into NHS funding.
In conclusion, the answer is yes - the statutory obligation quoted covers both
the drugs and the costs of the administration.
I hope you find this reply helpful.
Yours sincerely,
Victoria Adams
Customer Service Centre
Department of Health
Appendix 3: Outpatient secretary proposals March 2006: effects on
rheumatology services
Introduction
A suggestion has been advanced as part of the Queen Mary's Hospital “Fit for
Future” review that will reduce the complement of outpatient secretaries. The
proposal is flawed in its reasoning and will potentially cause severe damage to
rheumatology and rehabilitation patient care. It is regrettable that no-one
involved in developing the proposal has at any time discussed it with the
department’s consultants; no-one has sought the consultants’ views following
publication of the proposal; and it appears that it is being treated as a “faitaccompli”.
We believe that the proposal is unsustainable, is in breach of statutory
guidelines for NICE-approved drugs, will cause delays in communication with
primary care and is clinically unsafe. It also runs contrary to the spirit of
developing multidisciplinary teams and the guidelines for a musculoskeletal
service as laid down in the Standards of Care produced by the Arthritis and
Musculoskeletal Alliance (ARMA).
Background
The Royal College of Physicians and British Society for Rheumatology have
set guidelines for rheumatology secretarial staffing as 1 wte per consultant.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
27
In 2001, as part of an exercise to develop the management of TNF-α blocking
drugs for rheumatoid arthritis, a Peer Review was conducted on the
department. At that time there were only 2 consultants and a part-time SpR (4
sessions) in the department supported by part-time secretaries. The visiting
team comprised Professor DL Scott from King’s College Hospital and Dr J
Wotjulewski from Eastbourne. They concluded that the department ran a
good service but was seriously hampered by inadequate backup staff. In
particular they identified the need for a rheumatology specialist nurse and
increased secretarial hours.
By 2004 both of the issues had been addressed, with the establishment of a
Nurse Specialist post and an increase in the hours of Dr Bamji’s secretary.
These were agreed by management at the time as necessary developments
to maintain a high quality, safe clinical service and fulfil College guidelines.
The secretaries have been through an Agenda for Change review which
established their posts on Band 4.
It appears that the current proposal will have the effect of reversing these
changes.
Secretarial duties
These are appropriate for a Band 4 post and include a large component of
direct patient contact (dealing with urgent enquiries, booking urgent
appointments, sorting out problems with drugs and test results). The
secretaries also deal with GPs who may likewise request appointments to be
made. The secretaries may receive up to 40-50 calls per day. To deal
effectively with these requires them to know the patients – and this is best
achieved by typing the correspondence. While on occasion work has been
devolved to other secretaries this causes delays, and may indeed increase
work if secretaries untrained in terminology and not “tuned-in” to the dictation
styles of the consultants; work has to be edited and re-typed.
The typing itself is a substantial work component. This is shown on the work
breakdown constructed by the outpatient secretaries. Dr Bamji’s work alone,
not including his two Erith clinics, encompasses four consultant, three SpR
and three or four specialist nurse clinics. One is a rehabilitation clinic which is
long because letters are necessarily very detailed (and often require multiple
copies). This is simply not work that is appropriate for delegation to pool
typists. Additional correspondence is generated in responding to results of
tests. Thus the department’s work is not comparable to that of other medical
specialties where the workload, clinic-wise, is not of the same order.
Currently the workload is such that letters are delayed between dictation and
typing for up to 10 days. Any delay is unacceptable – and where drugs doses,
or types, are changed there is potential clinical risk. Dr Bamji has been on
two visits to local practices as part of the “Partnership project” to encourage
GPs to use Queen Mary's rather than an alternative. In each case the issue
of availability and communication was raised – if consultants cannot be
contacted, or if correspondence is delayed in transmission, then GPs will (and
do) look elsewhere for their services. Certain departments – and the
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
28
rheumatology department was among these – are deemed excellent,
communication-wise. It is only thus because there is adequate secretarial
support. To cut the secretarial time dedicated to the department will have a
significant effect on future GP referrals and on potential income. To suggest
that their posts can be subdivided into different bands is nothing short of
insulting and is probably contractually illegal.
Given this analysis it is all the more unfortunate that no-one involved in the
review had sought out the consultants to ask them what effect the proposed
changes might have.
It has apparently been argued that it is not the secretaries’ remit to deal with
appointment booking. However, the consultants must be asked regarding the
timing and appropriateness of moving or booking urgent appointments and
only the secretary is in a position to do this. Some appointment enquiries,
whether patient or GP initiated, require immediate action. Failure to act
appropriately will potentially expose patients to risk, and the hospital to
allegations of negligence. It is unreasonable to suggest that such a function
can be undertaken on a part-time basis if it would lead to messages being
delayed by 24-48 hours. However such delays would be inevitable if their
“PA” function is reduced to half-time. Our service only functions properly
because we have sufficient dedicated support and patients will be put at risk if
that support is diminished.
NICE-approved drugs
The role of the department’s nurse specialist has been outlined in a separate
submission – but underpinning the role of both the nurse and the secretaries
is the need to follow national guidelines. This is a statutory requirement and
extends to the infrastructure necessary to manage both new patients and
follow-ups – a requirement underlined in a memorandum from the Department
to Dr Bamji dated 9th June 2004 which reads:
Thank you for your recent email to Rosie Winterton about NHS funding for treatments
recommended by National Institute for Clinical Excellence (NICE) appraisals. Due to
her busy schedule Ms Winterton cannot respond to all of her correspondence
personally, therefore I have been asked to reply.
Having spoken to policy officials I can confirm that the costs for drugs are dependent
on the specific appraisal, on the whole drugs are fairly cheap to administer and
facilitate but if a drug has an administration cost then this will be factored into NHS
funding.
In conclusion, the answer is yes - the statutory obligation quoted covers both the
drugs and the costs of the administration.
I hope you find this reply helpful.
Yours sincerely,
Victoria Adams
Customer Service Centre
Department of Health
This statement is unequivocal. As a result the Trust has a statutory obligation
to comply. The secretaries play a pivotal role in the management of RA
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
29
patients on TNF-α blockers. They book and rearrange appointments for
infusions and help to communicate data collected by the specialist nurse to
the British Society for Rheumatology’s national Register. They also
communicate with GPs. As this class of drugs cannot be used in general
practice there can be no escape from the need to have sufficient secretarial
time to manage this – and we emphasis that the commitment in 2001, when
our Peer Review pointed up the shortfalls, was only to some 30 patients. Now
the department manages over 150. Given these changes it seems entirely
inappropriate to cut hours which are required for a statutory responsibility that
has increased five-fold since they were agreed.
Other issues
Dr Bamji shortly assumes the role of President of the British Society for
Rheumatology. This is a national post (unpaid) for which, like the officebearers of Colleges, it has been traditional for Trusts to release post-holders
without prejudice. Prior to offering himself as a candidate in January 2005 he
had discussions with Liz Roberts, Medical Director, on the implications of
taking up the post, and entered the election on the basis that staffing in the
department was now adequate, and that the time commitments needed for the
post of president would not therefore place extra strains on the department, its
staff and patient care.
Summary
The rheumatology consultants fully support the Fit for Future process and
accept that it is important to match income with expenditure. However it has
been emphasised both locally and nationally that any cuts made as the result
of trying to eliminate financial deficits will not jeopardise clinical services. The
combined effect of local proposals to reduce secretarial hours, and remove
the department’s specialist nurse, will do more than jeopardise our service –
they will make it impossible to run.
We are happy to enter negotiations for alternative measures that might secure
financial savings. However, as we have at no time been party to any financial
analysis of our service other than by receipt of the budget statements, and as
we have not been consulted about the present proposals, we are unable to
co-operate with them. We believe that they have been based on numerous
misconceptions as to the work of the secretaries in our specialty. We have no
doubt that the proposals will expose us, and the hospital, to significant risk;
that they will effectively be a cut in clinical services and that they will threaten
our ability to meet statutory national guidelines for NICE-approved drugs.
Dr Andrew Bamji FRCP
Dr Nap Cheung MD FRCP
26th March 2006
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
30
Appendix 4: Reducing rheumatology follow-ups:
Analysis of the problem June 2006
Introduction
The rheumatology department at Queen Mary’s has an excellent reputation
for good and sensitive patient care. It has been recognised as such by its
success as runner-up in the “Hospital Doctor” Rheumatology team of the Year
awards. The hospital’s management of back pain is considered a model of
good clinical practice. It has its own website for patients and GPs. The senior
consultant, Dr Bamji, has been involved over many years in the development
of care guidelines for the British Society for Rheumatology and the Royal
College of Physicians, and is currently President of the former and on the
Council of the latter.
It is suggested that rheumatology follow-up appointments should be reduced
so that Bexley Care Trust expenditure might be reduced. There are clear
limits to the possibilities. Firstly it must be accepted that long-term diseases
require long-term specialist input. Inflammatory joint disease can be managed
at arms length if patients are stable, but the Arthritis and Musculoskeletal
Alliance (ARMA) guidelines for managing rheumatoid arthritis (RA) – which
have been endorsed by the Department of Health – require patients to be
reviewed at least annually. Thus the potential to discharge long-term followup patients is limited. Both consultants already tailor follow-up intervals to
clinical need.
Secondly there are patients who “bounce”. They are happily managed in
secondary care with long appointment intervals but if an attempt is made to
discharge them they are re-referred. Sometimes they will be referred to other
departments, and then get re-investigated at considerable cost. It should be
agreed that such patients are managed both more cheaply and more
effectively by continued long-term follow-up.
Thirdly there are issues of patient safety. Thus patients with polymyalgia
rheumatica (PMR) are managed inconsistently and sometimes badly in
general practice.
Fourthly, a significant number of follow-ups are emergency appointments for
patients with disease flares, acutely swollen joints etc. The reason that
patients request early or urgent appointments is a reflection of their trust in the
secondary care service and their understanding that the problem cannot be
dealt with in a timely fashion in primary care. We need to recognize this and
that patient choice is reflected by sensible provision.
There is no advantage in financial terms to discharging patients who then
require re-referral, as this generates a significant cost differential (£230 for a
rheumatology new patient to £90 for a follow-up) and will be time-consuming
and time-wasting for GPs. Worse, the Choose & Book system will result in
patients reappearing on another consultant’s list. This is not conducive to
patient satisfaction or continuity of care.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Finally it should be pointed out that the Department’s working figures on ratios
contain a typographical error and cannot be relied on to give an accurate
nationwide picture.
The scope of the problem
We have been requested to remove about 950 follow-up attendances from the
clinic, which has a lost revenue implication of £86,500 per year to the Trust.
In 2005-6 Dr Bamji saw 2214 follow-up patients and Dr Cheung saw 1061.
Thus Dr Bamji would need to see 641 less follow-up patients in a year. Given
two weeks study leave and 6 weeks holiday this equates to a total of 15 per
week – three-quarters of a current follow-up clinic. This is neither possible nor
safe.
The scope of the solution
The calculations below are based on Dr Bamji’s follow-up database. This
comprises all patients who have not been discharged from clinic. Patients are
not entered onto the database unless they have had more than one follow-up
appointment.
The data is not entirely complete. Patients who are seen in the specialist
nurse clinic (in particular those on biologic agents) are entered onto a
separate database; thus, the dates that the patients were last seen may be
incorrect. However there is a certain drop-out rate of patients expected for
review who have defaulted long term. Dr Bamji’s practice is broadly similar to
that of Dr Cheung so the figures may be extrapolated.
RA patients
Total
575
Attended in last 2 years 561
Review @ ≤ 2 months
53
Review @ 9-18 weeks
151
Review @ 6 months
238*
Review @ ≥ 9 months
133 (mainly once yearly, as per ARMA guidelines)
First seen range
September 1983 – April 2006
Average time to next
24 weeks
appt
Total patients seen
335 (some seen more than once)
2006
Pts on biologic agents
98
* patients seen less often than 6 monthly are unstable
Seronegative arthritis, lupus and other connective tissue disease
patients
Total
Attended in last 2 years
Review @ ≤ 2 months
Review @ 9-18 weeks
Review @ 6 months
391
377
47
108
128
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Review @ ≥ 9 months
First seen range
Average time to next
appt
Total patients seen
2006
Pts on biologic agents
108 (mainly once yearly)
24 weeks
198
28
We do not believe that any of these patients can be safely discharged entirely,
not least because of the issues of guideline review. There is also a
substantial number of patients whose drug monitoring would necessarily have
to be done in general practice and it is certainly very doubtful that all GPs
would be prepared to take this on. If one was to prolong 6 monthly follow-up
patients to 1 year, that would save 360 appointments. Previous experience
has shown, though, that prolonging follow-up intervals beyond that which
patients find comfortable results in an increased number of requests for
emergency appointments. Thus, while there may be some scope for
reduction in numbers, it is probably only half this, and patients would be
unhappy with any arbitrary decision. Neither do the data allow us to identify
the number of patients who have had appointments brought forward on an
emergency basis but it is in the region of 5-10 patients per week.
In specific reference to the nurse-led clinics the patients are either on
biologics monitoring or are emergencies. Thus the scope for reducing
numbers in this clinic is nil.
This leaves the miscellaneous largely non-inflammatory conditions, OA, PMR,
gout, osteoporosis etc. There are only 151 of these, of whom only 62 have
been seen in 2006. The breakdown by condition is shown below: of particular
note is that there are no patients with mechanical low back pain who are being
followed up.
Condition
Osteoarthritis
PMR
Chronic pain
Gout
Giant-cell arteritis
Osteoporosis
Other
No on database
60
45
13
8
7
4
14
Appointments saved by discharge
81
137
N/A (see text above)
9
N/A
0
The calculations are made by using the interval to next follow-up and
extrapolating yearly (thus discharging patients on 26 week reviews would
save 2 appointments). The reason the figures are so small is that analysis of
the interval to next appointment against the date last seen indicates that a
number of patients have anyway defaulted from follow-up. Chronic pain
patients on Dr Bamji’s list are only there because experience (as mentioned
above) proves that discharge results in rapid re-referral; if a patient has a
safety net appointment they are more likely to hold on until it is due. A
number of OA patients (19) are on the regular books for viscosupplementation
or other injections. These are unlikely to be taken back into primary care.
Nevertheless about 190 follow-up appointments might be saved but, because
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
33
of the patient expectation referred to above, some will drift back by requesting
re-referral.
PMR discharge will require the development of a protocol of management of
steroid dose. This should be based on the PRODIGY guidelines available
through NLH (http://www.prodigy.nhs.uk/pmr_and_gca/view_whole_guidance.
Again, experience indicates that GP management is patchy and we have seen
more than one patient treated with inappropriately high doses of steroids for
relapses of symptoms that were something else – resulting in admissions and
a major expenditure on rescue management. This underpins the need to
examine carefully not only the savings of early discharge, but the cost of rereferral and mismanagement. We believe the risks, and potential medicolegal
costs, are substantial.
We estimate that 30% of our patients are from outside the Bexley Care Trust
area; they are from Greenwich, Bromley and Dartford with a smaller number
from further afield (Lewisham, Tunbridge Wells, Canterbury/Ashford). This
underlines our reputation as a good unit and that patients choose to be
referred to Queen Mary’s. We have not been asked to make any reductions in
follow-up of these patients. Thus we would be developing a system of
“postcode follow-up” which would be manifestly unfair. In numbers terms,
though, the figures given above would have to be reduced by 30% to reflect
the impact on Bexley Care Trust.
Summary
These figures thus show that the maximum safe reduction in follow-up
appointments, based on robust data and allowing for out-of-district patients, is
small. Of discharged patients a number will return because of failure of
primary care management. The number of saved appointments is so small is
because of the very rigorous follow-up policy already in place; the
preponderance of inflammatory joint disease patients in follow-up clinics; and
the requirements for ongoing specialist management laid out in Department of
Health endorsed guidelines. With clinics that are overbooked almost without
exception there is every incentive for the consultants to discharge patients –
and they already do so when it is clinically appropriate. On that basis it would
be unacceptable on grounds of patient safety, the following of guidelines and
clinical decision-making, to reduce appointment numbers just for the sake of
doing so.
A further analysis of outpatient work in rheumatology can be found in the
references below. These underline the proactive approach of the Department
at Sidcup to careful analysis of workload and clinic provision; the first shows
(and this has been confirmed by more recent studies) that 80-90% of new
patients have non-inflammatory disease but the ratio is reversed for follow-up
clinics. Interestingly there is variation in numbers of patients seen, and their
diagnoses; thus in the Middlesbrough department PMR was rarely referred.
This may reflect different GP experience and knowledge. Some recent work
from Bristol (Kirwan et al) has proposed a model of discharge with
emergency-only follow-up. This however is out of line with current guidelines
and its safety is disputed within the specialty – indeed the practice has not
been widely adopted.
Service Review: Dept of rheumatology, Queen Mary's Sidcup NHS Trust
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Dr Andrew Bamji
Dr Nap Cheung
Consultant Rheumatologists
Queen Mary’s Hospital, Sidcup
Dr Shanti Mendonça
GP with Special Interest
18th June 2006
References
Bamji AN, Dieppe PA, Haslock I, Shipley ME. What do Rheumatologists do?
A Pilot Audit Study. Br J Rheumatol 1990, 24, 295-8
Bamji AN. Waiting times and referrals (Editorial). Rheumatology 2000; 39:
349-352
Kirwan JR, Mitchell K, Hewlett S, M. Hehir M, Pollock J, Memel D, Bennett B.
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 2003; 42: 422 – 426
(Note: Since this paper was submitted it has become apparent that classifying
PMR/GCA as non-inflammatory is outdated and that there may be significant
risks from failure to monitor in secondary care)
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