Agreed standards for early diagnosis aim at managing inflammatory arthritis better and making savings as a result, say Richard Watts and Jenny Snell.
Cost effective commissioning for rheumatoid arthritis
Rheumatoid arthritis affects about 690,000 adults in the UK, with around 26,000 new cases per year. The National Audit Office estimates that earlier treatment could result in productivity gains of £31m for the economy by reducing sick leave and lost employment.
One of the most innovative standards is that all patients with suspected inflammatory arthritis should be seen within a multidisciplinary team set-up within two weeks of referral
The NAO report Services for People with Rheumatoid Arthritis puts the cost to the NHS of the disease at around £560m, with the majority of this in the acute sector. It believes the additional cost to the economy of sick leave and work related disability amounts to £1.8bn a year.
The report shows that early referral and diagnosis could lead to cost savings to secondary care of around £3.6m.
Management of the condition has changed dramatically over the past two decades with the recognition that there is a “window of opportunity” within the first three months, following the first development of joint symptoms. If aggressive immunosuppressive treatment is given at this stage, this can radically alter the course of the disease, with the potential for long term remission.
Tight control of disease activity by regular review and adjustment to therapy (treating to target) is critical for achieving good long term outcomes. This approach was adopted by the National Institute for Health and Clinical Excellence in the clinical guidelines on the management of adult rheumatoid arthritis. The other big development was the introduction in 2000 of biological therapies, which, while very effective, are costly.
By following NICE guidance and using the information in the NAO report, significant costs can be saved in terms of progression to a biological therapy, reduction in urgent surgical intervention and other costs outside the health budget, such as keeping people in work and preventing disability claims, or carers having to give up work.
The challenge now is how to implement this into the commissioning process.
One approach has been developed in East Anglia by the National Rheumatoid Arthritis Society with the support of NHS East of England.
A working group was established comprising patient organisations, the National Rheumatoid Arthritis Society, the National Ankylosing Spondylitis Society, NHS East of England and local consultant rheumatologists from across the region. The aim was to agree standards for commissioning services for patients with rheumatoid arthritis and other inflammatory arthritis.
They understood services must be commissioned cost effectively using the best available evidence. The standards do not prescribe the model of care but commissioned services can be measured against them (see box).
One of the most innovative standards is that all patients with suspected inflammatory arthritis should be seen within a multidisciplinary team set-up within two weeks of referral. Such an approach should ensure as many people as possible get access to treatment within the therapeutic window.
To achieve this will require considerable education by the rheumatology community of both the public and GPs to recognise the disease early.
This project has shown the positive collaboration of patient groups, clinicians and health service managers. Involving frontline staff and patients led to a commitment to a robust standard of care.
It provides commissioners with a clear steer to the quality of service to purchase and allows discussions to take place on how these standards can be delivered within budget and within the different geographical areas of the East of England.
The 10 commissioning standards developed by the National Rheumatoid Arthritis Society, East of England working group
● Public and professional awareness of early signs, symptoms and impact of inflammatory arthritis
● Recognition by primary care of “red flags” for rheumatoid arthritis and immediate referral and ordering of blood tests to identify patients with a significant probability of a recent onset inflammatory musculoskeletal condition
● Patients with inflammatory arthritis should be seen and assessed by a specialist service within two weeks of referral
● Pre-assessment blood test results to be with specialist care and available to the specialist at the time of first assessment. Patients referred for urgent specialist assessment for a possible inflammatory arthritis will have the “IA diagnostic blood test set”
● Any service that receives referrals of patients with musculoskeletal symptoms needs to be fully aware of the two week referral criteria for suspected inflammatory arthritis cases, and be able to identify and redirect such cases promptly and appropriately
● Rapid access service
● Patients who have had flares should have rapid access to the service with the same standards
● Optimum management of condition
● Research, development, audit, training, education and service improvement
● Patient empowerment