Rheumatology

Care for patients with non-inflammatory painful musculoskeletal conditions should be provided outside of hospital in primary and community care settings in line with NHS Long Term Plan ambitions to bring care closer to home for patients. a Co-design community services for patients with non-inflammatory painful musculoskeletal conditions in collaboration with patient groups and third sector organisations as a matter of urgency. b Review service provision across integrated care system (ICS) footprints with view to releasing capacity to enable rheumatology units to focus on priority specialty activity.

Referral to treatment (RTT) waiting times should not exceed eight weeks for all patients who need specialist rheumatology care. a Review referral management to ensure prioritisation based on risk of harm from delayed treatment. b Develop clear and consistent referral criteria in partnership with the British Society for Rheumatology (BSR) and primary care providers to enable rapid referrals and triage for rare and complex rheumatic and musculoskeletal disorders (RMDs) – balancing routine and urgent appointments appropriately (see 9a). c Develop specific referral criteria for vasculitis and connective tissue disease with the Clinical Reference Group.

Trusts should review their management of follow-up appointments and consider alternative models of outpatient care. a Explore options to increase use of virtual consultations, in line with NHS Long Term Plan and Outpatient Transformation Programme ambitions. b Consider how to safely reduce the frequency of review for stable patients, for example by: • reducing the need for attendances for escalation and flare with earlier use of definitive treatments; • enabling patients to record outcome measures remotely, with reviews triggered when outcomes exceed thresholds; • implementing National Institute for Health and Care Excellence (NICE) and British Society for Rheumatology (BSR) guidance; • increasing the involvement of multidisciplinary teams (MDTs) in annual reviews. c Review treatment thresholds for biologic agents, including the total costs of service not just drug costs. d Investigate the reasons why outpatient appointments are deferred by rheumatology units to ensure that this does not impact on quality of patient care.

Rheumatology medical training posts should maximise the quality and value of rheumatology-specific training components to ensure competence and meet patient needs. a Reduce variation in training by defining tasks that are of low educational value for trainees and minimise these in each trust. b Reduce variation in clinical supervision by fully implementing the Royal College of Physicians (RCP) training guidance in all trusts. c Carry out a review of rheumatology training to include training needs, curriculum, and service tasks, to establish clear principles for trusts to follow. d Assess the value of trainees being 'on call' for rheumatology and specify the experiences that trainees should acquire during their training period.

Trusts should make full use of the multidisciplinary skill mix and consider enhanced roles for nurses, pharmacists and allied health professionals, to meet increasing demand and improve services for patients, in line with the NHS Releasing Time to Care ambitions set out in the interim People Plan. a Ensure that patients have access to specialist nurses and a range of other health professionals, including physiotherapists, occupational therapists, pharmacists, podiatrists, psychologists and radiographers, through a single named co-ordinator. b Consider how specialist and consultant rheumatology pharmacists could play a greater role in patient care, education, drug management and monitoring, as well as prescribing.

Rheumatology services should be planned across a geographic area, with services for some conditions commissioned at integrated care system (ICS)/sustainability and transformation partnership (STP) level to improve efficiency and outcomes overall, with network support for smaller units to make them more sustainable and ensure equity of access for patients. a Review existing regional network arrangements for specialised services and consider broadening the scope or setting up parallel networks. b Review local workforce professional skills mix and succession planning and work collaboratively with other trusts to ensure regional services are sustainable in the longer term, reducing reliance on individual clinicians and further promoting the use of the entire multidisciplinary team.

Diagnoses should be coded for outpatients as part of routine activity to enable service planning and benchmarking between trusts. a Establish specified list of core diagnoses which should be routinely coded from clinic letters and inpatient and day case episodes. b Use the specified list of core diagnoses to identify cohorts of patients and enable review of condition-specific pathways to ensure frequency of care is aligned with national guidance. c Drive routine collection of patient-reported outcome measures (PROMs) to identify variation in outcomes and measure the benefit of services to patients. d Implement electronic prescribing for rheumatology outpatients, day cases and inpatients to support accurate clinical coding and provide information for comparison.

All rheumatology activity should be coded using treatment function code 410. a Ensure activity is correctly attributed to the specialty and staff group.

Management of suspected early inflammatory arthritis (EIA) should be improved through clearer referral criteria, effective triage systems and adequate resourcing to meet patient needs and comply with the audited National Institute for Health and Care Excellence (NICE) quality statements. a Develop standard nationally agreed referral criteria for suspected EIA, to support effective triage and evaluate them over time. b Liaise with primary care networks to review local referral rates/yield and refine referral processes in line with 9a to ensure patients are assessed within the three week target set by the audited NICE Quality Statement 2. c Model demand and ensure there is adequate dedicated clinical resource to meet local patient needs, including dedicated EIA clinics where possible. d Interrogate the audited NICE Quality Statement 3 performance data to assess and address root causes of delays in patients initiating treatment once diagnosed.

Participation in the National Early Inflammatory Arthritis Audit (NEIAA) should be enhanced by considering how the audit could be integrated into routinely collected data for rheumatology services. a Improve the quality of the electronic health record to allow for standardised data capture. b Review administrative and audit resourcing to support full participation in the NEIAA. c Review individual consultant recruitment to the NEIAA and discuss identified challenges/solutions. d Consider including NEIAA performance metrics in the development of a National Clinical Improvement Programme (NCIP) portal for consultant rheumatologists.

All rheumatology units providing care for rare rheumatic and musculoskeletal disorders (RMDs) should collect data on care, caseload and outcomes for people with rare RMDs, using routinely collected data where possible to reduce burden of clinician data collection and submission. a Reduce the burden of specialised commissioning quality dashboard data collection by aligning metrics to data that is already collected as part of standard practice. b Ensure that all rare RMDs are included in data collection. c Use audit, and dashboard data where appropriate, to understand how care is being delivered and develop quality improvement tools to improve outcomes. d Promote national rare disease registration with the National Disease Registration Service (NDRS) to facilitate use of routinely collected healthcare data to support high quality care and service planning, and consider adapting the NDRS pathway toolkit for rare RMDs.

People with rare RMDs should have rapid access to specialist expertise and effective treatments to ensure equity of outcomes regardless of geography and reduce the risks of morbidity and mortality. a Identify responsible clinicians and lead nurses/allied health professionals in each trust offering care for rare RMDs, to co-ordinate care for each main category of specialised rheumatology: connective tissue diseases, vasculitis, and rare metabolic bone diseases. b Ensure effective co-ordination of care across all specialties as required. c Develop analytical approaches to identify geographical variation and potential health inequality in the use of high cost drug treatments for rare RMDs and the application of national commissioning policy criteria, including treatment initiation at specialised centres. d Develop a National Institute for Clinical Excellence (NICE) Quality Standard for rare RMDs based on the new NICE-accredited British Society for Rheumatology (BSR) guidelines on care of rare RMDs. e Investigate apparent differences in diagnostic reporting times, for example related to anti-neutrophil cytoplasmic antibody (ANCA). f Investigate if care and outcomes for rare diseases differ between specialised and non-specialised centres and consider how to support units with low activity volumes to consolidate services across regions. g Investigate if litigation and claims for rare diseases differ between specialised and non-specialised centres. h Continue to implement NHS England and NHS Improvement's COVID-19 prioritisation.

The structure, operation and geographic reach of specialised rheumatology networks should be reviewed and improved to ensure equitable, sustainable provision of specialised care for rare RMDs across and between regions. a Mandate the delivery of effective specialised networks in each region, including principles, standard operating procedures and memoranda of understanding, building on existing best practice. b Establish a mechanism to ensure that all trusts with specialised centre status make full dashboard returns and meet the terms of their service specification, and report on progress in achieving these requirements. c Ensure that each specialised network holds regular virtual multidisciplinary team (MDT) meetings, including review of complex cases, to enable timely decision making and ensure patients do not have to travel to the specialised centre unnecessarily. d Review the provider eligibility list (PEL) of specialised centres to ensure it reflects current organisation of specialised services. e Consider new models for specialised commissioning of rare RMDs.

All trusts should meet the new British Society for Rheumatology guideline for giant cell arteritis (GCA); ensuring referrals are rapidly assessed using the latest techniques and pathways. a Update or establish trust-wide GCA pathways to meet the new National Institute for Clinical Excellence (NICE)-accredited BSR guideline and achieve the three working day target for initial assessment of referrals. b Appoint a GCA clinical lead in all trusts, responsible for co-ordinating care with ophthalmology and vascular departments. c Ensure rapid access to confirmatory diagnostic tests, either ultrasound or biopsy, for patients with suspected GCA. d Co-ordinate multidisciplinary team (MDT) discussions across rheumatology networks to support effective decision-making and prescribing of tocilizumab.

Trusts should review governance of ultrasound for musculoskeletal (MSK) conditions and giant cell arteritis (GCA) to ensure that the service is sustainable and provide equitable access to ultrasound diagnostic tests for all patients who need them. a Ensure MSK ultrasound services are not reliant on single-handed practitioners, that competence is maintained through regular practice and continuing professional development and that images and reports are securely stored, linked to the patient record.

Pathways for diagnosis and treatment of 'hot joints' should be consistent and led by orthopaedics to ensure 24/7 access for patients, with support from rheumatology as required. a Review local provision, liaising with local organisations to align pathways and ensure appropriate involvement of orthopaedics. b Establish mechanisms to review patient outcomes and variation in length of stay.

Trusts should optimise use of day case facilities and consider alternatives to day case admission for some procedures to reduce waiting times and improve the patient experience. a Review current day case activity and remove any that is inappropriate. b Review governance of non-cancer chemotherapy including training, competencies, auditing compliance with guidelines, and accessibility for urgent treatment. c Ensure day case units are nurse-led with appropriate and proportionate access to medical input for relevant patients/cases. d Preferentially use and transition to subcutaneous injection to reduce day case requirements where appropriate. e Consider greater use of dose banding where appropriate.

Trusts should use national medicines data reporting systems, together with local benchmarking, published through the NHS Model Hospital and Model Health System, to enable transparent local and regional comparison of high-cost medicines usage. a Ensure appropriate and accurate capture of prescribing spend by rheumatology departments. b Support and implement patient level electronic systems to report on both hospital and primary care prescribing by indication and patient numbers. c Develop analytical methodologies to identify opportunities to reduce local, system and regional variations, and improve patient outcomes. d Review high-cost drug management systems and develop interoperability with electronic prescribing systems to ensure accountability with minimal additional administrative burden.

Trusts and departments should continue to be supported to make rapid switches to use of best value biologic medicines, including biosimilars, where clinically appropriate. a Develop national approaches to the choice of best value biologics, similar to the national initiative for switching to biosimilar adalimumab. This should include appropriate commissioning levers including reference pricing to support the costs of clinical changes. b Continue to use Model Hospital (and future Model Health system) to monitor the uptake of best value biologic medicines. c Continue to monitor patient safety and optimal clinical outcomes to support future choices around best value biologics.

Disease-modifying anti-rheumatic drugs (DMARD) monitoring processes should be standardised across integrated care system (ICS)/sustainability and transformation partnership (STP) footprints and medical specialties, linked to an interoperable electronic monitoring system. a Standardise DMARD monitoring processes across ICS footprints, possibly co-ordinated by newly appointed clinical pharmacists working in Primary Care Networks (PCNs). b Align guidance on DMARD monitoring across all relevant specialties to reduce variation. c Move to electronic monitoring systems – ideally interoperable across ICS footprints.

Adequate resource should be allocated to ensure trust involvement in research and to support submission to relevant patient registries. a Allocate time to lead or contribute to research in consultant job plans. b Promote clinically-focused research questions from registries and disseminate results to clinical teams as well as via an academic route.

Reduce litigation costs by application of the GIRFT programme's five-point plan. a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT 'Litigation data pack' b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trust's panel firm should be able to provide support d Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SI)/Patient Safety Incidents (PSI) and where a claim has not already been reviewed as SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including Multidisciplinary Team meetings, Morbidity and Mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional teams to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a Use sources of procurement data, such as the Spend Comparison Service (SCS) and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes c Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.