Why does the British Society for Rheumatology (BSR) recommend a 12-week ‘window of opportunity’ for rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients?
Research shows that in cases of inflammatory joint disease, the earlier you catch the disease and suppress the immune system, the less likely a patient is to develop damaging and ongoing, chronic inflammation.
If it’s caught early, it’s much easier to control and it will not take as many toxic drugs to get the immune system under control.
In these disorders, the immune system is attacking the joints and is chronically activated, meaning it carries on attacking rather than being activated only for a short period.
The earlier the immune system is suppressed, the better the long term outcomes and the less likely it is that patients will end up with disabilities and deformities.
Please can you outline the recent research commissioned and funded by MSD, developed in partnership with the National Rheumatoid Arthritis Society (NRAS), and conducted by Kantar Health into the NHS’ efforts to reduce waiting times for RA and PsA patients?
This research involved patients and rheumatologists being surveyed to try and establish whether patients with inflamed joints had actually been seen by their rheumatology service and treated appropriately within 12 weeks.
It emerged that around a third of these patients had waited more than 12 weeks, which compares with a fifth when the survey was done in 2000 to 2005. Standards seem to be slipping with regard to patients being seen early on in the disease.
What are the main reasons why some patients in the UK wait longer than 12 weeks to see a specialist?
There’s a variety of reasons for this. There’s the initial problem with patients recognizing that the joint inflammation is an active, chronic, ongoing problem that they need to go to their GP about.
The second problem concerns whether the GP recognizes the onset of a chronic inflammatory process and refers the patient appropriately and urgently through the local system.
The third is the capacity of rheumatology services up and down the country to actually see these patients promptly. There is currently a lot of pressure to reduce hospital referrals and save money, based on the current climate.
There are therefore several barriers that are probably all contributing to this 12 week target not being met.
There’s also a great need for specialist rheumatology nurses but low staffing levels on wards have meant a lot of these nurses are being taken away from our patient clinics, and made to do ward duties.
This reduces our capacity to deal with outpatients because a lot of the patients with ongoing inflammation are followed up by specialist nurses, which frees the doctors up to actually focus on recognizing the patients that need to be started on the pathway.
How do waiting times in the UK compare to other countries?
In other countries, the health care system isn’t gated by general practitioners. Patients can refer themselves to a specialist’s care. If they suspect a problem with their joints, they can just go and see their rheumatologist, which of course significantly lowers waiting times.
In America, for example, the provision of rheumatologists per head of population is approximately three times that of our own.
In the UK, the number of rheumatologists per head of population is well below the average number recommended by the royal college of physicians.
There is an under provision of specialist care in terms of meeting the needs of the aging population and a lot of pressure on rheumatologists in terms of what they need to do.
What changes would you recommend to improve the UK waiting times for RA and PsA patients?
There must be recognition that patients with early inflammatory joint disease need to be referred urgently and the best practice tariff for these patients must be enforced.
The best practice tariff was introduced by the Department of Health and enforcing the tariff would make people understand that these patients need to be prioritised.
Repopulating the rheumatology nursing workforce is another important thing that needs to be done, rather than them being sent to other places such as the wards.
The third one is an awareness campaign targeted at the general practitioners and the general public. There have been several campaigns such as the “S factor campaign,” which raised awareness among the public that swelling and stiffness in joints that lasts longer than three weeks should be escalated urgently.
Finally, it must be understood at the primary care workplace that these patients need to be seen by their local rheumatology services sooner rather than later.
What are the main hurdles that need to be overcome in order to improve UK waiting times?
I think the main hurdle is recognizing that something can be done to suppress the inflammation in these patients and communicating that to both the patients and primary care. Patients tend to think that once they have arthritis, there’s nothing that can be done and that it is incurable, when actually, like rheumatoid arthritis, a lot can be done to treat it, especially if it’s caught early.
Where can readers find more information?
About Dr Marwan Bukhari
M.B,B.S, MSc, PhD, FRCP
Royal Lancaster Infirmary
Marwan Bukhari is a Consultant Rheumatologist and clinical lead for rheumatology at the University Hospitals of Morecambe Bay NHS Foundation Trust, Honorary Senior Lecturer at the University of Liverpool, and clinical lecturer at Lancaster University. His clinical base is at the Royal Lancaster Infirmary.
Marwan trained in Rheumatology and Epidemiology in Manchester. His research interests include inflammatory arthritis, quality of life in patients with arthritis and osteoporosis.
He is informatics lead for the British Society for Rheumatology and a Northern regional Adviser for the National Rheumatoid arthritis society. He also undertakes work for arthritis research UK as part of the USER committee commenting on research spending and is a national Arthritis research UK student mentor. Marwan is also the Educational Lead for Medicine for medical students for the Lancaster University.