Case study: Bristol Royal Infirmary


Standardised, integrated, multidisciplinary care pathway


  • - 65% - the number of patients achieving a low disease activity state after 12 months in the pathway, which means less irreversible joint damage and disability

  • - £45,800 - the estimated per annum savings due to reduced use of high cost therapies; equivalent to 20% of the total cost of the service


The implementation of an evidence-based, standardised, multidisciplinary care pathway at Bristol Royal Infirmary has helped to improve patient outcomes and through secondary prevention has improved value in healthcare. The provision of psychosocial support has improved the ability of patients to self-manage and return to work.

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The challenge

  • - The Bristol Royal Infirmary wished to improve the quality of care for newly-diagnosed rheumatoid  arthritis (RA) patients by aligning service delivery with best practice according to key guidelines to support care coordination across the pathway and reduce gaps and variation in care

The solution


  • - Based on a review of the literature and the BSR and EULAR guidelines, Bristol Royal Infirmary implemented a standardised, treat to target, care pathway for newly-diagnosed RA patients, focusing on early, intensive therapy to prevent disease progression
  • - The pathway splits patients into ‘mild’, ‘moderate’ and ‘severe’ disease groups based on their disease activity. Patients are then allocated to three different treatment regimens, depending on their disease group, and move into the standardised care pathway for up to 18 months
  • - The pathway fully integrates the Multi-Disciplinary Team (MDT) consisting of consultant rheumatologists, specialist nurses, a specialist occupational therapist, a specialist physiotherapist, and a psychosocial support specialist
  • - Between visits, patients have direct access to a telephone hotline, with specialist nurses acting as care co-ordinators to refer patients to members of the MDT as required

Service performance and outcomes


  • - The new RA pathway was launched in August 2009
  • - Approximately 65% of patients achieve disease improvement that is consistent with low disease activity within 12 months of starting in the pathway. This is a key target for RA patients, as low disease activity ensures patients experience reduced irreversible joint damage and disability
  • - This result is similar to the figures reported in the literature, and demonstrates the excellent clinical outcomes of patients in the Bristol RA pathway

Patient focus and satisfaction


  • - Patients were involved in the service redesign from the outset and the service continues to involve patients in review meetings, which help to improve the service
  • - Patients receive education packs about their treatment, and specialist nurses encourage self-management as well as providing further education
  • - Self-management clinics are held fortnightly to support patients in improving their fatigue, coping and well-being
  • - After the introduction of Choose and Book, the service saw a 55% increase in the number of new patients, providing further evidence for its popularity with patients

Financial performance and outcomes


  • - One of the main costs in treating patients with RA is the use of high-cost biologic treatment when patients fail to respond to traditional therapies
  • - Due to the intensive treatment strategy employed by the Bristol RA Pathway, which reduces the number of patients who required high-cost therapy, it is estimated that the pathway offers a saving of £45,800 per annum compared to a typical RA service. This is equivalent to 20% of the cost of the service (£236,000)



Commissioning priorities


The Bristol Royal Infirmary standardised, integrated, multi-disciplinary care pathway is an example of commissioning best practice in rheumatology and meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013:
  • - Care co-ordination – Bristol integrates all MDT members into the service and utilises specialist nurses as care co-ordinators to ensure that patients have access to the relevant MDT services when required
  • - Secondary prevention – the early, intensive treatment strategy used by Bristol helps to quickly control disease activity and prevent patients’ disease from getting worse
  • - Medicines management – through their initial review and allocation to a disease group, patients receive appropriate therapy at the beginning of the pathway and are regularly reviewed, allowing the modification of medications when needed
  • - Active support for self-management – specialist nurses educate patients about the need for self-management and educational packs are provided
  • - Improving the management of patients with both mental and physical health needs – patients have direct access to occupational therapists, physiotherapists and a cognitive behavioural therapist, to ensure that both the mental and physical aspects of their condition are fully addressed
  • - The service is therefore a Best Practice model demonstrating how to provide a fully integrated, standardised care pathway to improve the outcomes of patients and save costs by reducing the disease progression of patients and thus reducing the need for expensive therapies in the long-term

Sponsorship statement

This best practice case study project has been sponsored by UCB and Pfizer. UCB and Pfizer have not had any influence over content: editorial control remained with the British Society of Rheumatology.

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We gratefully acknowledge the generous support of our sponsors, which enabled the case study project to take place. This best practice case study project has been sponsored by UCB and supported by a medical education grant from Pfizer. UCB and Pfizer have not had any influence over content: editorial control remained with the British Society of Rheumatology.