Interview with Jo Ledingham, Clinical Audit Director

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Laura Penfold
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Interview with Jo Ledingham, Clinical Audit Director

We sat down with the NEIA Audit’s Clinical Director, Dr Jo Ledingham, to hear about its progress, what we can learn from the data and her aspirations for its future.

The National Early Inflammatory Arthritis Audit is the most comprehensive audit of the condition, charting waiting times, treatment and outcomes, and ultimately paving the way to improving patient care. Now in its second phase, we caught up with the Clinical Director, Dr Jo Ledingham, Consultant Rheumatologist at Portsmouth Hospitals NHS Trust, to find out about the progress of the audit. 

What is the audit about?
The audit covers England and Wales and it looks at new patients over the age of 16 who are presenting for the first time with suspected inflammatory arthritis. We’re looking at patient reported outcomes in addition to performance against the seven quality statements within NICE Quality Standard 33 for rheumatoid arthritis; waiting times for referral, specialty review and treatment, treatment escalation to achieve disease control and provision of education, urgent support/advice and annual review. 

In addition to that, we’re capturing data on the way units are structured, staffing levels and whether patients have access to the right allied health professionals, such as physiotherapists, occupational therapists, podiatrists and psychologists. 
The patient reported outcome measures that are included are crucial to provide evidence about the impact of arthritis on quality of life, ability to perform day-to-day tasks, ability to work and on mental health. 

Why is it so important?
We know early treatment can significantly improve patient outcomes. We have a window of opportunity and if we control inflammation early enough, before irreversible damage to the joints and the rest of the body, we can reduce the impact. 
Having a Healthcare Quality Improvement Partnership (HQIP) commissioned audit reflects that the management of early inflammatory arthritis is a national healthcare priority.  Historically, clinical audits have been huge levers for change for the better and we’re already seeing that. 

What did the first audit reveal?

We had brilliant support and engagement from clinical colleagues and 97% of trusts and health boards submitted data. There were huge variations in the way different hospitals performed, even in adjacent hospitals. 

In terms of how units are staffed there were far fewer consultants employed in England and Wales than the Royal College of Physicians recommends. That impacted on whether patients could be seen in a timely manner. The audit also showed that many patients don’t have access to the allied health professionals that they should. 

Headline results included: The vast majority of patients had severe disease and were of working age at the time of first specialist appointment. Only 20% of patients were referred promptly by their GP and within the timeframe recommended. Just 37% were seen within the recommended three-week timeframe from referral. Once they were in units, 68% were started on treatment within six weeks of referral. 

What impact did it have?
We got the data in front of decision-makers; there were parliamentary questions and data fed into parliamentary summits.
Some consultants have said to us that having asked for meetings with commissioners for a long time that they suddenly went up the priority list because of this audit. That’s started a dialogue about how we can improve services for patients. 
Rheumatology has got onto peoples’ radars more than it has before and it’s helping raise interest in what needs to be done to improve care. 

What changes have been made as a result of the first audit? 
The data has given units the evidence that having more consultants improves ability to see patients in a timely manner and that having enough specialist nurses improves ability to start treatment and achieve disease control in a timely manner. As a result, some units have been able to employ additional staff. 
Some have worked on GP education, setting up educational programmes for their local GPs and nurses.  They’ve created new referral pathways to make it clearer to GPs what information we need to prioritise patients into the right appointment slots. 
People are developing early inflammatory arthritis clinics to speed up seeing patients. Some units have set up ‘one stop clinics’ where patients come and have X-rays and ultrasounds. In the same day patients can see a doctor, have confirmation of their diagnosis and then see a nurse who can move forward with prompt treatment and education. 

Are you doing anything differently in your own Trust?
The biggest thing for my Trust is that we’ve agreed a new care pathway. We’ve been trying to get all seven consultants to agree to this for a while and the audit was the trigger for agreement. This uniform approach makes it much easier for our nurses to work more independently.

How is the data collection going for the current audit? 
We’ve recruited 12,000 patients so far, which is almost double the annual number last time around and we’re only six months in. People are engaging well and only a handful of trusts – 8 out of 146 – haven’t submitted any data yet. 

Do you have any words of encouragement for any units that haven’t been involved before?

I think units that aren’t recruiting have legitimate reasons, such as major staffing problems. Our experience from phase one is that if you can get some data submitted, this becomes a lever for people to support you to make change. 

The other thing we do know is that if you can get some admin support, that really helps with the management of the data collection processes. I think it’s important that Chief Executives find some way of doing that because it’s a relatively inexpensive way of supporting a unit. 

The people not recruiting to the audit will be a priority for visits from the Care Quality Commission (CQC), who will be looking at ways they can support units to engage in the audit. From our perspective, we’re working as closely as possible with the CQC to be constructive in terms of supporting those units. 

Where can units get help and support?
BSR is a great support to the audit and their Audit Project Manager, Jessica Ellis, is someone units can contact. We also have five regional champions, who are clinicians across England and Wales, who know the regions and can help units. On the BSR website there are webinars which show how to navigate the IT. We want to support people as best we can. 

How is the audit different this time?
For timelines to referral we’re also looking at axial spondyloarthropathy patients and that’s in recognition of the fact that we know there are significant delays and we need to find better ways to get these patients seen promptly. 
The other big change is that it’s a 12-month follow-up period, where in phase one it was just three months. That’s because we need to look over a longer period to see what impact we’re having, but also to look at the annual review, which is the seventh quality standard that we really couldn’t assess properly before.  
We have streamlined the data process to look at three crucial moments – baseline, three months and 12 months. Clinicians are getting email reminders when data is due for their patients, which should help capture the follow-up data. 

What can we expect for the future of the audit?
Currently it’s commissioned by HQIP for three years, but I’m very much hoping that it’ll continue past that. The longer it’s in place the more likely we are to deliver change. 

What are your hopes and aspirations for the audit?
My aspiration is that we achieve our goal of improving the quality of care for patients including their ability to keep in work and have their families. We can learn so much from those units that are doing well. We can see what those teams are doing right and then spread that good practice message to others.  
People often think of rheumatology as a specialty that treats “little old ladies with arthritis”, and that simply isn’t true. In the time I’ve been a consultant the specialty has changed beyond all recognition in terms of treatments we’ve got and the impact we can have. It’s a really exciting time if we get it right – getting people into remission from a disease which has historically been horribly disabling. If we can improve all of that – that’s my ultimate aspiration. 

Dr Jo Ledingham will be talking at our flagship Annual Conference which is taking place in Birmingham between 30 April and 2 May 2019. Find out more about the conference here.

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