The society and the Healthcare Quality Improvement Partnership (HQIP) published the first annual report of the ongoing National Early Inflammatory Arthritis Audit last week. Head of Policy John Hopgood takes a look at what the audit says, why it’s important, and what happens next.

The National Early Inflammatory Arthritis Audit is a truly mammoth undertaking – with 146 trusts and health boards across England and Wales taking part, more than 20,000 newly-referred patients with suspected early inflammatory arthritis were registered in the first 12 months of the project. The information that we’re able to track, thanks largely to the hard work of rheumatology teams and support staff, gives us the most comprehensive picture ever of rheumatology services.

Why is the audit important?

It all comes down to one thing – data. The NHS and the Department of Health and Social Care keep track of some basic data across the health system. Things like waiting times, number of admissions, referrals and similar are easy to track and give us a high-level look at how the NHS is performing and where pressure points exist. That’s where the audit comes in.

First, the audit team gathers data about every participating unit across England and Wales. This covers things like number of consultants, nurses and trainees in each unit, whether there is access to multidisciplinary support – services like physiotherapy, podiatry and mental health – and information on how each unit manages its early inflammatory arthritis patients, through dedicated clinics, telephone advice lines and similar.

Then, each patient referred into the unit with a confirmed diagnosis of inflammatory arthritis is monitored over the course of twelve months against NICE’s quality statements for the condition. These statements cover things like referral times, delays before starting treatment, frequency of monitoring and self-management assistance.

What does it say?

Perhaps most importantly, it lets every trust and health board compare how they’re doing with neighbouring services and the country as a whole. Trust-level data is available to download here – but don’t hesitate to get in touch with us if you’d like some help interpreting what the data means in your area!

It also gives us an overview across each key area of how things are going. For example, it shows us that, nationally, there are 1.3 whole time equivalent consultants (where one whole-time equivalent represents 37.5 work hours per week) for every 1,000 new appointments. This varies dramatically across the country, from as few as 0.3 in Powys, to as many as 3.4 in Kingston. We can also see that, while 94% of units have access to physiotherapy, just 39% have psychological support within the department.

In terms of performance against the quality statements, there is a huge degree of variation across the country. The first quality statement looks at referral times from primary care – with the target being within three days. Nationally, just 41% of referrals were made within this timeframe, with a high of 97% in Chester and a low of just 2% in Cambridge.

Interestingly, Cambridge is one of the top performers against quality statement 2, which looks at time between referral and clinic assessment. Here, 78% of patients are seen within three weeks of referral, compared to a national average of 38%. Chester, meanwhile, is slightly below average in this area, at 31%. It’s anomalies like this that really underline the value of the audit. Clearly we want to work to improve the situation across the board – 100% is always the goal – but the priority for Chester will be very different than in Cambridge.

Probably the starkest thing shown in the audit is the contrast between operational quality standards (referral times, assessment times) and clinical quality standards. Quality statements 3, 4, 5 and 6 look at, respectively:

3. Whether cDMARDs (conventional disease-modifying anti-rheumatic drugs) are prescribed within six weeks of referral

4. Whether patients have access to education and self-management support within a month of diagnosis

5. Whether treatment targets are set and disease activity is regularly monitored

6. Whether patients suffering disease flares or possible side-effects receive advice within a day of contacting the rheumatology service

In relation to these quality statements, the national average ranged between 54% (prescription of drugs) and 93% (access to disease-specific education). Again, there is a significant amount of regional variation, but the data tells us that services are largely working as they should do, once patients are within the system.

What happens next?

Our President, Dr Liz Price, has already spoken about supporting ‘outliers’ – those units performing below the national average.

Meanwhile, the report makes 12 recommendations, covering service providers, service users, educators and commissioners. Over the coming months, the audit working group and BSR’s policy team will be looking at ways in which we can help ensure that those recommendations are acted upon. One key aspect of this will be awareness work – using the data to let local decision makers and politicians know what the situation is in their area.

The audit data also helps highlight to everyone at the society where we should be focusing our attention in the years ahead. One area that we’re already committed to is about promoting rheumatology as a career – we can see the challenges that departments are facing over recruitment and retention of staff, and the data here really helps emphasise the potential impact that we can have in this area.

The audit itself is continuing to gather data for the next year, with another annual report next autumn. It should be noted that we’re also collecting patient-reported data on disease outcomes – this is included in the annual report, and we’ll be speaking more about these findings soon.

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