09 December 2019
Dr Elizabeth MacPhie, consultant rheumatologist at Lancashire and South Cumbria NHS Foundation Trust, talks about how her service has improved since being identified as an outlier in the 2018-2019 Annual Report for the National Early Inflammatory Arthritis Audit.
We were notified of potential outlier status within six months of starting to recruit patients to the audit. The outlier letters from BSR provided clinicians with a powerful lever to engage in discussions to increase consultant capacity.
At this time we had 2.6 WTE consultants to cover a population of 365,000. Our Chief Executive, Medical Director and Trust Audit Lead were all involved in the discussion and keen to have assurances as to what actions were being taken in addition to the proposal to increase consultant capacity.
What did we do?
Our trust quickly took steps to increase the consultant capacity and a locum consultant was appointed in February 2019. Work then started on a business case to replace this with a substantive consultant post. This business case was written in four weeks and submitted for approval; it was given priority at our network meeting as it was becoming increasingly clear that we wouldn’t be able to lift ourselves out of outlier status without additional consultant capacity.
The team was challenged to identify areas where the team could improve the triage process and improve the skill mix of the team and to include this in the business case. We were also able to utilise the Royal College of Physicians guidance from 'Medical Care' about consultant numbers based on population, a document BSR contributed to. The substantive post was advertised in July and interviews took place in September.
Importance of triage and understanding the numbers
It was acknowledged that the triage process was essential in identifying patients with a suspect early inflammatory arthritis and getting them booked promptly into clinic. All of our referrals are triaged by our Extended Scope Practitioner (ESP) and if it's felt there is insufficient information to triage, referrals are returned.
We realised that we were reacting to increasing waiting times and then adjusting clinic templates rather than taking a proactive approach. We therefore started to record triage outcomes so we could identify more quicky whether we had enough EIA appointments and make changes to clinic templates.
Improving the quality of referrals
There has been a reluctance to introduce a referral proforma as the CCG is mindful that if every service to which primary care clinicians refer have an individualised proforma, this causes frustration. We’ve also had experience some years ago that when a proforma was introduced, boxes were often ticked so as to get the patient seen sooner.
We therefore worked with one of the medical advisors from the CCG to develop a local pathway for suspected EIA. This pathway highlights what action needs to be taken by primary care and encourages prompt referral rather than reliance on blood tests to rule in or rule out an inflammatory arthritis. We’ve also introduced prompts on the GP pathology requesting system so that when a Rheumatoid factor or CCP antibody is selected, the choosing wisely recommendation is displayed.
Patients with a suspected inflammatory arthritis e.g. rheumatoid arthritis (RA) should be referred to rheumatology without delay (even before any blood tests are done). Rheumatoid factor and CCP/ACPA are important but should be avoided as screening tests. A negative rheumatoid screen does not exclude RA nor does a positive test equate to a diagnosis of RA.
Upskilling the team
We recognised the potential of expanding the roles of our multi-disciplinary team and our ESP has been seeing new patients with non-inflammatory complaints for the last 18 months. We felt that there was a strong case to be made for our ESP to also assess patients referred with suspect inflammatory back pain. We ensured there was consultant supervision in place to discuss patients and appropriate permissions in place to request investigations. This has helped to provide more EIA slots across our clinic templates.
Audit results improve
Results from the first year of the audit revealed we were only seeing 11% of referrals within three weeks. Since the start of year two, performance has improved to 46% and for the last quarter to 67%. We recognise that there is much work to be done to ensure that once seen and diagnosed, patients start treatment promptly and, similar to the approach taken to understand the numbers being referred in, we are keeping a close eye on numbers diagnosed and drug education clinic availability.