The available therapeutic options for rheumatoid arthritis have evolved dramatically in the last decade and a half, but has service delivery kept up?
Rheumatoid arthritis (RA) is a chronic and progressive autoimmune disease. It results in a great deal of pain and disability associated with swelling of multiple peripheral joints, with predilection for the hands, feet and wrists, and can have significant co-morbidities such as heart disease.
RA is estimated to affect 580,000 people in England alone. However, people with RA often experience delays in referral, diagnosis and treatment, which can cause their condition to worsen unnecessarily, causing long-term damage that could have been prevented.
There is compelling evidence that the best long-term outcomes achievable are associated with early and optimal treatment intervention.
“The best long-term outcomes achievable are associated with early and optimal treatment intervention”
There have been some national developments to address shortfalls in care for people with RA. The National Institute for Health and Care Excellence (NICE) published a quality standard for RA in June 2013, designed to encourage the quick referral of patients with suspected RA to rheumatology units; meaning speedy diagnosis and treatment.
The best practice tariff (BPT) for early inflammatory arthritis was also introduced in 2013 to provide a financial incentive to providers to deliver high quality services across the country for people with early inflammatory arthritis.
The success of such initiatives must be measured by the degree to which they have an impact on the ground.
RAising the game: translating national policy into local action for rheumatoid arthritis services, a report from the ABPI Rheumatology Initiative (ABPI RI) published December 2014, argues that it is not sufficient for these policies to exist, they must be actively taken up by local clinicians and commissioners alike.
The ABPI RI’s research indicates that this does not always happen.
There are also risks in pushing too hard for complete alignment with such policies.
Each person with RA will have different goals that they want to achieve through their treatment. Following one treat-to-target system for all, where a therapeutic goal such as remission may be desirable, but also aspirational and unattainable by the majority of patients, may result in personalised needs and goals being ignored.
Furthermore, it is essential that this wide variety of guidelines and recommendations genuinely raise standards of care rather than reduce commissioned service to a lowest common denominator that levels down service quality. Similarly, if a secondary care unit is inadequately resourced to deliver the targets associated with the best practice tariff, failure to achieve these goals may actually incur a financial loss to the unit.
For example, while NICE guidance can be useful in focusing the minds of those yet to deliver a high quality service, in some areas care for people with RA will be excellent and may be performing beyond the expectations of such guidelines.
“Any initiatives that support greater prioritisation of RA on a local level must be welcomed”
In RAising the game, to illustrate this point with regard to the BPT, I point out that a six week discharge where there are not clinical findings, as advocated by the BPT, may not be reasonable where a patient has a convincing history, and that the tariff therefore incentivises a reduced level of surveillance and care.
Nevertheless, in a cash-strapped NHS, any initiatives that support greater prioritisation of RA on a local level must be welcomed.
It is essential that all CCGs start to think actively about the needs of this group of patients and the particular needs of the population they serve. This is best done through greater collaboration and dialogue between commissioners and secondary care experts aware of the full range of therapeutic options for this highly heterogeneous syndrome, so that we can work together to ensure person-centred, high quality services for people with RA.
It is reasonably possible to provide the right treatment to the right patient at the right time.
The treatment paradigm and available therapeutic options for RA have evolved dramatically in the last decade and a half, but optimising service delivery at a local and national level to make the most of these advances still has some way to go.
We cannot yet prevent RA but by speedier diagnosis and treatment we can optimise outcomes and mitigate its impact on individual patients, the wider society and the NHS. We can reduce comorbidities and the need for surgical intervention, preventing disability and maintaining employment status and independence.
Professor Peter Taylor is Norman Collison Chair of Musculoskeletal Sciences