Primary care rheumatology—leading the way?

P. S. Helliwell and J. Hetthen1

University of Leeds and St Lukes Hospital, Bradford and
1 St Lukes Hospital, Bradford, UK

Correspondence to: P. S. Helliwell, Rheumatology and Rehabilitation Research Unit, 36 Clarendon Road, Leeds LS2 9NZ, UK.

Yet another National Health Service (NHS) reorganization is upon us. This `restructuring' (more a change of emphasis) has the potential to cause major changes in the way health care is delivered. The government, encouraged by the success of pilot total purchasing schemes, wishes the NHS to be driven by primary care. Since 1 April general practices have been organized into primary care groups (PCGs) of about 100000 patients and each PCG has a management structure of a chief executive, chairman and board which includes lay and non-medical professionals. Each PCG will provide and commission services according to local need. PCGs will be `feeling their way' initially, but those who develop innovative structures will be given appropriate accolade. Cost savings will be carried over. There is a possibility that some PCGs will eventually become trusts and thus function effectively as `health maintenance organizations'.

Prior to the current reorganization, new Health Service Guidelines allowed general practitioners (GPs) to be renumerated for providing secondary care services in primary care [1]. GPs providing such a service were to be accredited and renumerated by the local health authority. The extent and nature of accreditation seem to have varied, but the guidance recommended that the health authority appoint an advisory panel to check appropriate qualification, experience and practice facilities. The exact format of this panel was not specified, but the inclusion of the relevant local specialist was felt to be essential.

In November 1996, two GPs were contracted by Bradford Health Authority to provide specialist rheumatology care in general practice. These GPs, from different practices, were also employed as clinical assistants within the rheumatology out-patient department, working alongside consultant rheumatologists. An audit of the first year of this service (covering such issues as case-mix, waiting times, morbidity and patient satisfaction) is published in this issue [2]. One of the opportunities for PCGs will be to increase the provision of secondary care services within the PCG. In this editorial we will discuss the wider implications of such a development and offer suggestions to ensure the maintenance of clinical standards.

Of course, other medical specialities are also faced with this scenario. Dermatology, in particular, has been the focus of heated discussion on the issue of outreach clinics [3] and a recent report from the Royal College of Physicians of London, prompted by GPs providing specialist care without adequate training, has debated some of the issues [4]. The problems facing dermatology are akin to those facing rheumatology: first, the extent, range and quality of the services provided in general practice; second, the issue of training; and third, the impact on secondary care.

There is little value in addressing concerns regarding utilization of services without considering access and the sensitive issue of the quality and specialist nature of the services available. The BLAR essential standards of care for patients with osteoarthritis or rheumatoid arthritis include the provision of written information on arthritis in general, medication taken, exercise and self-help/support groups [5]. The BLAR standards are met by the secondary care service through provision of a specialist multidisciplinary team and availability of relevant literature. In general practice, written information produced by the Arthritis Research Campaign is available. However, primary care patients seldom have access to a rheumatology nurse practitioner, whose role encompasses patient education and counselling. Rheumatology nurse practitioners have been shown to be most effective in this role [6], and research has demonstrated that nurse-led clinics produce positive outcomes in terms of pain, knowledge and patient satisfaction [7]. Other professionals such as physiotherapists and occupational therapists are usually accessible to patients in primary care but they often have no specialist training and work in isolation, a cause for concern in their professional bodies [8].

Training is possibly the most important point. From a medico-legal point of view a GP providing specialist services will be judged by the standards of consultant peers, not primary care colleagues [4]. This has enormous implications for accreditation and training. Current undergraduate training in rheumatology is clearly inadequate for this role. The customized postgraduate diploma at the University of Bath may help to fill this gap but, since 1995, only 21 doctors have completed the course, although over 100 are currently registered (N. McHugh, personal communication). Of course, many GPs providing specialist services will have spent 6 months as a senior house officer (SHO) in rheumatology and many will have been, or will be as in the case of Bradford, clinical assistants in rheumatology. Unfortunately, the role of a clinical assistant in rheumatology is often limited to providing routine follow-up care for patients with rheumatoid arthritis. Seldom do these posts provide the time and opportunity to see and discuss new referrals (who will have a greater spectrum of rheumatic disease) in tandem with the consultant. Furthermore, the renumeration is so poor, and time in general practice so scarce, that recruitment to these posts is very difficult—we have two posts vacant at the present time. A recent initiative by the Arthritis Research Campaign, the Primary Care Rheumatology Society and the Royal College of General Practitioners has provided a draft core curriculum on musculoskeletal problems for general practice registrars which, if implemented, should ultimately improve the knowledge and skills of all GPs. But this is in the future.

How do primary and secondary care-led rheumatology services compare in terms of the provision of care? The organization of hospital out-patient clinics means that patients cannot expect to see the same doctor at each visit and there is minimal flexibility in terms of the timing of appointments. The current norm in primary care is that patients are seen in usual surgery hours, often by their own GP, with more flexibility over appointment time. However, should the scope of this service be increased to cover the whole PCG then the differences between the provision of these services in primary and secondary care will diminish. It is possible that PCGs will seek to employ a `certified' rheumatologist to fulfil this role, although utilizing existing `specialist' GPs seems the most likely. In this situation the GP's role will change and may also bring problems relating to their role as the patient's advocate.

The extent of the service provided in primary care will obviously differ between GPs according to their level of expertise. The introduction of item of service payments for minor surgery, within which soft-tissue injections were included, envisaged GPs treating a range of soft-tissue disorders, such as tennis elbow. Our recent audit showed that the service in Bradford is not limited to non-inflammatory soft-tissue disorders and that a full spectrum of rheumatological disease was seen. If this were to be the case elsewhere a major consequence would be the selective referral of more complex rheumatological patients to secondary care. This changing case-mix would adversely affect the hospital service, the increased morbidity being reflected in increased costs. These costs would have to be referred back to the contracting process in order to maintain the viability of secondary care provision.

This gloomy picture of the future can be avoided. Rheumatologists should take the lead in working with primary care physicians to ensure that expert training and support ensure patients receive high standards of specialist care, regardless of whether it is delivered in a primary or secondary setting. The early initiation of disease-modifying therapy and subsequent management of patients with inflammatory joint disease is a case in point. In our audit of primary care provision, the majority of patients presented directly to the specialist GP, facilitating early assessment and the initiation of appropriate treatment, although the results indicate that only a minority of these patients were started on disease-modifying drugs. For these patients there is a need for mutually developed protocols within which patients can be appropriately managed in primary care with rapid access to secondary care if necessary. With the advent of clinical governance it may not be acceptable simply to offer guidelines when there is a need to set clinical standards and the means by which they can be audited to ensure the equitable delivery of care.

Local solutions to training needs should also be considered. In Bradford we have attempted to establish a clinical assistant post for each PCG. Notwithstanding the above comments on such posts, we hoped that we could provide in-service training and a direct line of communication for each of these specialist practitioners but, to date, the posts are unfilled. Other solutions are possible. Dermatologists in Bradford have developed a package which involves a series of training days covering a few common dermatological conditions (such as eczema and leg ulcers) with the deployment of specialist outreach nurses to provide continuing support. Setting standards for which rheumatology patients should be managed in primary care sounds restrictive, but it could provide a way of avoiding the adverse case-mix noted above and it would ensure that all patients with, for example, rheumatoid arthritis had access to a specialist opinion.

We favour the option of providing specialist allied health professionals as a link between general practice and hospital care. For rheumatology this outreach service might consist of a nurse, physiotherapist and occupational therapist based in the hospital setting but providing peripatetic support for primary care specialists. We do not support the idea of consultant outreach services, which have been shown to be costly and provide little educational support for primary care [9]. Providing funds for an allied health professional support team would also need careful thought and would probably need to be negotiated as part of the contracting process.

Whatever solution is adopted, a proactive approach with the fledgling PCGs is recommended. At this time they are attempting to cope with (depending on preceding experience of commissioning) a wide range of tasks including how to manage the traditional ways of health care delivery. The new structure has the potential for revising outdated organization and in order to ensure that patients with specialist disorders receive a high quality of care we need to open a dialogue with the respective PCG boards. Each provider is likely to have several PCGs to negotiate with but it may well be possible to implement a common approach if a workable solution can be made with an index group. Complacency and inaction are not recommended at this time.

References

  1. NHS Executive. HSG (96) 31 Health Service Guidelines. A national framework for the provision of secondary care within general practice. Leeds: NHSE, 1996.
  2. Hetthen J, Helliwell PS. A comparison between primary care-led rheumatology services and secondary care provision. Rheumatology 1999;38:1294–5.[Free Full Text]
  3. Russell-Jones R. The future of dermatology—in hospital or out? J R Coll Phys London 1996;30:413–4.[ISI][Medline]
  4. Guidelines from the Royal College of Physicians Dermatology Advisory Committee. Provision of secondary care for dermatology within general practice. J R Coll Phys London 1999;33:246–8.[ISI][Medline]
  5. Rowan K, Doyle A, Griffiths I. Standards of care: towards meeting people's needs. Arthritis: getting it right guide for planners. London: Arthritis Care, 1997.
  6. Ashcroft J. Arthritis: understanding people's everyday needs. Arthritis: getting it right guide for planners. London: Arthritis Care, 1997.
  7. Hill J, Bird HA, Hopkins R, Lawson C, Wright V. Survey of satisfaction with care in a rheumatology outpatient clinic. Ann Rheum Dis 1992;51:195–7.[Abstract]
  8. Report of a joint working party between the Royal College of General Practitioners and the Chartered Society of Physiotherapy. Relationships between general practitioners and chartered physiotherapists. London: Royal College of General Practitioners, 1990.
  9. Helliwell PS. Comparison of a community clinic with a hospital out-patient clinic in rheumatology. Br J Rheumatol 1996;35:385–8.[ISI][Medline]