Consultant rheumatology workforce in the UK: changing patterns of provision 19972001
G. Turner,
D. Symmons,
A. Bamji1 and
T. Palferman1
ARC Epidemiology Unit, University of Manchester, Manchester and
1 British Society for Rheumatology Clinical Affairs Committee, London, UK
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Abstract
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Objectives. To summarize the changes in rheumatology provision and working practice that have occurred on the basis of the results of the 1997, 1999 and 2001 surveys carried out to update the British Society for Rheumatology/Arthritis Research Campaign Rheumatology Workforce Register.
Methods. The Workforce Register includes all consultant rheumatologists in the UK who do at least one NHS clinical session per week. Questionnaires were sent to all consultants on the register at the beginning of 1997, 1999 and 2001. The questionnaires asked about clinical commitments and workload.
Results. The response rates for 1997, 1999 and 2001 surveys were 85, 86 and 92% respectively. Scotland, Wales and Northern Ireland all had fewer consultant rheumatologists per capita than any English region. Within England, the London region had 60% more rheumatologists per capita than any other English region.
Conclusion. There are ongoing inequalities in the provision of rheumatology, especially between London and Scotland, Wales and Northern Ireland.
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Introduction
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The United Kingdom (UK) Rheumatology Workforce Register was established in 1971 by the British League against Rheumatism, and has been held jointly by the British Society for Rheumatology (BSR) and the Arthritis Research Campaign (ARC) Epidemiology Unit since 1983. It contains details of all rheumatologists in the UK who hold consultant appointments and provide at least one clinical session per week in adult rheumatology to the National Health Service (NHS). There are separate registers of paediatric rheumatologists, rheumatology trainees and those in non-career grade appointments.
In 1987 the Committee on Rheumatology of the Royal College of Physicians was concerned about the shortage and uneven geographical distribution of consultant rheumatologists in the UK. At that time the District was the unit of provision of secondary health-care services. The population served by a district hospital varied tremendously, but two-thirds served a population of between 150 000 and 300 000. The Committee felt that each district should have at least one rheumatologist and recommended that one consultant per 150 000 population be viewed as optimum [1]. In 1995, the BSR conducted a needs-based estimate of rheumatology health-care requirements [2], which indicated the need for one whole-time equivalent (WTE) consultant rheumatologist per 85 000 population. This estimate assumed that all patients with musculoskeletal conditions who required hospital referral for non-surgical assessment and treatment should be referred to a rheumatologist.
Previous publications from the BSR/ARC Workforce Register have monitored progress towards this goal [3, 4]. This monitoring process is hampered by the frequent redrawing of administrative boundaries within the NHS. District hospitals no longer serve a defined catchment population and the smallest identifiable unit of service provision is now an NHS Executive Region. The most recent regional reorganization of the NHS was in the year 2000. Even though the names of some regions remain unchanged, the boundaries may have been redrawn. Nevertheless, the lowest levels of consultant rheumatology provision have always been in the areas of greatest socio-economic deprivation. The last review was published in 1996 [4]. This paper summarizes the changes in rheumatology provision and working practice that have occurred since then and highlights ongoing inequalities.
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Methods
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Information held on the BSR/ARC Rheumatology Workforce Register is updated biennially. All consultants listed on the register are sent a copy of the details held about them and asked to amend them. The data held include information on employer (e.g. NHS or academic), speciality (e.g. rheumatology, rheumatology and general medicine, rheumatology and rehabilitation), the hospital sites at which they work, the names of other rheumatology consultant colleagues, and the names of any newly appointed consultants in neighbouring NHS Trusts. Any new consultants identified in this way, who are not already on the Workforce Register, are then sent a set of questionnaires. A separate timetable questionnaire asks about patterns of work and on-call commitments. After approximately 6 weeks, non-responders are sent a reminder. This paper summarizes the results of the 1997, 1999 and 2001 surveys.
The level of provision for each NHS Executive Region is calculated by estimating the number of WTE consultants. A WTE is regarded as 10 sessions. NHS rheumatologists with full-time or maximum part-time contracts are assumed to be working in the NHS for 10 sessions per week. Other consultants provided information on their weekly number of NHS sessions. Where this information was missing, we assumed that consultants with general medical commitments or with university appointments worked five NHS rheumatology sessions per week.
The denominator population is based on the NHS Executive Regions. Although these changed after 1999, for continuity and to enable comparison, we present the data for the regions that existed before 2001 where possible.
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Results
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The numbers of questionnaires mailed and returned in 1997, 1999 and 2001 are shown in Table 1
. The response rate rose with each successive survey. In 2001 the highest response rate (100%) was from the West Midlands Region and the lowest (78.9%) from Wales (Table 2
). The proportion of consultants whose contract included general medicine remained stable at around 20% (Table 3
), but the proportion doing rheumatology and rehabilitation has slowly fallen.
When calculating the number of WTE rheumatologists in each region, we included all consultants on the register, whether or not they responded to each individual survey. The absolute number of WTE rheumatologists has gradually increased in all regions except Northern Ireland (Table 4A
). Nevertheless, in 1999 only three regions (North Thames, South Thames and Northern and Yorkshire) had more than 50% of the optimal provision of rheumatologists (one WTE per 85 000).
Scotland, Wales and Northern Ireland all had lower levels of provision in 2001 than any English region. The new regional boundaries highlight the discrepancy in rheumatology provision between the capital and the remainder of England. Among the English regions, Eastern has the lowest provision, but the range between the regions is relatively small outside the capital (4755%) (Table 4B
).
The way in which consultants in pure rheumatology spend their time has not altered substantially over the last 5 yr (Table 5
). However, there is a trend towards spending a lower proportion of their time on ward work. The median number of clinics per week per WTE is now 4.0 (Table 6
). As might be expected the number of clinics per 100 000 population reflected the pattern of consultant provision (Table 7
). The increasing number of consultants led to a small fall in the median number of new referrals per consultant per week from 19 (range 150) in 1999 to 17 (range 160) in 2001. The median waiting time fell from 16 (range 262) weeks in 1999 to 15 (1100) weeks in 2001. This suggests both that there is still unmet need for rheumatology referrals within the population, and that appointing more consultants does have an impact on the provision of services.
The proportion of consultants providing an on-call service for rheumatology rose from 31.6% in 1997 to 62.9% in 2001. The median frequency of rheumatology on-call is one week in four.
Around a quarter of adult rheumatologists do paediatric rheumatology clinics, a median of one clinic per month. The number of consultants who have a clinical nurse specialist in their multidisciplinary team rose from 75% in 1999 to 81% in 2001.
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Discussion
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The level of rheumatology consultant provision is gradually improving. Taking the whole of the UK, the population served by one WTE rheumatologist has fallen from 191 913 in 1997 to 164 165 in 2001. Within the UK there are inequalities in provision between countries. Northern Ireland has the lowest level of provision, and is the only country in which the level of provision fell between 1999 and 2001.
Within England there are striking differences in the level of provision between the capital and the rest of the country. The same pattern of ranking is seen in many of the other major medical specialities (Table 8
). London has the highest number of consultants per capita for four of the seven major medical specialities and ranks in the top three highest levels of provision for all seven medical specialities. Two of the regions bordering London (South East and Eastern) fall consistently in the lowest three ranks of consultant provision. This may be explained because patients from these regions may travel to the London region for their health-care. By contrast, the levels of consultant orthopaedic surgeon provision follows a different distribution, the highest-ranking regions being in the north and the lowest-ranking in the south of England. This means that the ratio of consultant rheumatologists to orthopaedic surgeons varies from 1:2.4 in London to 1:4.4 in the North West (Table 8
). Presumably London-based rheumatologists are seeing patients who, elsewhere in England, would be referred to orthopaedic surgeons. This offers interesting opportunities for health services research with regard to costs and outcome.
Department of Health figures also show that patients from the least socially deprived areas are more likely to be referred to a rheumatologist or an orthopaedic surgeon (regional boundaries as defined prior to 2000, Fig. 1
) [5]. This is surprising, as published evidence suggests that the prevalence of musculoskeletal symptoms and disability is higher amongst those from the most socially deprived areas [6, 7]. In addition, there is evidence that patients with rheumatoid arthritis have a worse prognosis if they live in areas of high social deprivation [7, 8]. These observations would suggest that the highest rheumatologist referral rate should be for those most socially deprived. London is by far the most socially deprived region (Table 8
) and so should have the highest number of WTE if appropriate referral rates take place.

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FIG. 1. Age-standardized referral rates to rheumatologists and orthopaedic surgeons by deprivation category.
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The number of hours that rheumatologists are working has increased since 1997. More are providing an on-call service. Nevertheless, the median number of clinics per consultant remains stable at 4.0. The proportion of ward work is decreasing. This suggests that rheumatologists are spending an increasing amount of time on administrative tasks and continuing medical education.
In conclusion, the level of rheumatology for the UK as a whole is improving but the distribution of rheumatologists does not adequately match the distribution of health-care need [9].
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Acknowledgments
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The ARC/BSR Rheumatology Workforce Register is supported by a 5-yr programme grant from the Arthritis Research Campaign and a special-purpose grant from the British Society for Rheumatology. We are grateful to the rheumatology consultants in the UK who have completed the biennial questionnaires mailed to them by the Workforce Register staff.
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Notes
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Correspondence to: D. Symmons, ARC Epidemiology Unit, University of Manchester Medical School, Oxford Road, Manchester M13 9PT, UK. 
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Submitted 21 December 2001;
Accepted 28 December 2001