A comparison between primary care-led rheumatology services and secondary care provision

J. Hetthen and P. S. Helliwell

St Luke's Hospital, Little Horton Lane, Bradford BD5 ONA, UK

Correspondence to: J. Hetthen.

SIR, The traditional organization of specialist out-patient services in the National Health Service (NHS) has been challenged in recent years [1]. Changes in government policy, including the purchaser/provider split and contractual funding, have accelerated the shift towards a primary care-led NHS and this trend appears set to continue with the introduction of primary care groups and locality commissioning [2]. This climate of change, combined with higher public expectations, is leading to a degree of specialization amongst general practitioners (GPs), especially in larger fund-holding practices. The provision of specialist rheumatology care by selected GPs has not yet been evaluated. We have audited a newly accredited primary care rheumatology service and provided comparative data from a sample of patients seen in hospital clinics.

In November 1996, two GPs were contracted by Bradford Health Authority to provide specialist rheumatology care in general practice. These GPs, from different practices, are also employed as clinical assistants within the rheumatology out-patient department, working alongside the consultant rheumatologists. In primary care, rheumatology patients are either seen by the specialist GP at presentation or they are referred by another doctor in the practice for a specialist opinion. Neither GP holds a designated rheumatology clinic within their practice. Within primary care, 119 rheumatology patients were seen between 1 November 1996 and 31 January 1998; the first 100 patients were reviewed, producing a relatively even spread of 48 patients from GP practice 1 and 52 from GP practice 2. For comparison, the first 100 consecutive patients seen in the month of June 1997 were identified from the hospital database.

The mean age of the primary care patients (secondary care in parentheses) was 56.2 (55.8) yr with 62% (65%) female and 5% (18%) Asian. Table 1Go summarizes the case mix distribution in primary care in comparison with secondary care. The median waiting time for the first appointment in primary care was 0 days compared with 37.5 days in secondary care. Table 2Go shows the pharmacological interventions used in patients with rheumatoid arthritis and unspecified inflammatory arthritis. In terms of utilization of support services, radiographs were performed in primary care on 36 (61 in secondary care) patients, blood tests on 66 (86) patients, physiotherapy on 29 (33) patients, occupational therapy on 0 (4) patients, appliances 4 (14) patients and podiatry on 5 (6) patients. Referrals to the practice nurse in primary care numbered 18, all for blood tests. Referrals to the rheumatology nurse practitioner, a service not accessible for the primary care patients thus far, numbered 26.


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TABLE 1.  Case mix by health care setting. Where dual diagnoses occurred, the main diagnosis was recorded
 

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TABLE 2.  Pharmacological interventions in inflammatory arthritides (rheumatoid arthritis and inflammatory arthritis). Figures are numbers (%)
 
A postal questionnaire was sent to all patients; 66 returns from primary care and 55 returns from secondary care were received. The majority of respondents in both groups appeared satisfied with the convenience of their appointments, although 3% of primary care patients and 9% of secondary care patients stated that their appointment was not convenient. Very few patients reported experiencing any difficulty reaching either their surgery or the hospital, although 7% of secondary care patients utilized the ambulance service. The majority of respondents in both groups were seen for between 10 and 15 min, and felt that this was sufficient time to discuss their health. A similar proportion in each group had questions they wanted to ask, but felt unable to (13% primary care, 15% secondary care); a similar number citing lack of time, opportunity and privacy. Written information was provided for 45% of primary care patients compared to 52% of secondary care patients. Consultation satisfaction was measured with a standard instrument [3]. Marginally greater scores in the dimensions of general satisfaction, professional care and depth of relationship were found for primary care respondents, but the converse was found for length of consultation. Disability, as measured by the Health Assessment Questionnaire score, was less in primary care (0.625 compared to 1.625), but this may result from the secondary care patients having established disease. A total of 78% of primary care patients concluded that overall they had received a good or excellent service, compared with 80% of secondary care patients.

Glazier [4] believes that, rather than waging war over turf, rheumatologists should take the lead in working with primary care physicians to ensure that expert training and support ensure that patients receive high standards of specialist care, regardless of whether it is delivered in a primary or secondary setting. These descriptive data provide for the first time a glimpse of one way of providing secondary care rheumatology services in primary care. Although the aim of the study was to compare two levels of care, it must be acknowledged that the lack of complete data on morbidity in general practice precludes a meaningful assessment of the suitability of care delivered. However, it is of interest that 32% of patients consulting in primary care had an inflammatory polyarthritis—this figure approaches that for new referrals to secondary care [5] and suggests that the service provided in these cases is a substitute for hospital referral. These data indicate the need for mutually developed protocols within which patients can be appropriately managed in primary care with rapid access to secondary care if necessary.

For the practices concerned, there was a net financial gain through renumeration and savings on referrals to secondary care. From a secondary care perspective, if more GPs follow this initiative, and if they preferentially see the less severe cases, more complex cases will be concentrated on in secondary care, which will increase the costs per patient accordingly. New contractual arrangements would have to take this into consideration, otherwise the facilities, services and skills which secondary care currently provides would no longer be viable.

In summary, patients are highly satisfied with the care received in primary care and most of the patients are appropriately managed in this health care setting. Issues raised include concerns about future changes in referral patterns and the lack of specialist multidisciplinary team input for patients in primary care, particularly for those with inflammatory joint disease. Further work is needed to determine how this affects knowledge, coping strategies and outcomes in primary care patients. Guidelines for the organization and audit of primary care services, and methods of interaction with the hospital team, are urgently required. Further consideration should be given to the concept of an outreach service led by rheumatology professionals working closely with specialist GPs.

References

  1.  Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in general practice. Br Med J 1994;308:1083–6.[Abstract/Free Full Text]
  2.  Department of Health. The new NHS: modern, dependable. London: The Stationery Office, 1997.
  3.  Baker R. Use of psychometrics to develop a measure of patient satisfaction for general practice. In: Fitzpatrick R, Hopkins A, eds. Measurement of patients' satisfaction with their care. London: Royal College of Physicians, 1993:57–75.
  4.  Glazier R. The future of rheumatology: paradigm shift or turf war? J Rheumatol 1996;23:1494–6.[ISI][Medline]
  5.  Kirwan JR, Snow SM. Which patients see a rheumatologist? Br J Rheumatol 1991;30:285–7.[ISI][Medline]
Accepted 21 June 1999