Department of Rheumatology, Queen Mary's Hospital, Sidcup, Kent DA14 6LT, UK
The UK has a unique problem, or asset, called the National Health Service (NHS). A state run and funded healthcare system, it has since 1948 purported to provide an efficient and all-embracing service that is free at the point of contact. That it has never actually achieved this has been glossed over by successive generations of politicians who have striven to show that their government has provided more incentives and funds than any of its predecessors. While the input of resources has indeed increased year on year, it has never actually kept pace with the demand of the service. Diseases that were untreatable 50 yr ago may now be curable; new drugs, investigations and surgical techniques have revolutionized many areas of medicine; but all of these advances have had a price tag attached. In recent years there have been many attempts to reduce waiting lists for surgery, reduce waiting times for out-patients, introduce standards by which hospitals may be judged (or punished) and improve healthcare delivery by re-organizing the basic NHS structures. But complaints continue to rise and some commentators point out that constant government insistence that the highest standards must be achieved is unrealistic in the face of persistent underfunding. The proportion of Gross National Product spent on health in the UK remains lower than most developed countries; a recent comparison suggested than in Europe only Albania spent less. The number of specialists compares unfavourably with other countries, and if they are working at capacity then the only way to reduce waits for new out-patient appointments is to have more of them. In surgery, if such a reduction can be achieved it then generates a waiting list for operations, which can only be reduced by having more hospital beds, theatres and surgeonsor by controlling the input to clinics which of course will once more increase the waiting time for a new appointment. Alternatively, patients may seek to avoid waiting by seeking private healthcare, an option that is encouraged by one major political party while bitterly condemned by the other.
Rheumatology is not exempt from any of these problems. If hospital rheumatology services continue to provide broad cover that embraces inflammatory joint disease at one end of the spectrum and chronic pain management and sports medicine at the other, as is currently proposed, then analysis of workload suggests that there should be one consultant rheumatologist for 85 000 population [1], a ratio that is achieved hardly anywhere in the UK. The picture is complicated by the split responsibilities of consultants who may also deal with non-rheumatological rehabilitation (although this is a diminishing group, owing to the absence of training posts with dual accreditation) or general medicine (where the acute medicine component is often substantial, yet the consultant may be counted as being full-time in rheumatology). Despite initiatives to return some elements of management to the primary care sector, such as in back pain or osteoarthritis (OA) [24], many consultant rheumatologists report a continuing rise in referrals with a corresponding rise in waiting times for new appointments [5]. It is often difficult to balance the quality and quantity aspects of a rheumatology service. While guidelines suggest that new patients should have an initial appointment of 30 min and a follow-up patient 15 min and that consultant rheumatologists should have only four to five clinics weekly [6], few can aspire to such figures when assailed by demanding patients or primary care physicians. Further inroads on time are made by new requirements for pursuing clinical governance issues; and it is surprising how many clinic statistics fail to record the immense amount of time spent, once the last patient has left, in organizing the correspondence. Teaching is time-consuming but few consultants outside the teaching hospitals can afford the luxury of reducing clinic sizes to allow time for discussion, and simply allow their clinics to overrun. Many senior rheumatologists who hold academic posts may actually spend relatively little time in the clinic because of their research and teaching commitments [7]. There are then the issues of whether a rheumatology department may be requested to provide an outreach service by doing clinics in primary care centres (which is generally agreed to be highly inefficient, as in dermatology [8]); the negotiations required, in the NHS purchaserprovider split, to ensure that services can be maintained and developed; the issues of whether new expensive drugs can be afforded. Locum costs are unaffordable by most hospitals, so when staff go on holiday or study leave the service comes to a stop. The UK allowance of 6 weeks annual leave and 2 weeks study leave may not all be taken up, but effectively a service may only run for 10 months of the year. All of these factors contribute to the undoubted truth that patients may wait an inordinately long time to be seen.
These problems are not confined, of course, to rheumatology; substitute any other specialty name for rheumatology and the same may be true. In any system where there are competing claims for resources the best case should stand some chance of success, but recent British government proposals have placed other medical problems above those of arthritis. One might argue that current priorities of heart disease, stroke and cancer would be best addressed by banning smokingbut in the absence of any serious central pressure on purchasers it has largely been left to hospital departments on a local basis to negotiate service agreements. The success or otherwise of rheumatology in putting its case is thus fragmented and has clearly led to discrepancies in supply between areaspostcode referral rather than postcode prescribing.
Does it matter? In this issue Hurst and colleagues argue that it may not. I am not so sure. Their paper (and previous work from their department [9]) sets out many of the problems implicit in rationing and underlines the fact that many clinical departments use the waiting list as a rationing system. They conclude that overall the wait for non-urgent referrals does not lead to significant problems in mental or physical health. While this may be true in the population selected, the selection process itself has introduced some bias. On the basis that 10% of new referrals to rheumatology clinics are for inflammatory joint disease [10] that 10%, by being categorized as urgent, has escaped analysis. It is in the treatment of rheumatoid arthritis (RA) where the evidence for the benefit of early referral is perhaps strongest and where clinical practice reflects the growing agreement that early referral and initiation of second-line treatment improves outcome [11, 12]. Hurst argues that the rheumatology service should, for these reasons, be targeted at this group. But if priority setting favours this disease, and by being explicit in its aim leads to more referrals of RA, then the routine waiting list will inevitably lengthen. And there is still a high false positive referral rate; too many patients are labelled as having RA on the basis of (often inconclusive) blood tests alone. As Hurst concedes, the setting of a priority depends on the information and this may be inadequate.
So by definition Hurst's non-urgent group as defined is largely made up of mechanical problems and soft tissue injuries that are self-limiting. Thus one might expect a significant proportion of patients referred to get better spontaneously and the longer they are left for this to happen the more likely it is to happen. Alternatively some long waiters may vote with their feet and seek private attentionthus, perhaps, skewing further the study population by selecting out those who are physically worse or simply more impatient. Docile, placid patients do not complain and may well report a better outcome.
Neither does the study provide sufficient diagnostic information to be clear about whether there are differences between different subgroups. Does delay in a referral for back pain differ from delay in one for OA? Does delay in OA of the knee differ from OA of the thumb carpo-metacarpal joint? Is there a likely difference in outcome between a frozen shoulder and a rotator cuff injury? The answer to each of these questions is yes, in my opinion. And the measured outcome may well also depend on patient expectation, which, even with the advent of accessible information through the media and the Internet, is still very low. How would a patient's perception of satisfaction be altered, for instance, by knowing that persistence of unmanaged back pain may predispose to chronicity? Do patients know of the efficacy of quadriceps exercises and the possibility of reducing symptoms and progression by doing them [13], or are they simply happy to accept that knee pain is part of the normal ageing process? Does the frozen shoulder patient who has waited for specialist attention past the turning point of spontaneous recovery realize their suffering could have been alleviated by injection [14], and is their questionnaire response influenced by the relief of their improvement? Hurst allows that any attempt to measure employment status other than by a crude in and out is almost impossible, but lost working days have a huge economic impact (and even soft endpoints, like the effect of sleep disturbance on work capacity, may be important). One could ask whether the huge costs of back pain to society could be mitigated by early active management supervised in specialist centres, and whether in societal terms this would be economically more efficient than placing RA patients at the head of the referral queue. There is clearly still work to be done in setting strategies for prioritization.
It is unfortunately clear from the experience of many consultant rheumatologists that shortening the waiting list merely encourages referrals [15, 16]. I agree with Hurst that in a system of limited supply it may be necessary to regulate access. But how? Sorting the box of referral letters is a stage too late in the process. It should be done at a point before the referral occurs, and this requires better dialogue between referring physician and specialist. There needs to be a clearer definition of what is treatable in primary care and what is not. Steps have been taken in this direction, as already mentioned, but such initiatives are unlikely to succeed if the standard of undergraduate teaching in rheumatology remains so poor. There are still relatively few British medical schools that provide, in a bursting curriculum, what I would consider an adequate exposure to rheumatology (the problem is even worse in some overseas countries) and so it is hardly surprising that primary care physicians get rapidly out of their depth [17, 18]. They are also overstretched and so, if offered postgraduate training, may simply realize how much the specialist service can offer and unload even more; and of course, once the referral has been made there is nothing more that can be done. On the other hand, the primary care specialist is a concept that has some risk; if a consultant rheumatologist requires 4 yr of full-time training (and still, if like me, has an enormous amount to learn in the next 16 yr) then patients may not get the fully trained specialist they need from a general practitioner who has completed a part-time course over 2 yr. Nevertheless such experience should enable the primary care sector to look more effectively after its own. This may improve outcome in some areas (it is a bit silly for a specialist to see a back pain sufferer after a 6 month wait and tell him that early mobilization is the key to curethis is a job for primary care) but may leave the secondary sector with more difficult and therefore more expensive referrals.
Hurst has argued that to attack the waiting list problem by throwing money at it in the form of additional specialist care is unjustified, but the data from his study are small and I believe open to challenge on that count alonethey do not allow sufficient analysis of differences between different conditions. However, I entirely agree that uncritical appointment of specialists to deal with waiting lists is unacceptable. We have seen attempts to crack waiting lists by creating short-term specialist posts, but the follow-up load is then thrown back on the substantive consultants when the extra help goes away, and the problem rebounds. But there is more to being a specialist than number-crunching in clinics. If existing consultants are hard pressed then additional manpower will enable far more than the cracking of the waiting list nutit will offer time. Not just extra time for the patient in the clinic, but time for the development of referral strategies, time for the discussion of management protocols, time for undergraduate and postgraduate education, time for the supervision of non-medical specialists and all the soft input that will improve services to patients. Attention to these may rationalize referrals and reduce waiting times and, in all honesty, if you were told that there was a choice between waiting 1 month or 5 months but the outcome would be the same, whichever choice was made, would you really be happy to wait? This, in the end, may be the only response to politicians who seek to use this sort of data to justify their failure to invest in our specialty, and conveniently choose to ignore that doctors do far more than see patients.
References