Rheumatoid arthritis: bringing care closer to home

Abstract

The move to offer more treatment in primary care started before the current round of NHS reforms and is generally well supported With the advent of GP and clinician led commissioning, and the move to shift the care of people with long term conditions out of the hospital setting, the focus on care in the community has never been stronger. Recent publications from organizations such as the King’s Fund (2011) argue for greater integration between primary and secondary care, improved medication management and self management. However, for some conditions the move has been slower and developing good community care requires funding and the parallel de-commissioning of hospital based services, something that patients themselves at times resist. Rheumatoid Arthritis is one example of this. It is a complex disease which is primarily currently treated in secondary care by a consultant led, specialist multi-disciplinary team, which also includes the GP and other primary care professionals as well as, of course, the patient themselves. Major government funding and training has enabled conditions such as asthma, diabetes and cardiovascular assessment and prevention strategies to be successfully delivered in primary care in recent years. Alongside this has been significant improvement in patient education and self management particularly in diabetes. No such funding or training has been allocated to the treatment of inflammatory arthritis (IA) and the majority of GPs lack the experience and skills necessary to safely diagnose or follow up patients with Inflammatory Arthritis. Treatment of IA has changed in a revolutionary way since the introduction of biological therapies over 10 years ago and such drugs can only be prescribed by a consultant rheumatologist, with the result that GPs are often unaware of the advances in treatment regimens for people with Rheumatoid Arthritis. The need for rapid referral for anyone with suspected inflammatory arthritis to a consultant rheumatologist to obtain a diagnosis at the earliest opportunity in order to maximize long term outcomes is paramount but delays persist. Whilst the issue of GP education was flagged in 2009 in the National Audit Office Report into Rheumatoid Arthritis services, it will take time for the Royal Colleges to address changes in the training of health professionals. However, there are aspects of the care of people with RA which are well placed to sit within primary care, such as cardiovascular risk assessment and advice. CV disease is increased in people with RA and similar to the risk in people with Type II Diabetes. The benefit of effective patient education and self management is also something which is well understood by GPs. The National Rheumatoid Arthritis Society has developed a self management programme for Rheumatoid Arthritis that is delivered by allied health professionals in rheumatology and people living with Rheumatoid Arthritis. Results of the pilot are encouraging and indicate positive changes in health-related behavior and an increase in the skills needed to manage the condition which in turn may help reduce the risk of developing cardio vascular disease especially where there are lifestyle issues present. Disease specific programmes such as the RA Self Management Programme could be commissioned and prescribed by GPs and community nurses who are providing support to people living with RA. This will benefit patients and potentially help improve medication adherence and increase health-related behaviours, which may offset some of the risk factors of cardiovascular disease. It may also help patients living with rheumatoid arthritis who are used being managed through secondary care begin to think about making more use of support that is closer to home. BJCN