Modern rheumatology-A dynamic and accessible service

Jeremy Jones

Consultant RheumatologistClinical Lead CMATS*

Betsi Cadwaladr University Health Board,North West Wales

Honorary Research Fellow

The School of Sport, Health and Exercise Sciences,

Bangor University

*CMATS = Clinical Musculoskeletal and Treatment Service

Rheumatology (used in its widest sense)

• Geography• History• Development of Services with time• Prudent Health care• MSK Service in 2016• Rheumatology Service in 2016

• Early Synovitis Clinic• Update on Gout• From heart sink to stout-heartedness; Ten top tips from the

fibromyalgia clinic

North West Wales

• 250,000 people

• Retired/second homes

• Agriculture

• Outdoor tourism

• Bangor University

• Long and winding roads; full of tractors, milk trucks etc

• Public transport; rural

Curriculum vitae Qualified at St Marys Hospital

1973-4 Registrar Rheumatology at Guys Hospital 1974-84 Senior Registrar Rheum and Rehab

at Kings College Hospital1979-80 Sabbatical; ARC Research Fellow at

Addenbrookes Hospital, Cambridge 1984- 2002 Specialist in Rheumatology and Rehabilitation Medicine,

Queen Elizabeth Hospital for Rheumatic Diseases,Rotorua, New Zealand

2002 –present: North West Wales

• Rheumatologist• Clinical lead for TEAMS/CMATS• THE fibromyalgia doctor• Appointment at Sports Science School, Bangor University

The 1970s

Rheumatology and Rehabilitation

Ann rheum Dis 1963 22 91-100

Management of rheumatoid arthritis

• Steroids

• Gold/Penicillamine

• Aspirin

• Phenylbutazone

• Early days for surgery,

anaesthetics etc

• Bed rest

• Splinting

• Hydrotherapy

1970’s; Skills required of trainee rheumatologist

• Rheumatic diseases• Make POP splints• Corticosteroid injections• Yttrium injections• Polarising light microscopy for

crystals• Nerve conduction tests and EMG• Physical medicine• Spinal epidurals• Oversight of physiotherapists• Electrotherapy• Hydrotherapy• Remedial gymnasts• Sports medicine• Osteoporosis• Orthopaedic clinics

• Rehabilitation• Neurological conditions MS

strokes etc • Orthotics• Surgical footwear• Wheelchairs• Callipers• Artificial limbs• Phenol injections for spasticity

• Research and publications

• General medicine

• Medical student teaching• Lectures for nurses and PTs

Case mix; Rheumatology Sen Reg KCH1979-1980

Total New Patients 818

Soft Tissue Rheumatism• Backs 170 (20%)• Shoulders 97• Knees 87• Hand/wrist 88• Necks 73• Elbows 57• Feet 52• Hips 39• Nerve (ex CTS) 15Total 674 (82%)

Inflammatory • RA + Inflam arthritis 30 • Gout 9• PMR 6• Ank Spond 5• Psoriatic arth/spond 6• Reiters Syndrome 3 • AOSD 2• Wegeners 2• Scleroderma 1• Various 3Total 67 (8%)

Others 10%

Where was fibromyalgia?

• Smythe HA, Moldofsky H. Two contributions to understanding of the "fibrositis" syndrome

Bull Rheum Dis. 1977

1980s Queen Elizabeth Hospital

Rotorua, NZ

Queen Elizabeth Hospital, RotoruaNursing staff

Sister Mary Lean writes from Rotorua NZ 16/6/11

• “A thing that I remember well in the 70's when inflammatory arthritis was not well controlled was the pain that patients experienced from their inflamed joints”.

• “The handling of the patients, getting them up, settling them, transferring them etc was a mission. You had to be so careful and listen to the patient who knew best the least painful way to be moved”

• “I was going to mention the “Duthies" and how we had to take 1 limb out of the splint at a time, wash the limb and then put the splint back on before we did the next one”.

Muscle atrophy in chronic arthritis

RA medication timeline

1900 1930s 1950s 1980s 2005-2006 2008+

Aspirin

GOLD

steroids

MTX

TNF

1999

RTXAbatacept

TocilizumabCetroluzimabGolimumab??????

Treat signs and symptoms in established disease

Aggressive MTX dosing, combination therapy, disease

modification

TEAMSHistory

• Started as TEAMS (Targeted Early Access Musculoskeletal Services*) 2002

• Introduced to rationalise MSK referrals to orthopaedic, rheumatology, physiotherapy, pain management

• Established MSK, Spinal Services• Introduced GPwiSIs and Extended Scope practitioners (ESP)s• Electronic referral• Clinician rather than GP based triage• Each patient to see most appropriate clinician• Interface primary/secondary care

*Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. Peter Maddison, Jeremy Jones, ...Craig Barton, ........ Chris Tilson. British Medical Journal 2004; 329: 1325-1327

Before TEAMS

15 MONTHS

1 ORTHOPAEDIC

9 MONTHS

2 RHEUMATOLOGY

14 MONTHS

3 CHRONIC PAIN

VARIABLE

4 PHYSIOTHERAPY

GP

Musculoskeletal symptoms

After TEAMS2 years on

3 Physio

PT

1-3 months

7 Fibro

Cons

4 weeks

4 MSM

(GPwSIs

ESPs)

10 weeks

5 Back pain

ESPs

6 weeks

9 Sports

clinic

5weeks

MSM 1 Ortho

3-15 months

2 Rheumo

6 weeks

8 Pain Management

3-6 months

TEAMS OFFICE

GP

MS symptoms

CMATSCentrally NOT locally designed

• WAG applied TEAMS model to all Health Boards in Wales in 2012 calling it CMATS.

• WAG based CMATS in primary care so the Clock for Referral to Treatment Time did not start

• WAG designed electronic referral system

• WAG introduced any referral for hip/knee surgery with BMI over 35 to go to lifestyle programme not surgeon

• WAG said no surgery for halux valgus or ganglion

GP referralClinician

triage

MSK

Spinal

Orthopaedic

Rheum

Podiatry

Pain

Bone

Tingly Fingers

Physio/OT

CMATS referralsOct 2016

CMATS PersonnelWest

ESPs

MSK x 5

ESPs

Spinal x 3

GPwiSIs

MSK x 3

ESP Podiatry

ESPs

Hand x 2

Consultant

MSK

ESP = Extended Scope Practitioner

Extended scope practitioners

• Injection certified

• Prescribing certified

• Privileges to order strictly defined imaging

• One stop shop if possible

• Prudent Health Care Principles

MSK/Spinal TRIAGE

• ?Red flag/Urgent/Routine

• ?ESP/GPwiSI/Consultant/

Podiatrist

• Injection certified?

• Held in physio dept

WHERE?

• Ysbyty Gwynedd

• Llandudno

• Bryn Beryl (spinal only)

• Holyhead

• Allt Wen

• Dolgellau

CMATS• +/- 12 clinics per week• +/- 80 patients per week• Waiting time

Urgent – 4-6 weeksRoutine – 12-14 weeks

• Waiting time for letter typing – 2-3 weeks• Waiting time for;

MRI - 8 weeksNCTs

Routine- 8 weeksComplex- 10 weeks

HOT OFF THE PRESSThe ESP in primary care

• ESPs now seeing MSK patients off the street in GP surgeries for diagnosis and management plan

• Patients with MSK complaints directed to ESP by the receptionist

• Brought about by crisis (no GPs) not as part of a plan

• Not providing hands on Physiotherapy

• Seems to be working OK

CMATS Down side

• Only a limited number of physios

• Now providing diagnostic/treatment services

• Reducing resource for therapy

• Reducing resource for supervision/ management of just qualified Physios

Prudent health care

The way forward for NHS Wales

The Bevan Commission

• A group of international experts giving advice to the Minister for Health and Social Services to help ensure that increasingly Wales can draw on best practice from across the world while remaining true to the principles of the NHS as established by Aneurin Bevan.

The challenge

Considerable challenge to improve health and heath/social systems in an era of:-

1) Increasing demand2) Increasing expectation3) Increasing inequality4) Severe financial restraint5) Shortage of clinicians

i.e. AUSTERITY

Prudent healthcareDefinition

• “Healthcare which is conceived, managed and delivered in a cautious and wise way, characterised by forethought, vigilance and careful budgeting which achieves tangible benefits and quality outcomes for patients”

• “By placing greater value on patient outcomes rather than volume of activity and procedures delivered, as we currently do, prudent healthcare aims to rebalance the NHS around the patient or population it serves”

Developing the principles

1 - Equity based care, treating greatest need first2 - Do no harm- do some measureable good3- Do the minimum appropriate to achieve desired

outcome4- Choose the most prudent health care openly

with the patient5- Consistently apply evidence based medicine in

practice6- Co-create health with the public, patients and

partners

4 principles of prudent healthcare

1. Achieve health and well being with the public, patients and professionals as equal partners through co-production

2. Care for those with the greatest health need first, making most effective use of all skills and resources

3. Do only what is needed, no more, no less; and do no harm

4. Reduce inappropriate variation using evidence based practices consistently and transparently

Prudent Healthcare - Securing Health and Wellbeing for Future

Generations. 12 February 2016. Welsh Government. CID. 913470

MSK intervention evidence base• A controlled trial of arthroscopic surgery for osteoarthritis of the

knee. Mosely et al N Eng J Med 2002: 347; 81-88.

• Arthroscopic Partial meniscectomy versus sham surgery for a degenerative medial meniscus. Sihvonen et al. N Eng J Med 2013: 369;2515-2524.

• No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome; five-year results of a randomized controlled trial. Ketola et al. Bone and Joint Research DOI: 10.1302/2046-3758.27.2000163 Published 9 July 2013

• Systematic Review of Caudal Epidural Injections in the Management of Chronic Back Pain. Dighe and Friedman. RIMJ 2013 12-16.

“There is no convincing evidence for the efficacy of Corticosteroid injection in chronic low back pain”

MSK and prudent health care

• Will referral result in change in management?

• Will investigation result in change in management?

• Will the referral show incidentaloma

• Often the referral is made because the patient is very distressed, the patient is pushy or important

• The opportunity cost of the lost appointment or MRI for the case in whom it will change management

• Try to get the best value for patient from our (very) limited resources

RHEUMATOLOGY

Before TEAMS

15 MONTHS

1 ORTHOPAEDIC

9 MONTHS

2 RHEUMATOLOGY

14 MONTHS

3 CHRONIC PAIN

VARIABLE

4 PHYSIOTHERAPY

GP

Musculoskeletal symptoms

Problems Pre-TEAMSNew patients

• Long wait for appointments (9 months)

• Lots of DNAs

• Inappropriate casemix (40% medical; 60% aches and pains)

• Unpredictable casemix

• Might have very medical case (30 mins), then sore elbow (15 minutes), then Fibromyalgia (40mins)

• So sometimes thumb twiddling and sometimes way behind time (unpopular patients, clinicians and nursing staff)

• Inpatient beds

Problems Pre-TEAMS (cont)Follow up Clog up (FuCu)

• Masses of follow up patients (traditional model)*

• Inflexible ++++

• All follow up appointments taken for foreseeable future

• When patients came to routine appointments they were usually well

• When they were ill there was no appointment for them

• They would not allow themselves to be discharged because of the long wait (months) for a new appointment.

*75% of British rheumatologists’ work load is with FU pts. Kirwan & Snow BJR 1991;30:285-7

After TEAMS2 years on

3 Physio

PT

1-3 months

7 Fibro

Cons

4 weeks

4 MSM

(GPwSIs

ESPs)

10 weeks

5 Back pain

ESPs

6 weeks

9 Sports

clinic

5weeks

MSM 1 Ortho

3-15 months

2 Rheumo

6 weeks

8 Pain Management

3-6 months

TEAMS OFFICE

GP

MS symptoms

GP referralClinician

triage

MSK

Spinal

Orthopaedic

Rheumo

Podiatry

Pain

Bone

Tingly Fingers

Physio/OT

CMATS TRIAGE

OCT 2016

CMATS RHEUMO

URGENT CLINIC

EARLY SYNOVITIS CLINIC

ANK SPOND CLINIC

BONE CLINIC

LUPUS/VASCULITIS CLINIC

GOUT CLINIC

PAEDIATRIC CLINIC

FIBRO CLINIC

ROUTINE

RHEUMATOLOGY TRIAGE Oct 2016

Rheumatologists

X 3Nurses x 3 * #†

Occupational therapist x1

Physiotherapists

X 1.5 * †

Pharmacist x 1 *GPwiSI

Trainee

Rheumatology Multidisciplinary Team

*Prescribing privileges† Injecting privileges

# Ultrasound privileges

Peter Maddison Rheumatology Centre Llandudno Hospital

Hub

• Base

• Clinic rooms etc

• Own staff

• Ultrasound

• Helpline

• Admin

• Not acute hospital

• No Beds

Spokes at;

• Bangor

• Caernarfon

• Porthmadoc

• Pwllheli

• Holyhead

• Blaenau Ffestiniog

• Dolgellau

Now

New patients

• Purely outpatient service

• Outpatient case mix is predictable

• Appropriate clinician

• Appropriate length of time

• Appropriate setting

Follow up Patients

• Nurses FU re DMARDS

• Helpline

• Shared care

• Annual practitioner clinics

• Patient initiated referral rather than regular FU

Challenges

• Can’t get the staff! (Doctors/physios/nurses)

• Irrational central government dictats

• Poor lines of communication between Primary and secondary care

• Silo hospital management

• Geography

• Prudent Health Care versus Defensive Medicine

1970’s; Skills required of trainee rheumatologist

• Rheumatic diseases• Make POP splints• Corticosteroid injections• Yttrium injections• Polarising light microscopy for

crystals• Nerve conduction tests and EMG• Physical medicine• Spinal epidurals• Oversight of physiotherapists• Electrotherapy• Hydrotherapy• Remedial gymnasts• Sports medicine• Osteoporosis• Orthopaedic clinics

• Rehabilitation• Neurological conditions MS

strokes etc • Orthotics• Surgical footwear• Wheelchairs• Callipers• Artificial limbs• Phenol injections for spasticity

• Research and publications

• General medicine

• Medical student teaching• Lectures for nurses and PTs

Four Decades of Rheumatology – Clinical Practice;

The future

• Huge changes in the understanding and management of rheumatic disease

• Much of what used to be rheumatology has been captured by others

• Rheumatology is now an outpatient activity and care of long term conditions is moving into primary care

• Rheumatologists are in danger of becoming rheumatoidologists

• The management of RA is largely cook book medicine and no longer needs a consultant rheumatologist to oversee it

• There will soon be a cure for RA (or it will die out)

• What will become of the rheumatoidologist then?

There’s always fibromyalgia!

Should rheumatologists retain ownership of fibromyalgia?

Shir Y, Fitzcharles MA.

J Rheumatol 2009;36(4):667-70.

Modern rheumatology-A dynamic and accessible

service

1970s

2016

Whatever will things be like in 2062??