Services for people with rheumatoid arthritis - Public Accounts Committee Contents

Examination of Witnesses (Question Numbers 1-19)


23 NOVEMBER 2009

  Q1  Chairman: Good afternoon. Welcome to the Committee of Public Accounts where today we are considering the Comptroller and Auditor General's Report on Services for People with Rheumatoid Arthritis. We welcome back to our Committee David Nicholson, who of course is the Department of Health's accounting officer and chief executive of the National Health Service. Would you like to introduce your colleagues please, Mr Nicholson?

  Mr Nicholson: Yes. David Colin-Thomé, the national clinical director for primary care. Gary Belfield, the acting director general for commissioning and Dr Alan Nye, who has a variety of roles but he helps the 18 week team. He is a general practitioner and an expert in the field.

  Q2  Chairman: If we look at this Report, Mr Nicholson, we can see that too many people with rheumatoid arthritis have not been diagnosed and treated early enough and that, once they are diagnosed with this debilitating disease, they do not always get the services they need. There are obviously value for money considerations here because many people find it very difficult to work, so if we could get them diagnosed and treated early enough it would both save money and of course help them enormously. We want to try and pursue these issues with you in as positive a frame of mind as we possibly can. What are you doing, Mr Nicholson, to try and make GPs better at spotting the signs of rheumatoid arthritis and referring the patients to specialists early enough?

  Mr Nicholson: I think it is worth saying to begin with—I am sure my clinical colleagues at some stage will talk about this—that it is quite a difficult thing to do, the early diagnosis of rheumatoid arthritis. We can see that by the response of general practice and people in the clinical community. It is not through want of effort or trying that people have had difficulties in this area. There are three areas that I think we would focus our attention on. The first one is recognition and diagnosis. There is a whole set of issues around information to patients through patient choices, through the various leaflets and documents that both ourselves and the voluntary sector put out. There is the work that the Royal College of GPs is doing around the training and education of general practitioners. There is a whole set of issues around public recognition of this particular illness. All of those things need to be pursued in terms of recognition and diagnosis. The second issue I think is in relation to timeliness that you describe and again it is very important for us to continue to drive forward the 18 week programme because of the effects that has on rheumatology generally; the publication of commissioning guidance, making sure that our commissioners are absolutely on top of it. The final issue is about the effectiveness of treatment, again focusing on the delivery of the various guidance that NICE has put out about what works and the commissioning guidance that they are about to put out later on this year. All of those things together I think, driven from the department, will have a significant effect in this area.

  Q3  Chairman: Presumably you have no trouble, Mr Nicholson, with recommendation (a), paragraph 18 on page nine: "The Department of Health should explore the cost-effectiveness of options for raising public awareness of the symptoms of inflammatory arthritis, including rheumatoid arthritis, to encourage people to present to the NHS promptly after symptom onset." You have no difficulty with that?

  Mr Nicholson: I think it is absolutely the right thing to do but that is not to under estimate how difficult it might be. There is not a particular time of the year when this particular condition comes about. There is not a particular patient group, so it is quite difficult to focus your attention and make it happen. We are considering, I think quite actively at the moment, a bid from Birmingham, as it happens, for research into the area of public awareness so we can absolutely focus our attention on things that will work. We are open to that.

  Q4  Chairman: Have a look again at paragraph 2.6 on page 17 of this Report which describes how GPs may carry out diagnostic tests. It is still not clear to me why GPs are wasting resources and not getting people promptly to a specialist. They are risking people's health, unless you get this dealt with very quickly. As I understand it—correct me if I am wrong—with modern drugs it is possible on most occasions to arrest this or alleviate it but you have to start very quickly indeed. If you read paragraph 2.6, it seems that either GPs are not sufficiently trained in carrying out these tests or recognising what they do or they are simply not doing it. It is worrying, is it not?

  Mr Nicholson: I am sure it can be done better. Just to put it in context—Alan might say something about this clinically in a minute—about a quarter of all the work that general practitioners do is in the area of musculoskeletal problems. Quite a lot of work that GPs do is in this area and it is quite difficult in that group of patients to identify specifically the ones that would benefit.

  Q5  Chairman: Let us ask Dr Nye then. He is the expert in this. What is the problem?

  Dr Nye: If I may try and put this in context for you, as David Nicholson says, around 20% to 25% of all GP consultations are musculoskeletal related. The average GP sees one new case of rheumatoid arthritis a year, so there is a real issue about sorting that one case out from the many hundreds, if not thousands, of musculoskeletal problems that a GP sees. Added to that there is not a single way in which rheumatoid arthritis presents. It can present in many, many different forms. Further complicating it, when a GP gives standard treatment for a patient with joint pain such as anti-inflammatories, patients with rheumatoid arthritis often respond very well in the initial stages, which can further cloud the issue as to what can be going on. As regards the diagnostic tests, there is a multitude of clinical conditions that can present with joint pain. I think it is often completely appropriate that GPs carry out a range of diagnostic tests to make sure there is not some other condition that requires prompt treatment for their patients.

  Q6  Chairman: It says that you are doing quite well on meeting this 18 week standard but, as I understand it Dr Nye, ideally you should be in with a specialist in six weeks. Is that not right?

  Dr Nye: That is what the Report—

  Q7  Chairman: You really have to move fast. How could we incentivise GPs to refer people who are diagnosed more quickly, do you think?

  Dr Nye: I think there is a number of steps that we have taken. We have published an inflammatory arthritis commissioning guide in the summer of this year, which is there to encourage commissioners, both PCT and practice based, and clinicians to work together to actually redesign and deliver better services to people with inflammatory arthritis and obviously rheumatoid arthritis is part of that. We are also carrying out a range of training events. I am in Leeds on Wednesday looking at shifting services into community settings, so we are trying to improve the services for local health communities, trying to encourage them to look at redesigning and managing this problem better.

  Q8  Chairman: Can we talk about depression because this is often a very big problem with rheumatoid arthritis, is it not? If we look at 3.16 in this part of the Report here, we see that only one in seven trusts is providing help for people with depression. Are you doing enough to get this message down to the primary care trusts?

  Mr Nicholson: There is no doubt that the relationship between physical and mental health has not been well supported in the past and not well understood, I do not think, in the past. It was one of the reasons that Lord Layard wrote his report in 2006 and it is one of the reasons why we have launched the whole set of issues around psychological therapies. That is why we are rolling it out across the NHS as a whole. You will no doubt know that 75% of our PCTs now have access to psychological therapies as part of a general picture. We do believe that the clinical guidelines set out by NICE that are coming this year will reinforce the importance of psychological therapy to people who have rheumatoid arthritis.

  Professor Colin-Thomé: The other issue is that a lot of these patients would see their GPs as well. This often happens with chronic disease. It would be via access through their GP to the psychological therapies and some of the counsellors that we employ ourselves that patients could get access. Just measuring the acute trust referral patterns would not cover the whole picture of referral for depression.

  Q9  Chairman: What about supporting people now once they have this disease? If we look at paragraph 4.18, we see that the help that they receive in trying to get them back to work is really totally haphazard. Is there any more progress you can make on this, do you think?

  Mr Nicholson: I think this is a really important issue for us, not just for the general population but also for our own staff. We have 1.3 million people in the NHS, some of whom have long term conditions as well. Today we have announced the Bowman Report on staff health. I will ask David Colin-Thomé to talk about this and people with rheumatoid arthritis in general.

  Professor Colin-Thomé: It is an area we have not done well in but I think Carol Black's review last year has given us the focus to do better. The work that generated from her is now rolling out. There are several things. We have had Pathways to Work, which is an opportunity funded by Jobcentre Plus for patients with issues about work to go and get a consultation and help to go back to work. We have found that the studies show that that produced a lot more people going back to work or staying in work than the control group. They were not as good for mental health problems and that is why we have this condition management programme which focuses more on mental health problems. We have a major bit of work. Since Carol Black's work, we also have the Fitness to Work pilots, because there are several bits. One is that Carol has recommended now that we should have a fit for work note for GPs rather than a sickness note to change the thinking about people's opportunities. We want to have more opportunity for occupational health and employment advisers to be based in general practice. This is the work that we will be producing from next year as a result of Carol Black's work. For people in work to stay in work, we need support which is what we are offering, but also for the workless some of these programmes will help them get them back to work when they have been out of work for some time.

  Q10  Chairman: Some of these patients will be in unbearable pain. What work are you doing to try and ensure that they get the services they need promptly and easily, that they are specially helped, targeted and all the rest?

  Professor Colin-Thomé: They are seeing their specialist but also their general practitioner and I think the mixture of the pain relief plus the anti-rheumatic drugs is the way forward.

  Q11  Chairman: I mean help day or night.

  Professor Colin-Thomé: We have both us available as well as our community nursing services, some of which maybe are not working overnight at the moment, but that is the area we will be looking to try and develop in the future. They would have access. What we have done in this particular group of patients, as with other people with chronic conditions, is at least give them access to a key worker, a case manager, so that, for the more complex end of these conditions, they can have access to somebody. That would not be day and night, but it would give them a tremendous amount of cover, more than they have had hitherto. That is part of our chronic disease programme for all people with chronic diseases.

  Q12  Chairman: Could I ask the Treasury a question finally? If you look at paragraph 3.10, we do not want to get fixated on the costs to the economy because clearly people are suffering appallingly from this and what is important is to get them helped and treated, but as far as the Treasury is concerned we see that for those of working age the NAO's model suggests that this earlier treatment could result in productivity gains of £31 million for the economy due to reduced sick leave. A very high proportion of people who get rheumatoid arthritis have had to leave work, but there is no particular incentive on the NHS, is there, to fund this? Do you take a view on this when you are funding the NHS? Do you say that this has an enormous impact on the economy and therefore we want to fund the NHS in such a way that they are incentivised to deal with it; or do you just wash your hands of it and say, "It is over to them"?

  Ms Diggle: I had precisely the same reaction as you do. It seemed to me that if we could do something about earlier diagnosis it would be extremely welcome because it would mean less living on benefits, more tax coming in. That would almost certainly well cover the cost of extra treatment. However, the sad point of the story is that it is very hard to diagnose. Having talked to the people who are in front of you, I do understand that it is very, very hard to spot people with this disease any quicker. If it could be done, I think there would be a jolly good case for looking at that equation.

  Q13  Angela Browning: Dr Nye, are you the clinical lead for the Department of Health in musculoskeletal conditions?

  Dr Nye: No, I am not. I am clinical adviser for elective care for the department.

  Q14  Angela Browning: Who is the clinical lead in the department?

  Mr Nicholson: We do not have one.

  Q15  Angela Browning: Why do you not have one?

  Mr Nicholson: We do not have a clinical lead for every condition. If we did, there would be over 200 clinical leads in the department. It is not necessarily the case that, because you have a clinical lead, it means that focus is put on it. There are lots of other services that improve without having a clinical lead per se at national level.

  Q16  Angela Browning: When we see that back in 2004 there were guidelines set down about the length of time between referral from GP to a consultant, has anybody taken the initiative within the department to review it, if there is no clinical lead? I am asking because obviously we have all read about this window of opportunity.

  Mr Nicholson: Just because there is not a clinical lead does not mean there are not clinicians involved in all this. We put it into the pathway guidance that went out. We have strengthened it. It will be in the NICE guidance that comes out this year and we expect all organisations to follow that guidance.

  Q17  Angela Browning: Could I just ask you to look at page 19, paragraph 2.12? We heard a little bit just now about the difficulty because the average GP would only see one case presented a year and obviously with patients like that one can understand it would be difficult to just pick up these odd cases. There is quite a damning paragraph there about the way trainee GPs are still being tutored in musculoskeletal conditions. It says here, "Seventy per cent of GPs had tutorials ... receiving an average of two hours teaching" and the most common topics were back pain, joint injections and osteoarthritis. Just where does rheumatoid arthritis feature in all of this?

  Professor Colin-Thomé: It would fit in with musculoskeletal conditions. When you are a GP registrar, a GP in training, which is a three year programme, it covers a wide range of the responsibilities. Musculoskeletal conditions cover a lot but rheumatoid arthritis is a part of that so it would be covered in that training. Then we have to learn about cancer, diabetes and all the others, so it is probably an area that maybe we should improve but everybody else has pressures as well as to what slice of the GP training programme they get.

  Q18  Angela Browning: It does say in this paragraph that the GPs who were surveyed here felt that their training on musculoskeletal conditions was inadequate.

  Professor Colin-Thomé: Completely. In fact, that is why we have the Royal College of GPs focusing on this—Alan is involved with working with them—looking at improving the curriculum around postgraduate education for GPs. The issue is that if you are a generalist, which I was until I retired, every condition is part of our responsibility so trying to allocate it sufficient training for all is quite a difficult area. Every condition comes to us, whether it is diabetes, angina and so on and so forth. In that, if there has been a highlighted need that GPs are identifying, that is why we are looking with the Futures Group at how we might get better training for GPs. I can see why in the past there has been so much conflicting pressure. Now we have some harder evidence I think your group, Alan, is going to be focusing on this.

  Dr Nye: The Rheumatology Futures Group and myself, the Royal Colleges and some patient groups are working to help produce some educational material for GPs to help them spot those difficult to detect early warning signs. Hopefully, we will produce something by later this year or very early next year on that.

  Q19  Angela Browning: I think, Mr Belfield, this is probably for you. We have heard that once a GP has made a referral, time is of the essence etc., but we understand—I must say I am a little confused by this—that because of the way commissioning is exercised once a consultant has seen the patient for the first time they go back into the care of the primary care field and that there is great difficulty for some consultants in being able to actually initiate follow-up appointments. Everybody is shaking their heads but we have this on very good evidence. It is something I really would like to be followed up, because I understand it is not to do with patient care per se; it is to do with the ramifications of how commissioning is carried out in this country. It is to do with money, I think.

  Mr Belfield: I do not recognise that.

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