Services for people with rheumatoid arthritis - Public Accounts Committee Contents

Examination of Witnesses (Question Numbers 60-72)


23 NOVEMBER 2009

  Q60  Keith Hill: That is also encouraging. Is it the case that this kind of holistic approach is expensive and need it be expensive?

  Mr Belfield: No, I do not think that it should be expensive. If you get this right first time, as the Report says, and you help identify the need early enough, then in the longer term it saves money. Certainly the Department of Health has a very strong view that quality should not cost because getting it right first time should save taxpayers' money.

  Q61  Keith Hill: It sounds like a propitious development, Mr Nicholson. Is this something you are going to put your back into?

  Mr Nicholson: Absolutely. Gary is absolutely right. This is not an issue about huge amounts of extra resource. This is about organisation, management, planning and execution.

  Q62  Keith Hill: Smart solutions, in other words?

  Mr Nicholson: Yes. It is all of those things. That is why it is so important we set national benchmarks and set out our expectations.

  Q63  Keith Hill: This I think is one for Mr Nicholson: do you recognise the risk that the focus on getting the newly identified rheumatoid arthritis patients through the system can lead to slower or indeed deficient treatment of existing patients?

  Mr Nicholson: No, I do not see the connection at all. We have grown capacity significantly in the NHS over the last few years. As you have heard me talk about on numerous occasions, before we had the capacity to deal with this, it is for relatively small numbers of patients.

  Q64  Keith Hill: It is mentioned for example in the DVD that patients already in the system seem to perceive they have problems in accessing the services they are looking for because of the concentration of units on meeting the 18 weeks target. That is not something that you recognise?

  Mr Nicholson: No, I do not think so. To be honest, with the 18 week pathway and the way it is designed, we would not expect that to be one or the other.

  Q65  Keith Hill: Could I ask the NAO to come in on this point?

  Ms Taylor: If you look at paragraphs 4.6 and 4.7 and also to an extent 4.10, some of the evidence we collected is that people are having problems when they have a flare up or in continuing to get treatment after the initial diagnosis. There are a number of examples given there that were reported to us by both the acute trusts and through our patient survey.

  Professor Colin-Thomé: The figure you have given for rheumatology is that about a fifth of the cases are for rheumatoid arthritis. If we could get, as we have in some places, primary and community services working with our hospitals, some of the repetitious work for people who are not having flare ups could be done quite well in primary care. Certainly in my practice—and I know in Alan's—we used to have a rheumatoid arthritis nurse working with us for the general reviews of patients once significant symptoms had settled. Working with our physiotherapy colleagues, we could obviate the need for a lot of referrals to orthopaedics or rheumatology because we needed an opinion about better care. One of the issues for us, which practice commissioners will have to major on, is how do we get that better system. A lot of the reason we have expense in our health care system is because of duplication. You find that a lot of patients are seeing the specialist when they are not acute and also seeing their GP and so on. That is the area where we could make a significant improvement in quality, release our consultants for more time for flare ups and acute care and yet still look after patients in a systematic way. I think that is the real test for us where there are examples already happening, but not widespread enough yet.

  Mr Nicholson: I hear these comments about choose and book, which is the issue that is raised. I do not believe that these are reasons why we cannot organise the services better than we do. It is, at the end of the day, a mechanism for planning capacity and there is no short cut for PCTs and acute trusts planning their capacity properly. Choose and book makes you do things in a much more transparent way which I think is a good thing and I do not believe that choose and book is the reason why people are having problems with that service; I think we need better organisation.

  Q66  Angela Browning: We have read that the average age for this condition to start is about 40, or people in their 40s; it is not necessarily a condition of old age. It seems to me increasingly that where people have developed it in their 40s or 50s—I have a certain personal interest, not that I have rheumatoid arthritis—and where people present with chronic conditions, they get specialist treatment up to a point and then they pass a certain age barrier and they suddenly become the responsibility of geriatricians. I wanted your assurance that in a case like this, for rheumatoid arthritis, that people who are, say, over 65 or over 70, would continue to get the specialism from the consultants and not from a generalist?

  Professor Colin-Thomé: The answer is yes, and in fact a key responsibility lies with the general practitioner deciding, once they are referred, who is the most appropriate. If you are a care-of-the-elderly specialist it is more to do with the organisation of care for people with lots of chronic problems, but for specific things like diabetes and so on they will need to see a specialist, and that generally happens. If there was a rule to say otherwise, I think you would find a lot of people like Alan and I would say that this was a nonsense and challenge it quite strongly. The answer is, you have to find the specialist who is most appropriate for the presenting problem, and to say you have to go off to a different system is not right. As Alan says, this report and the NICE guidance will reinforce that even more strongly.

  Mr Nicholson: There should be no age cut-off, either implicitly or explicitly for rheumatoid arthritis.

  Angela Browning: That is very encouraging, thank you.

  Q67  Chairman: We have had a very helpful submission from the National Rheumatoid Arthritis Society and they have submitted an analysis to the Committee highlighting the difference in spending on rheumatoid arthritis between PCTs—£5.68 per head in Bexley and £17.58 in Gateshead; the English average is £10.97. What is going on? Are they just diagnosing it much better in Bexley and need to spend less, or are they just being mean in Bexley? What is happening?

  Mr Nicholson: I think there is a whole set of issues. People are collecting the information and sharing it and looking at it for the first time, and you may find in those circumstances that people are collecting it and showing it in different ways.

  Q68  Chairman: We need to get to the bottom of this, this is very important.

  Mr Nicholson: I agree. That is one of the issues. The other issue is that the populations are different as well, in terms of the age structure of the population. What we have not done is connected those two things together.

  Q69  Chairman: It is hard to think that there is such a difference in the age structure in Bexley and Gateshead. There is something else going on here, I suspect. The Society is unable, they tell us, " ... to conduct an assessment to ascertain whether there is any correlation between levels of spending and service quality since the findings of the NAO's survey of the quality of acute care are anonymised. The Public Accounts Committee may wish to consider investigating this directly, or asking the Department of Health to do so." I am now asking you to do so.

  Mr Nicholson: We would be happy to investigate because it raises a whole series of issues.

  Q70  Chairman: We do not want a postcode lottery here, do we?

  Mr Nicholson: No.

  Q71  Chairman: You mention Dame Carol Black, who is mentioned right at the back of the Report. Do you think she would be satisfied with progress if she were here?

  Mr Nicholson: No.

  Professor Colin-Thomé: No. Whenever you write a report, and we have all written our reports, you are frustrated by the pace of progress, and I think that is an issue. In answer to your previous point, of course Carol's work straddled both the DWP and the Department of Health, to try and get more coherent working together, but in terms of the programme I think she would have expected more to have happened. We are putting a lot of store on these fit-for-work pilots, because that is a more comprehensive look at it, not just whether GPs have fit notes but getting more occupational health people working at earlier interventions and so on and so forth to see if that is possible. But the answer is, whenever any of us write a report, we are always frustrated by the pace of progress.

  Q72  Chairman: That is a very honest answer. Thank you for that. I think that concludes our hearing, gentlemen, thank you very much. I think it has been an important and interesting hearing. As I often say on these occasions, we are very proud of the fact on this Committee that we have managed to put a spotlight on certain conditions, such as hospital-acquired infections, dementia, stroke, over the years, and we are very grateful to Karen Taylor for all the wonderful work she does for this Committee in the field of health. She has done a lot of work over the years to bring these subjects forward. So we are very grateful to you, Karen. May I just say that although we were told that a GP may only see one case a year, this is still an enormous problem. There are, we are told, an estimated 580,000 adults in England who have rheumatoid arthritis, and there are 26,000 new diagnoses each year. It costs the NHS £560 million a year in health care costs but the cost to the economy is £1.8 billion a year. What is even more worrying is that three-quarters of people with rheumatoid arthritis are first diagnosed when of working age. Women are more than twice as likely as men to have the disease, and one third of people will have stopped working within two years of being diagnosed with rheumatoid arthritis. So I am sure you would agree, Mr Nicholson, this is a very serious problem indeed. It is extremely worrying that the public awareness of the disease is so very low. Before I got involved in this, my own personal awareness of this disease, I have to accept, was very low indeed. We need to ensure that diagnosis comes much quicker because it is undoubtedly true from what we have heard today that if you are diagnosed quickly you can arrest this disease. We expect to have a very helpful but hard-hitting report, Mr Nicholson, to encourage your efforts in this field.

  Mr Nicholson: Thank you.

  Chairman: Thank you.

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