1 Early identification and diagnosis of
rheumatoid arthritis |
1. Rheumatoid arthritis is a lifelong, progressive,
musculoskeletal disease. An estimated 580,000 people in England
have the disease, with around 26,000 new cases diagnosed each
year. Each year it costs the NHS £560 million and the wider
economy at least £1.8 billion. Three quarters of people with
rheumatoid arthritis are 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.
Almost half of people with rheumatoid arthritis are of working
age, and over 60% have been living with the disease for more than
2. To minimise damage to joints as a result of
rheumatoid arthritis, treatment should start within three months
of the onset of symptoms.
Aggressive treatment very soon after the onset of symptoms can
lead to remission. Early
treatment can also prevent pain and disability, and help people
go on working and producing an economic return to society.
Since 2003, however, the average time from onset of symptoms to
diagnosis and first treatment has remained constant at around
3. Between half and three quarters of people
with rheumatoid arthritis delay seeking medical help from their
GP for three months or more following the onset of symptoms, and
around a fifth delay seeking medical help for a year or more.
There has been no real improvement between 1995 and 2005 in the
number of people seeing their GP within three months of the onset
of symptoms and there continues to be a general lack of understanding
and awareness of the disease and its impact.
The Department accepted the need to raise public awareness of
the symptoms of inflammatory arthritis, including rheumatoid arthritis,
so that people who experience them visit their doctor more promptly.
4. Public education campaigns using television,
the internet, leaflets and GP practices have been successful at
raising public awareness of specific diseases, but such a campaign
had not yet been undertaken for inflammatory arthritis, including
The Department believed that design of such a campaign would be
challenging because of the lack of a clear target population.
Working with the Rheumatology Futures Group, it was considering
a campaign, The S Factor, to help people recognise the symptoms
The Department also acknowledged the need for better understanding
amongst primary care staff, including GPs, practice nurses and
1: 'The S Factor': Recognising the symptoms of inflammatory arthritis
||Recognising the symptoms
|Swelling||Swelling of the small joints, particularly the small joints of the hand.
|Stiffness||Profound stiffness of the joints. People may be almost unable to move, and unable to fasten their buttons or bra.
||It is painful to compress across the knuckles of the hand or the same joints in the feet.
|Severe buttock pain
||Patients with ankylosing spondylitistypically young adult malesdevelop quite severe buttock pain and morning stiffness in their back.
Source: Qq 45 and 46; C&AG's Report, Figure
5. The Department accepted that the route to
diagnosis could be better.
People with rheumatoid arthritis visit a GP on average four times
before being referred to a specialist for diagnosis, and 18% of
patients visit eight times or more before being referred.
The Department argued that in part this is because early disease
is difficult to identify.
Outcomes were better for patients whose GPs spotted the signs
of suspected rheumatoid arthritis at an early stage and referred
patients promptly to specialists for early diagnosis (Figure
2). There was
also scope for greater use of specialist nurses and early arthritis
2: The diagnosis and treatment pathway for people with rheumatoid
Source: C&AG's Report, Figure 2
6. With the annual number of new cases estimated
to be 26,000 and the number of GPs in England around 34,000,
each GP may only see one new case or less a year. It is difficult
for GPs to pick up new cases of rheumatoid arthritis from the
thousands of musculoskeletal conditions that a GP sees.
GPs are not well informed about the disease, with a lack of education
on rheumatoid arthritis during medical training.
Whilst around one fifth to one quarter of all GP consultations
are musculoskeletal related, a trainee GP's tutorials on musculoskeletal
conditions are on average just two hours of teaching, of which
coverage of rheumatoid arthritis may be just a part.
A survey in 2004 found that teaching in musculoskeletal conditions
was rated as inadequate by trainee GPs.
7. The Department accepted that more extensive
training was needed in musculoskeletal conditions,
and was working with the Royal College of GPs, the Rheumatology
Futures Group and some patient groups to improve post graduate
training for GPs. It expected to produce, by early 2010, educational
material for GPs to help them spot the difficult-to-detect early
warning signs of rheumatoid arthritis.
The Department was also looking at extending the training time
required of GPs before becoming fully qualified principals in
general practice, from the current three years post hospital work
to at least four years and possibly five years, to reflect the
complexity of conditions now seen in primary care, including rheumatoid
8. In June 2004, the Department made a commitment
that by December 2008 no one would have to wait longer than 18
weeks from GP referral to the start of specialist treatmentthe
18 week 'referral to treatment' standard.
By December 2008, 97% of rheumatology patients were being treated
within 18 weeks of GP referral. The average time from GP referral
to being seen by a specialist was around six weeks, although acute
trusts' individual averages ranged from two to thirteen weeks.
9. The Department published a Commissioning Pathway
for Inflammatory Arthritis in July 2009 which emphasised that
GPs should refer their patients to a specialist where they suspect
inflammatory arthritis and not rely solely on the results of blood
tests and x-rays which may not detect rheumatoid arthritis during
its early stages.
The Pathway encourages commissioners in Primary Care Trusts and
general practices to work with clinicians to redesign and deliver
better services for people with inflammatory arthritis. A range
of training events was taking place to encourage better design
and management of services.
The Committee recognised that the Pathway was a positive step
and offered the prospect of better services for patients, although
its development also highlighted that the current reality fell
far short of the ideal.
3 Q 72 Back
C&AG's Report, Services for people with rheumatoid arthritis,
HC (2008-09) 823, para 1.7 Back
C&AG's Report, para 2 Back
C&AG's Report, para 1.2 Back
Qq 43, 44 and 52 Back
C&AG's Report, para 6 Back
Q 25 Back
Q 27 Back
Q 3; C&AG's Report, para 18a Back
Qq 28, 36, 39 and 47 Back
Qq 38, 40 and 42 Back
Qq 45 and 46; C&AG's Report, Figure 1 Back
Qq 29 and 49 Back
Q 4 Back
C&AG's Report, para 2.7 Back
Qq 32 and 33 Back
Q 2 Back
Qq 34 and 35 Back
C&AG's Report, para 2.5 Back
Qq 4 and 5 Back
Q 31 Back
Q 17 Back
Q 18; C&AG's Report, para 2.12 Back
Qq 52 and 54 Back
Qq 18 and 53 Back
Q 54 Back
C&AG's Report, para 2.16 Back
Q 6; C&AG's Report, para 2.17 Back
Qq 30, 41 and 51 Back
Q 7 Back
Q 57 Back