4. Memoandum from National Rheumatoid
Arthritis Society (NRAS)
INTRODUCTION
The National Rheumatoid Arthritis Society (NRAS)
welcomes the recommendations of the National Audit Office report
into Services for people with rheumatoid arthritis, many
of which reflect the concerns raised in the King's Fund Report
on behalf of the Rheumatology Futures Group.[23]
We agree with the NAO that action needs to be
taken to improve overall outcomes for people with rheumatoid arthritis
(RA), in particular by implementing the NICE Clinical Guideline
on RA which was published in February 2009,[24]
and to promote the commissioning of RA services in line with the
IA commissioning pathway which is available on the DH 18 week
website.
It is widely recognised that early diagnosis
and appropriate treatment can decrease the risk of joint damage
thereby maintaining the mobility of people with RA for longer
and avoiding costly and unnecessary surgery.
The NAO's own modelling has identified that
a person treated within three months rather than four months could
see an improvement in quality of life by around 4% over the first
five years, as measured by quality adjusted life years (QALY)
gained.[25]
NRAS was therefore concerned but not surprised
by the NAO's research which shows that delays in the system are
contributing to late diagnosis and treatment and poorer outcomes
for people with RA. These delays are also contributing to the
inefficient use of health services resources and productivity
losses for the economy.
We have outlined below our concerns and the
recommendations from the NAO report that we believe require urgent
attention and that the Public Accounts Committee should address
in their inquiry.
RECOMMENDATIONS
1. The Department of Health, PCTs and Royal
Colleges should improve GP awareness of RA to reduce costly delays
in the system
— GPs are the gatekeepers to specialist
diagnosis and treatment yet, as the NAO recognises, people with
RA visit a GP on average four times before being referred to a
specialist and 18% more than eight times.[26]
This is not only causing poor clinical outcomes for people with
RA but is also costing the NHS £6 million a year in unnecessary,
repeated visits.[27]
— The current management of people of RA,
as revealed by the NAO's research, appears to be inconsistent
with the Department of Health's policy to move treatment of long-term
conditions into primary care rather than reactive acute care.
Supporting People with Long term Conditions called for
a move away from "reactive, unplanned and episodic approach
to care" and for people to be treated, "sooner, nearer
to home and earlier in the course of the disease."[28]
It is however important that the Committee realise that whilst
we welcome greater integration of services between primary and
specialist care and there are some things which GPs are well placed
to undertake such as CV risk assessment and monitorinig of RA
patients, people with RA will continue to require access to specialist
care, as needed, throughout the lifetime of their disease.
— The Public Accounts Committee therefore
may want to ask how the Department of Health plans to address
poor GP awareness and what discussions officials have had with
Royal Colleges regarding the inclusion of rheumatoid arthritis
in continued professional education as recommended by the NAO.[29]
2. The Department of Health should undertake
a public awareness campaign on the signs and symptoms of RA to
encourage early presentation.
— Low public awareness is compounding
the problem of late diagnosis and treatment for people with RA.
As the NAO has identified, between half and three quarters of
people with RA delay seeking medical help from their GP for three
months or more following the onset of symptoms. A fifth of patients
delay seeking help for a year.[30]
— The NAO has identified that this
could be addressed by increasing the number of people diagnosed
with RA in the first three months from the current 10%:
"Our economic modelling suggests increasing
this to 20% could initially increase costs to the NHS by £11
million over five years due to higher expenditure on drugs and
the associated costs of monitoring people with the disease (after
around nine years, earlier treatment could become cost neutral
to the NHS). This increase in earlier treatment could, however,
result in productivity gains of £31 million for the economy
due to reduced sick leave and lost employment." [31]
— The Public Accounts Committee therefore
may want to ask Department of Health officials what assessment
the Department has made of the cost-effectiveness of an RA public
awareness campaign in light of the NAO's estimate of the productivity
savings that could be delivered through earlier diagnosis and
treatment of people with RA.[32]
3. Musculoskeletal services are an inefficient
area of health service spending
— In the last year, NHS expenditure on
musculoskeletal conditions increased from £3.5 billion to
almost £4.1 billion—an increase of over 15%—even
though improvements in outcomes were not delivered by this extra
spending.[33]
— One critical factor in the success of
national frameworks in other therapeutic areas has been the presence
of national clinical leadership to drive change (eg in cancer,
diabetes, mental health, and cardiac care). However, there is
no such National Clinical Director to drive progress in musculoskeletal
services unlike in other areas. Even though liver disease consumes
around half the NHS resources currently accounted for by musculoskeletal
conditions, the Department of Health announced on 20 October that
it was appointing a National Clinical Director for Liver Disease.
— The Public Accounts Committee may wish
to consider asking Department of Health officials whether greater
clinical leadership at the national level will improve the efficiency
of resource spending for RA.
4. Delays in referral to specialists should
be addressed to improve timely access to appropriate treatment
— NRAS recognises the importance of early
and aggressive treatment for RA which can reduce the need for
costly procedures such as joint surgery and maintain mobility
for longer. Delays in referral to specialists are preventing people
with RA getting access to appropriate treatment early enough.
— A study published in 2002, cited in the
NAO report, found that 11% of people with rheumatoid arthritis
on conventional drug therapy (ie not biologics) will need joint
surgery within five years of treatment.[34]
It also found that within five years of treatment, between 10
to 15% of people went into remission with no evidence of persistent
disease.[35]
— The Public Accounts Committee therefore
may want to ask Department of Health officials what plans they
have to communicate to PCTs and health care professionals "the
benefits to long-term health and the economy of early treatment
of people with rheumatoid arthritis."[36]
4
5. Variations in the quality of RA Services
should be urgently looked at
— NRAS is concerned by the variations in
quality of RA services identified in the NAO report. The NAO's
audit has revealed wide variations in provision of services, due
to capacity issues around appointing staff in MDTs. Only 14% of
acute trusts provided access to psychological services despite
the fact that depression is common amongst people with RA.[37]
— RA services should be commissioned on
the basis of a thorough assessment of local need. However, the
NAO report revealed that 71% of PCTs had not carried out a local
needs assessment for rheumatology services overall and 73% had
not undertaken any assessment to establish the number of people
with RA living in the locality.[38]
— The failure to conduct needs assessments
may contribute to the wide variations in spending on RA services,
which in turn may contribute to the variations in service quality.
NRAS has undertaken an analysis of the level of spending on rheumatoid
arthritis services in each PCT area (reproduced in the annex)
which reveals that spending on RA services varies in different
PCT areas from £5.68 per head in Bexley PCT to £17.58
per head in Gateshead PCT—a great-than-threefold variation—with
an England average level of £10.97 per head.
— NRAS is unable 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.
— Furthermore, the variable quality of
services can be explained by the absence of musculoskeletal conditions
from the national levers the Department of Health uses to influence
the direction of local policy. For example, the Department of
Health's flagship World Class Commissioning programme list
54 national indicators—from which PCTs are able to pick
and choose according to their local priorities, and against which
their progress will be measured—but none relate to musculoskeletal
conditions.[39]
— The Public Accounts Committee should
consider asking Department of Health officials how it plans to
measure the outcomes of local RA service delivery to ensure the
consistent implementation of national guidance. The IA commissioning
pathway, which references the NICE RA Guidelines published earlier
this year, would be a suitable benchmark for PCTs to use here,
but there will undoubtedly be PCTs who are unaware of its existence.
6. People with RA are not being given sufficient
support to stay in work creating a financial burden for both society
and the individual
— The NAO estimated that for the cost to
the economy of sick leave and work-related disability for people
with RA is £1.8 billion a year,[40]
which is substantially more than the NHS costs associated with
treating RA.
— NRAS believes that in addition to earlier
diagnosis and treatment, people with RA could be better supported
in staying in work. Only 20% of those surveyed by the NAO stated
that they had received sufficient information about employment
issues and that services to support patients in work were the
"least effective services compared with other aspects of
their care." Only 12% of GPs surveyed offered people diagnosed
with RA information on staying in work.[41]
— Our own research has shown that once
on Incapacity Benefit (now known as the Employment and Support
Allowance) 80% of people with musculoskeletal conditions never
return to work.[42]
— The Public Accounts Committee should
therefore consider asking Department of Health officials how they
plan to encourage PCTs to establish clearer links with Jobcentre
Plus services and ensure adequate provision of holistic care for
people with RA.[43]
7. The NAO survey of 1,400 people with rheumatoid
arthritis found there is a lack of coherence in the support and
information available to help them self-manage their condition
As with the findings of the earlier Kings Fund
report, the NAO report found that people wanted more information
about living with RA and 59% agreed that having access to a named
individual to whom they could turn when in need and/or experiencing
a flare would be extremely beneficial. One of the key NRAS priorities
is to "empower" people with RA by teaching them more
about their disease and providing them with timely information
and support to enable them to self manage their disease more effectively.
A key part of our strategy to improve patient self management
in RA has been to partner with EPPCIC (Expert Patients Programme)
to develop an RA specific self management programme which was
successfully piloted in three locations in England in early 2009.
It is anticipated that this programme will be ready for commissioning
mid 2010.
Annex
ESTIMATED EXPENDITURE OF RHEUMATOID ARTHRITIS
SERVICES PER HEAD OF POPULATION, BROKEN DOWN BY PRIMARY CARE TRUST
AREA
The following is an analysis of expenditure
on rheumatoid arthritis services per head of population in each
Primary Care Trust area in England. It is calculated as follows:
— The second column shows the total amount
each PCT spent on musculoskeletal services in the 2007-08 year,
and is taken directly from the Department of Health's programme
budgeting data.[44]
— Across England, total programme spend on
musculoskeletal conditions in 2007-08 was £3,848,281,000.
The National Audit Office estimates that total expenditure on
RA services in 2007-08 was £557,000,000[45]—suggesting
that 14.5% of expenditure on musculoskeletal services was on rheumatoid
arthritis services.
— The third column in the table below therefore
multiplies each PCT's expenditure on musculoskeletal services
by 0.145 (ie a percentage of 14.5%) to find each PCT's expenditure
on RA services.
— The fourth column divides each PCT's
expenditure on RA services by its resident population,[46]
giving each PCT's spend per head on RA services
— The table shows that spending on RA services
ranges from £5.68 per head in Bexley PCT to £17.58 per
head in Gateshead PCT—a greater-than-threefold variation—with
an England average of £10.97.
Primary Care Trust
|
Expenditure on
musculoskeletal
services in
2007-08 (£000s)
|
Estimated
expenditure on
rheumatoid
arthritis (£000s)
|
Total
population |
Estimated
expenditure on
rheumatoid arthritis
services per head of
population (£)
|
Bexley Care Trust | £8,268
| £1,197 | 210,846 |
£5.68 |
| Camden PCT | £9,596 |
£1,389 | 232,476 | £5.97
|
| Luton PCT | £8,311 |
£1,203 | 185,044 | £6.50
|
| Ealing PCT | £14,614 |
£2,115 | 320,247 | £6.60
|
| Hounslow PCT | £10,367
| £1,501 | 220,839 |
£6.79 |
| Barking and Dagenham PCT | £7,867
| £1,139 | 165,224 |
£6.89 |
| Brent Teaching PCT | £13,354
| £1,933 | 279,831 |
£6.91 |
| City and Hackney Teaching PCT | £10,523
| £1,523 | 220,479 |
£6.91 |
| Richmond and Twickenham PCT | £8,385
| £1,214 | 172,967 |
£7.02 |
| Redbridge PCT | £11,764
| £1,703 | 239,977 |
£7.10 |
| South West Essex PCT | £19,575
| £2,833 | 397,364 |
£7.13 |
| Hammersmith and Fulham PCT | £8,409
| £1,217 | 169,996 |
£7.16 |
| Westminster PCT | £12,072
| £1,747 | 234,500 |
£7.45 |
| Wandsworth PCT | £14,873
| £2,153 | 280,145 |
£7.68 |
| Kensington and Chelsea PCT | £10,187
| £1,474 | 190,514 |
£7.74 |
| Bradford and Airedale PCT | £26,670
| £3,860 | 497,635 |
£7.76 |
| South East Essex PCT | £17,948
| £2,598 | 333,348 |
£7.79 |
| Solihull Care Trust | £11,131
| £1,611 | 206,552 |
£7.80 |
| Mid Essex PCT | £19,364
| £2,803 | 356,281 |
£7.87 |
| Leicester City PCT | £17,147
| £2,482 | 308,699 |
£8.04 |
| Bedfordshire PCT | £23,096
| £3,343 | 411,716 |
£8.12 |
| West Hertfordshire PCT | £30,332
| £4,390 | 536,390 |
£8.18 |
| Kirklees PCT | £22,372
| £3,238 | 391,969 |
£8.26 |
| Wakefield District PCT | £19,045
| £2,757 | 333,186 |
£8.27 |
| Berkshire East PCT | £22,056
| £3,192 | 384,225 |
£8.31 |
| Blackpool PCT | £8,173
| £1,183 | 140,104 |
£8.44 |
| Telford and Wrekin PCT | £9,516
| £1,377 | 160,910 |
£8.56 |
| Islington PCT | £11,079
| £1,604 | 187,275 |
£8.56 |
| Calderdale PCT | £11,877
| £1,719 | 200,421 |
£8.58 |
| Suffolk PCT | £34,858 |
£5,045 | 587,972 | £8.58
|
| Leeds PCT | £45,813 |
£6,631 | 767,081 | £8.64
|
| Croydon PCT | £20,313 |
£2,940 | 335,142 | £8.77
|
| Portsmouth City Teaching PCT | £12,231
| £1,770 | 199,522 |
£8.87 |
| East and North Hertfordshire PCT | £34,163
| £4,945 | 549,793 |
£8.99 |
| Buckinghamshire PCT | £30,897
| £4,472 | 496,622 |
£9.00 |
| Kingston PCT | £10,842
| £1,569 | 172,013 |
£9.12 |
| Southwark PCT | £16,413
| £2,376 | 258,245 |
£9.20 |
| Medway PCT | £16,975 |
£2,457 | 265,207 | £9.26
|
| Cambridgeshire PCT | £36,949
| £5,348 | 577,074 |
£9.27 |
| Havering PCT | £15,276
| £2,211 | 237,212 |
£9.32 |
| East Riding Of Yorkshire PCT | £19,703
| £2,852 | 304,296 |
£9.37 |
| Doncaster PCT | £19,016
| £2,752 | 293,143 |
£9.39 |
| Hull PCT | £18,187 |
£2,632 | 280,044 | £9.40
|
| West Kent PCT | £43,203
| £6,253 | 662,250 |
£9.44 |
| Manchester PCT | £32,085
| £4,644 | 485,511 |
£9.57 |
| North Tyneside PCT | £13,504
| £1,955 | 204,085 |
£9.58 |
| North Lincolnshire PCT | £10,542
| £1,526 | 158,259 |
£9.64 |
| Liverpool PCT | £29,696
| £4,298 | 443,988 |
£9.68 |
| Greenwich Teaching PCT | £15,423
| £2,232 | 230,462 |
£9.69 |
| Lambeth PCT | £19,502 |
£2,823 | 289,747 | £9.74
|
| Enfield PCT | £18,076 |
£2,616 | 267,869 | £9.77
|
| Darlington PCT | £6,631
| £960 | 98,203 | £9.77
|
| County Durham PCT | £34,556
| £5,002 | 509,491 |
£9.82 |
| Sheffield PCT | £36,525
| £5,287 | 534,251 |
£9.90 |
| Hampshire PCT | £85,266
| £12,341 | 1,235,910 |
£9.99 |
| Berkshire West PCT | £31,766
| £4,598 | 455,101 |
£10.10 |
| Derbyshire County PCT | £48,630
| £7,039 | 692,696 |
£10.16 |
| Stoke On Trent PCT | £18,211
| £2,636 | 258,117 |
£10.21 |
| South Staffordshire PCT | £41,309
| £5,979 | 583,057 |
£10.25 |
| West Essex PCT | £18,563
| £2,687 | 261,656 |
£10.27 |
| Worcestershire PCT | £38,780
| £5,613 | 545,377 |
£10.29 |
| Harrow PCT | £14,239 |
£2,061 | 198,505 | £10.38
|
| Bristol PCT | £30,762 |
£4,452 | 428,124 | £10.40
|
| North East Lincolnshire Care Trust | £11,853
| £1,716 | 163,551 |
£10.49 |
| Sutton and Merton PCT | £27,511
| £3,982 | 377,654 |
£10.54 |
| North Yorkshire and York PCT | £55,919
| £8,094 | 767,344 |
£10.55 |
| Rotherham PCT | £17,781
| £2,574 | 243,888 |
£10.55 |
| South Birmingham PCT | £25,331
| £3,666 | 347,014 |
£10.57 |
| Torbay Care Trust | £10,211
| £1,478 | 139,121 |
£10.62 |
| North East Essex PCT | £23,355
| £3,380 | 317,972 |
£10.63 |
| Great Yarmouth and Waveney PCT | £16,281
| £2,357 | 220,674 |
£10.68 |
| Lewisham PCT | £18,996
| £2,749 | 257,419 |
£10.68 |
| Haringey Teaching PCT | £17,792
| £2,575 | 240,403 |
£10.71 |
| Bromley PCT | £22,622 |
£3,274 | 303,504 | £10.79
|
| Cornwall and Isles Of Scilly PCT | £39,395
| £5,702 | 525,942 |
£10.84 |
| Tower Hamlets PCT | £16,073
| £2,326 | 214,523 |
£10.84 |
| Northamptonshire PCT | £50,287
| £7,279 | 660,508 |
£11.02 |
| Bournemouth and Poole PCT | £24,842
| £3,596 | 321,235 |
£11.19 |
| Bury PCT | £14,086 |
£2,039 | 182,116 | £11.20
|
| Wiltshire PCT | £33,732
| £4,882 | 434,921 |
£11.23 |
| Nottingham City PCT | £23,709
| £3,432 | 305,234 |
£11.24 |
| Brighton and Hove City PCT | £20,263
| £2,933 | 259,100 |
£11.32 |
| Barnet PCT | £26,126 |
£3,781 | 331,471 | £11.41
|
| East Lancashire PCT | £29,537
| £4,275 | 373,519 |
£11.45 |
| Isle of Wight NHS PCT | £10,947
| £1,584 | 137,985 |
£11.48 |
| Herefordshire PCT | £13,871
| £2,008 | 174,778 |
£11.49 |
| Peterborough PCT | £11,884
| £1,720 | 149,603 |
£11.50 |
| South Gloucestershire PCT | £19,257
| £2,787 | 242,175 |
£11.51 |
| West Sussex PCT | £61,650
| £8,923 | 773,856 |
£11.53 |
| Sandwell PCT | £24,054
| £3,482 | 301,397 |
£11.55 |
| Bassetlaw PCT | £8,517
| £1,233 | 106,594 |
£11.56 |
| North Staffordshire PCT | £16,342
| £2,365 | 204,101 |
£11.59 |
| Warwickshire PCT | £41,377
| £5,989 | 516,157 |
£11.60 |
| Leicestershire County and Rutland PCT | £51,892
| £7,511 | 645,279 |
£11.64 |
| Coventry Teaching PCT | £25,972
| £3,759 | 322,771 |
£11.65 |
| Walsall Teaching PCT | £20,099
| £2,909 | 249,756 |
£11.65 |
| Northumberland Care Trust | £25,165
| £3,642 | 311,274 |
£11.70 |
| Birmingham East and North PCT | £32,196
| £4,660 | 398,186 |
£11.70 |
| Heywood, Middleton and Rochdale PCT | £16,539
| £2,394 | 203,963 |
£11.74 |
| Gloucestershire PCT | £47,058
| £6,811 | 579,098 |
£11.76 |
| Warrington PCT | £15,740
| £2,278 | 192,778 |
£11.82 |
| Waltham Forest PCT | £18,725
| £2,710 | 228,251 |
£11.87 |
| Oxfordshire PCT | £50,412
| £7,297 | 612,823 |
£11.91 |
| Dudley PCT | £24,837 |
£3,595 | 301,297 | £11.93
|
| Lincolnshire PCT | £58,350
| £8,446 | 698,635 |
£12.09 |
| Halton and St Helens PCT | £25,512
| £3,693 | 304,194 |
£12.14 |
| Surrey PCT | £90,124 |
£13,045 | 1,072,388 | £12.16
|
| Swindon PCT | £16,195 |
£2,344 | 192,541 | £12.17
|
| Shropshire County PCT | £24,050
| £3,481 | 285,158 |
£12.21 |
| Norfolk PCT | £61,094 |
£8,843 | 723,638 | £12.22
|
| Hillingdon PCT | £20,365
| £2,948 | 240,291 |
£12.27 |
| Dorset PCT | £32,906 |
£4,763 | 382,266 | £12.46
|
| Wolverhampton City PCT | £20,463
| £2,962 | 237,535 |
£12.47 |
| South Tyneside PCT | £13,037
| £1,887 | 150,957 |
£12.50 |
| Trafford PCT | £18,223
| £2,638 | 210,704 |
£12.52 |
| Central and Eastern Cheshire PCT | £38,943
| £5,637 | 445,787 |
£12.64 |
| Tameside and Glossop PCT | £19,835
| £2,871 | 225,259 |
£12.74 |
| North Tees PCT | £16,689
| £2,416 | 188,522 |
£12.81 |
| Middlesbrough PCT | £12,781
| £1,850 | 144,105 |
£12.84 |
| Bolton PCT | £23,404 |
£3,387 | 262,529 | £12.90
|
| Blackburn with Darwen PCT | £13,512
| £1,956 | 151,187 |
£12.94 |
| Heart of Birmingham Teaching PCT | £25,502
| £3,691 | 282,156 |
£13.08 |
| Stockport PCT | £25,502
| £3,691 | 281,488 |
£13.11 |
| Devon PCT | £66,378 |
£9,608 | 732,201 | £13.12
|
| Newcastle PCT | £23,711
| £3,432 | 260,861 |
£13.16 |
| Derby City PCT | £24,729
| £3,579 | 271,023 |
£13.21 |
| Newham PCT | £23,604 |
£3,416 | 254,504 | £13.42
|
| Sefton PCT | £25,640 |
£3,711 | 270,639 | £13.71
|
| Hartlepool PCT | £8,662
| £1,254 | 91,132 | £13.76
|
| Eastern and Coastal Kent PCT | £68,302
| £9,886 | 715,899 |
£13.81 |
| Sunderland Teaching PCT | £26,183
| £3,790 | 273,990 |
£13.83 |
| Cumbria PCT | £48,141 |
£6,968 | 502,103 | £13.88
|
| North Somerset PCT | £19,373
| £2,804 | 201,811 |
£13.89 |
| Knowsley PCT | £14,653
| £2,121 | 150,286 |
£14.11 |
| North Lancashire PCT | £31,912
| £4,619 | 326,341 |
£14.15 |
| Nottinghamshire County PCT | £62,796
| £9,089 | 638,935 |
£14.23 |
| Western Cheshire PCT | £24,205
| £3,503 | 245,689 |
£14.26 |
| Central Lancashire PCT | £43,959
| £6,363 | 438,711 |
£14.50 |
| East Sussex Downs and Weald PCT | £32,783
| £4,745 | 326,732 |
£14.52 |
| Milton Keynes PCT | £23,346
| £3,379 | 232,448 |
£14.54 |
| Redcar and Cleveland PCT | £13,359
| £1,934 | 132,813 |
£14.56 |
| Salford PCT | £22,473 |
£3,253 | 222,861 | £14.60
|
| Hastings and Rother PCT | £18,137
| £2,625 | 171,398 |
£15.32 |
| Oldham PCT | £23,714 |
£3,432 | 222,362 | £15.44
|
| Barnsley PCT | £24,698
| £3,575 | 231,551 |
£15.44 |
| Bath and North East Somerset PCT | £19,883
| £2,878 | 186,018 |
£15.47 |
| Plymouth Teaching PCT | £26,830
| £3,883 | 250,297 |
£15.52 |
| Ashton, Leigh and Wigan PCT | £32,870
| £4,758 | 301,596 |
£15.77 |
| Somerset PCT | £56,685
| £8,205 | 513,108 |
£15.99 |
| Wirral PCT | £34,407 |
£4,980 | 309,821 | £16.07
|
| Southampton City PCT | £27,679
| £4,006 | 245,611 |
£16.31 |
| Gateshead PCT | £23,570
| £3,412 | 194,043 |
£17.58 |
| England Average | |
| | £10.97
|
| |
| | |
INFORMATION ABOUT
NRAS
NRAS is the only charity in the UK dedicated to working towards
a better quality of life for people with RA specifically (as opposed
to other forms of arthritis).
NRAS has a national network of volunteers (400), people living
with RA, who support the charity in a wide variety of ways and
provide peer to peer telephone support.
NRAS has helpline which operates Monday—Friday, a comprehensive
and informative website and a range of publications and information
sheets available for both people with RA and the health professionals
who treat them.
November 2009
http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743?IdcService=GET_FILE&dID=200999&Rendition=Web
23
The King's Fund, A Consultancy Report by The King's Fund for
the Rheumatology Future's Group: Perceptions of patients and professionals
on rheumatoid arthritis care, January 2009. Back
24
National Institute for Health and Clinical Excellence, Rheumatoid
arthritis: The management of rheumatoid arthritis in adults,
February 2009. Back
25
National Audit Office, Services for people with rheumatoid
arthritis, July 2009, page 25. Back
26
Ibid page 5. Back
27
Ibid page 15. Back
28
Department of Health, Supporting people with long-term conditions,
January 2005. Back
29
National Audit Office, Services for people with rheumatoid
arthritis, July 2009, page 9. Back
30
Ibid page 9. Back
31
Ibid page 9. Back
32
Ibid page 9. Back
33
Department of Health, Programme budgeting data 2007-08,
16 July 2009. Back
34
Ibid page 4. Back
35
National Audit Office, Services for people with rheumatoid
arthritis, July 2009 page 4. Back
36
Ibid page 10. Back
37
Ibid page 26. Back
38
Ibid page 34. Back
39
Health Mandate, National priorities, local action, July
2009. Back
40
Ibid page 5. Back
41
Ibid page 32. Back
42
National Rheumatoid Arthritis Society, I want to work... Employment
and rheumatoid arthritis, a national picture, 2007 page 8. Back
43
National Audit Office, Services for people with rheumatoid
arthritis, July 2009, page 10. Back
44
Department of Health, Programme budgeting data, 16 July
2009; available here: Back
45
National Audit Office, Services for people with rheumatoid
arthritis, July 2009, page 15. Back
46
NHS Information Centre, Attribution dataset GP registered populations
2008, 30 January 2009. Back
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