Manchester Royal Infirmary

Virtual multidisciplinary clinic to improve medicines management and reduce delays to drug therapies


The virtual biologics clinic (VBC) at the Manchester Royal Infirmary has reduced delays in biologics initiation, improved outcomes and increased clinical trial recruitment whilst also reducing the cost of biologics to the CCG by £113k in the first 6 months through introduction of standardised biologics prescribing pathways and multidisciplinary team review of patients initiating biologics.
  • 97% Compliance with the GMMMG biologics pathways for rheumatoid arthritis1 increased from 37% to 97% after the introduction of the VBC 
  • £113k Implementation of the prescribing pathways and increased recruitment into trials resulted in cost-savings of £113k in the first 6 months 
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The Challenge

  • After mapping the “typical patient journey” for an individual starting on a biologic therapy, the Manchester Royal Infirmary rheumatology clinical team identified several problems with their biologics service, including inefficient use of appointments, delays in initiating biologics, administrative burden on nursing staff, variation in practice, and missed translational research opportunities.

The Solution

  • The VBC was established to review all patients recommended for a biologic to ensure compliance with the regional Greater Manchester Medicines Management Group (GMMMG) biologic prescribing pathway and to integrate research, thereby containing prescribing costs.
  • The VBC consists of a weekly 1 hour multidisciplinary team meeting between a consultant rheumatologist, rheumatology specialist nurse, research nurse and specialist pharmacist.
  • New standardised documentation was introduced based on the GMMMG pathway, which included a safety checklist for every patient, the rationale for biologic choice, a new standardised GP letter, and a bespoke electronic ordering screen for screening tests.
  • Each patient is reviewed against prescribing checklists to ensure biologics prescribing is compliant with regional pathways, limiting variation in practice and also maximising prescription of the least expensive biologics, unless indicated otherwise. Patients are also reviewed against research study opportunities and invited to discuss entry into a clinical study at a patient education session if appropriate.
  • A biologics database, which is updated in real-time, records core quality data (NICE eligibility and monotherapy rates). Using this data, six-monthly reports are produced and annual audits conducted.

Service Performance and Outcomes

  • Compliance with the GMMMG biologics pathways for rheumatoid arthritis1 increased from 37% to 97% after the introduction of the VBC.
  • The proportion of patients with good or moderate response to biologic therapy (according to the EULAR criteria) has increased; at the most recent audit (2014) 100% of patients had a good or moderate response compared to 82% in 2011.
  • A substantial increase in recruitment to research studies was seen after the VBC was initiated; 60 patients were recruited in the year 2012-13 and 98 patients recruited in 2013-2014, the year in which the VBC began.

Financial Performance and Outcomes

  • Implementation of the prescribing pathways and increased recruitment into trials resulted in cost-savings of £113k in the first 6 months; £90k additional revenue was generated from recruitment into clinical trials of investigational medicinal products and biologics prescribing changes gave rise to savings of £23k to commissioners.
  • The VBC did not required any additional financial investment as no additional staff were required at the outset. Administrative support for the VBC was obtained later, based on nurses seeing 6 extra patients per week, who are urgent helpline patients, in place of 6 to 8 hours administration for the biologics service.

Patient Focus and Satisfaction

  • The VBC means that the weekly patient education sessions are up-to-date, based on queries and issues that arise and are discussed by the team in the VBC.
  • Nursing staff can act as the patient advocate at the VBC.
  • Fewer consultation visits to the hospital are now necessary for the patient prior to biologic initiation, and there has been a reduction in the median treatment delay from 59 days to 25 days after the introduction of the VBC.

Commissioning Priorities

The Manchester Royal Infirmary virtual biologics clinic is an example of commissioning best practice in rheumatology and meets a number of priorities for commissioners, clinicians and patients:


  • Medicines management – through implementation of standardised biologics prescribing pathways, patients receive the most appropriate biologic first, and the least expensive biologic is initiated first (where indicated)
  • Active support for self-management – the VBC enables the service to deliver up-to-date patient education sessions
  • Guideline-compliant biologics prescribing – the VBC ensures that regional and national guidelines are met, minimising variation in clinical practice
  • Streamlined patient journey – patients now require fewer appointments before their biologics treatment can be initiated, reducing treatment delays
  • Opportunities to participate in research – at the VBC, every patients is considered against the eligibility criteria for recruiting clinical studies

The service is an outstanding best practice model for all services that prescribe high-cost therapies, demonstrating that outcomes can be improved and costs saved while meeting guidelines for the use of high-cost therapies.

Service diagram