Royal Devon and Exeter NHS Foundation Trust

Early Arthritis Clinic

  • - Over £173K pa potential savings on biologics prescribing
  • - 95% of patients surveyed reported overall satisfaction with the service

The Exeter Early Arthritis Clinic was introduced in 2006 to facilitate the prompt and aggressive treatment of early rheumatoid arthritis. Patients can now enter a one-stop clinic within two weeks of GP referral, with access to assessment, investigations, counselling and dispensing in one visit, rather than repeated trips to the hospital.

Download a printable pdf of the Royal Devon and Exeter case study

The challenge

- To enhance the identification and prompt treatment of patients with early rheumatoid and inflammatory arthritis
- To reduce the number of trips each patient makes to the hospital.

The solution

The service uses a local referral management service to match referrals to Early Arthritis Clinic (EAC) slots. Within two weeks of referral the one-stop clinic provides access to:
- Assessment by a consultant
- Investigations such as X-ray, ultrasound, blood and pulmonary function tests
- Nurse-led DMARD and disease counselling
- Corticosteroid regimen
- Aftercare therapists to assess and help with exercises and to provide off-the-shelf splints and orthoses

The service profile

The service is based at the Royal Devon and Exeter Hospital, with a catchment area that includes much of rural Devon. Patients are seen for follow-up appointment by a nurse six weeks after the initial clinic visit. Six weeks later each patient is reviewed by a consultant, and then again later in four or twelve weeks, dependent upon disease activity.
- Each week the service runs consultant and nurse specialist clinics in parallel
- Pre-methotrexate pulmonary function tests are available on the day
- Clinics are supported by a nurse-led telephone helpline that takes on average of 115 calls per month
- The service uses diagnostic and treatment algorithms to standardise the approach to treatment and follow up

Service performance and outcomes

- Audit demonstrates that 100% of patients diagnosed with inflammatory arthritis begin on an initial corticosteroid regime at their first clinic appointment, while 80% of patients begin on DMARDS within two weeks of their first clinic visit
- 87% of patients were seen within two weeks of referral to the EAC in 2012/13
- Audit of DMARD counselling demonstrates that 100% of patients are counselled before treatment

Patient focus and satisfaction

One of the founding principles of the one-stop EAC has been to relieve the burden of travel, sometimes from remote rural locations, on patients. Results from the first 50 completed returns of a patient experience survey:
  • - 90% of patients referred were seen within two weeks
  • - 93% of patients started on treatment at their first appointment
  • - 100% of patients received counselling for medication and monitoring of blood tests
  • - 98% of patients received a nurse advice response within 24 hours
  • - 95% of patients reported overall satisfaction with the service

Financial performance

Consultant, pharmacy and administrative savings are calculated to be around £15K per year. The early intensive treatment model could lead to a reduction in prescribing costs associated with biologic therapies – saving more than £173K per year.

Commissioning priorities

The Royal Devon and Exeter Hospital Early Arthritis Clinic service is an example of commissioning best practice in rheumatology and meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013:
  • - Active support for self-management – patients are given advice and education as necessary
  • - Care co-ordination – the specialist nurses help and signpost patients to access appropriate services quickly and easily
  • - Medicines management – medication compliance is achieved through ongoing counselling and monitoring at clinic