Trafford General Hospital, Central Manchester NHS Foundation Trust

Open access management of rheumatoid arthritis

  • - 2:1the ratio of nurse specialists to consultants

  • - More than 90% of patients say that they understand the treatments offered and that they are involved in decisions

Download a printable pdf of the Trafford General Hospital best practice case study

Developed over a twenty year period, the Trafford General Hospital Rheumatology unit has an open access service, supported by a drop-in clinic and telephone helpline. Rapid, open access, patient-focussed multi-disciplinary services enable tight control of inflammatory diseases.

The challenge

  • - To rapidly achieve and maintain remission in inflammatory joint diseases
  • - To treat all patients with a flare within twenty-four hours
  • - To overcome logistical issues in managing disease flare

The solution

  • - A helpline and drop-in clinic were established in the 1990s, run by rheumatology specialist nurses. All patients with inflammatory joint disease have contact information for the help line
  • - Clinic time was protected with the establishment of a drop-in clinic in the rheumatology unit. Patients are encouraged to contact the helpline in the first instance
  • - A purpose-built unit houses the open access unit along with two clinical rooms for those patients who ‘drop in’
  • - Nurse time previously taken up in reviewing blood results has been freed by the introduction of a computerised drug monitoring system
  • - Nurse specialists are employed at a 2:1 ratio to consultants
  • - The service refers to psychiatric support via primary care
  • - Physiotherapy, podiatry and occupational therapy support is provided within the team
  • - Once referred, patients have direct access to the service

The service profile

  • - All patients are treated with clinical pathways that are audited and modified where appropriate
  • - Nurse specialist DMARD initiation clinics are delivered with monthly review for the first three months
  • - The six-monthly review is carried out by the consultants
  • - A computerised system is used for screening drug toxicity and also used for monitoring and reviewing disease activity

Service performance and outcomes

Data from more than 4,000 patients attending for annual review between 2003 and 2008 demonstrated the following:
  •       - 15% had previously undiagnosed osteoporosis and treatment was initiated
  •       - 31% suffered from anxiety and/or depression and were recommended to consult their GP
  •       - 65% had significant sleep disturbance; advice was given on sleep hygiene, nocturnal analgesia and other drug therapy
  • - 100% of patients are reviewed within six months (compared to less than 95% nationally)
  • - More than 50% of patients have monthly reviews (regional score is less than 40%)
  • - 60% of patients have a DAS28 score recorded at each visit

Patient focus and satisfaction

  • - All patients with inflammatory arthritis have a comprehensive annual review.
  • - The telephone helpline and drop-in clinic enable ease of access for patients experiencing a flare in disease.
  • - Quality of care has improved by strengthening shared care with general practice. The software platform alerts rheumatology specialist nurses to abnormal results, and these are then picked up in primary care, for community-based care.
  • - A recent patient satisfaction audit carried out over a three week period showed:
  •      - More than 95% of patients agree or strongly agree that the service treats them as individuals
  •      - Over 90% say they are involved in decision making
  •      - Over 90% say they are given timely information
  •      - More than 95% feel they have good understanding of the treatments offered
  •      - More than 80% say they receive prompt help with flares
  •      - More than 90% feel that the MDT is approachable when they need to discuss any concerns they may have

Commissioning priorities

The Trafford General Hospital 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 eg those with sleep disturbance issues are advised regarding sleep hygiene and drug therapies
  • - Secondary prevention – telephone helpline and open access drop-in clinics help to control disease activity
  • - Care co-ordination – the development of the rheumatology nurse specialist role helps patients to access appropriate services quickly and easily
  • - Medicines management – treat to target therapies delivered by nurse-led pathways facilitate, appropriate escalation to DMARDS, flare management and access to biologic drugs for those eligible
  • - Improving the management of patients with both physical and mental health needs – patients suffering from anxiety and/or depression are identified and advised