Policy archive

Health and Social Care Bill A briefing from the Coalition of UK Medical Specialty Societies

This briefing has been sent to all members of the House of Lords as they start to debate the Health and Social Bill. The briefing, which was coordinated by BSR, has been agreed by all members of the Coalition of UK Medical Specialty Societies. We hope that our collective voice will have a greater impact than us all briefing peers as individual societies and enable peers to understand the concerns we have about the bill and the changes it proposes.

Joint briefing document 

Rheumatoid Arthritis Care Perceptions of Patients and Professionals

Rheumatology Futures report The Rheumatology Futures Forum released its report on Perceptions of Patients and Professionals on Rheumatoid Arthritis (RA) Care. It clearly sets out the variability of care and the challenges that we face to ensure that services for people with rheumatoid arthritis are improved and that patients get appropriate and timely treatment. The Rheumatology Futures Group is a consortium of the main patient, professional and pharmaceutical organisations including the BSR, BHPR and ARMA, involved in RA care.

Report > Perceptions of Patients and Professionals on RA care
Supporting evidence > Findings of patient focus groups and professional interviews

NAO report: Services for people with rheumatoid arthritis

BSR statement

"We welcome this report. It demonstrates the gap between the recommendations in the NICE rheumatoid arthritis management guidelines, and what is actually delivered in the NHS. Consequently, it sets a challenge to both government and clinicians alike.

For government the message is that patients are missing out on vital treatments & services, and it is time to invest in inflammatory arthritis services. It demonstrates that if rheumatoid arthritis is not seen by specialists promptly and treated intensively, it will end up costing both individual patients and the country much more in the long run.

Therefore, rheumatoid arthritis services must now have the highest priority. For clinicians the message is that we must ensure that we are providing the best quality care for our rheumatoid arthritis patients.

"This is a great opportunity for the government and the musculoskeletal community to work together for the benefit of rheumatoid arthritis patients."

Dr Deborah Bax
BSR President

View > National Audit Office report: Services for People with Rheumatoid Arthritis

Quality and outcomes framework (QOF)

The quality and outcomes framework (QOF) is a programme of incentives offered annually to GP surgeries in the UK. Rewards are given for, among other things, how well they manage some of the most common chronic diseases, and how well they improve the health of the populations they serve. A key intention of the QOF is to identify ways of reducing preventable morbidity and cost. The absence of any musculoskeletal conditions from the present QOF must be a major concern to government given the substantial impact these conditions have on disability and reduced quality of life.

Quality metrics

Quality Metrics are a means of measuring the quality and performance of services to patients using a range of indicators and measures.
Although we believe most rheumatological out patient practice does not fit into this scheme, from a general perspective, there are some important points we would like to raise:

   -  We support standards such as those in the cancer section on Peer Review, National Audits and their analysis, and the use of specialist nurses.
   -  We support the promotion of standards for our inpatients in relation to assessment and treatment of serious disease.
   -  We are disappointed that none of the long term indicators are specifically relevant to rheumatology.
   -  We agree that there should be patient experience and patient environment indicators. However, we feel there are far too many, which could have a negative effect on discharge policies if all patients had to complete these.
   -  We support the development of Patient Related Outcome Measures (PROMS). We support timeliness of care indicators particularly in relation to Referral to Treatment (RTT).

Free prescriptions

Prescription charges for those with long term conditions are currently being reviewed. We believe that patients should be exempt from prescription charges for Disease Modifying Anti Rheumatic Drugs (DMARDS) and biologic agents. Serious forms of arthritis typically affect an age group not covered by existing exemptions. These individuals are dependent on regular and often multiple medications to control the diseases and their frequent co-morbidities.

The National Health Service Constitution

The NHS Constitution will establish the principles and values of the NHS in England. The draft consultation sets out commitments to patients, public and staff in the form of rights, pledges and responsibilities. All NHS bodies, private and third sector providers supplying NHS services will be required by law to take account of the Constitution in their decisions and actions. The Constitution will be renewed every ten years.

NHS Constitution key points:

  -  The NHS provides a comprehensive service available to all
  -  Access to NHS services is based on clinical need, not an individual’s ability to pay
  -  The NHS aspires to high standards of excellence and professionalism
  -  NHS services must reflect the needs and preferences of patients, their families and their carers
  -  The NHS works across organizational boundaries and in partnership with other organizations in the interest of patients, local communities and the wider population
  -  The NHS is committed to providing best value for taxpayers’ money and the most effective and fair use of finite resources
  -  The NHS is accountable to the public, communities and patients that it serves

    Visit the Department of Health website for further information on the constitution.

    Integrated Healthcare

    BSR has been working with the NHS Alliance, and colleagues from other organisations, on integrated care. The NHS Alliance is a collaboration of clinicians, managers and board members. It is an independent body that represents NHS primary care.

    The document “Integrated Healthcare: from aspiration to implementation” sets out a vision of integrated care, as well as responding to the NHS Next Stage Review. It compliments the work that is also being undertaken by the Royal College of Physicians with their “Teams without Walls” initative.

    Visit the NHS Alliance website for a full copy of Integrated Healthcare.

    NHS White Paper Equity and Excellence: Liberating the NHS

    View BSR's comments:

    BSR comments on NHS White Paper
    [October 2010]

    BSR comments on Commissioning for Patients
    [October 2010]

    BSR comments on Transparency in Outcomes
    [October 2010]

    Response to the Francis report


    The final report of the public inquiry into the events at the Mid Staffordshire NHS Trust between 2005 and 2009 was published by Robert Francis QC on 5 February 2013. It detailed a range of serious failings which caused significant pain and suffering to patients and their families.The report demonstrates a clear need for individuals and healthcare organisations to work together to create a different kind of culture where the quality of patient care is at the heart of everything that the NHS does. We support this focus and have identified a number of priorities in response to the report relating to the development of standards, audit and guidelines, leadership, support for effective commissioning and sharing of best practice through information systems. We have also considered our governance arrangements, both in terms of increasing the patient voice within the organisation and also the framework by which all future policy, activity, statement or guideline is produced.

    BSR priorities

    1. Standards, audit and guidelines

    BSR guidelines are NICE accredited and their development and revision must follow the approved protocol. Guidelines on the use of vasculitis management and tocilizumab use in rheumatoid arthritis have recently been submitted to Rheumatology for peer-review. Other guidelines are in development and/or currently under review. Further details will be published on the this website and updated on a regular basis in order to keep members informed.

    We intend to work with NICE to develop measures of outcome in relation to their work and to assist in the development of measures of standards compliance. To reinforce this, we believe that minimum levels of staff numbers and skill mix should be defined. To this end, the society will offer to support NICE in developing an evidence base and appropriate benchmarks to take into account the needs of the service. As part of this, we have established a working group to take forward our work on peer-review.

    BSR has been awarded a contract by HQIP to deliver an audit of rheumatoid and early inflammatory arthritis. As part of this, metrics will be identified which are relevant to the quality of care and patient safety in rheumatology. The audit will also provide high quality data comparing different providers and collect validated patient reported outcomes and experience measures.   Where variations in practice are identified in the course of the audit, we will provide support to individual units and ensure that the reasons for variation are understood and acted upon where appropriate.

    The NHS Commissioning Board has also been tasked with developing metrics for use by commissioners and we will offer support to their regional offices in taking these forward.

    2. Leadership

    The British Society for Rheumatology represents all members of the rheumatology multidisciplinary team, including doctors in training. Our courses and policies emphasise the importance of all team members understanding their responsibilities in promoting patient safety and being empowered to challenge colleagues, however senior, in the best interests of patients. We are also keen to promote clinical leadership, and are currently developing an educational program for members.

    3. Support for effective commissioning

    The Best Practice Tariff for early inflammatory rheumatoid arthritis (EIA), the first tariff for rheumatology, was introduced in April 2013 and supported by BSR, Arthritis Research UK and the Department of Health. The aim is to drive improvements in management of EIA, and particularly to support the many units that have struggled to provide timely and intensive intervention. BSR is currently working with the seven pilot sites and is in the process of analysing feedback and benchmarking it against non-pilot sites.

    4. Sharing of best practice

    We launched the Best Practice Awards to encourage innovation in rheumatology. The 17 finalists have all made changes to their practice in order to improve outcomes for patients and we will publish the winners at the end of September.

    BSR is also developing a software program designed to help commissioners in relation to best practice, costs and epidemiological data. We will work with the Department of Health, the Information Centre and the Care Quality Commission to consider how to develop comparative statistics on the efficacy of treatment in the specialty, for publication and use in performance oversight, revalidation, and the promotion of patient knowledge and choice.

    We run two registers of patients receiving biological treatments - BSRBR Rheumatoid Arthritis and BSRBR Ankylosing Spondylitis. The registers collect data on patient safety for these relatively new treatments as the long term effects are still unknown for biologic drugs. We are currently considering how to develop the registers’ potential and will take into account the recommendations on common information practices and data records.

    5. Governance

    There is currently no patient voice within BSR to provide advice, guidance and monitoring as to whether the work of BSR gives true priority to the patient. Whilst the recommendations relate to improving the patient focus of other organisations, such as Monitor and the CQC, the establishment of adequate patient representation will be incorporated into our new strategic plan and become a standing item for Executive Committee meetings.

    In addition, we intend to adopt a series of organisational tests which would be applied to any current or future policy, activity, statement or guideline. These would be based around the key recommendations of the Francis report and the identification of any potential conflicts of interest. In summary the tests to be applied would be:

      -  Core values: does the policy, activity or statement give appropriate priority to the patient and is it driven by evidence-based best practice in rheumatology?
      -  Leadership and dissemination: is it clear how the content of any policy, statement or guideline will be disseminated and implemented to the membership and beyond?
      -  Information: what measureable outputs are available from the policy or statement? Is it clear how these will be collected and used?
      -  Candour: Is any information likely to affect patient interests to be freely available? If not, how can this be justified?
      -  Conflicts: are potential conflicts of interest identified and balanced in favour of patient care?

    Next steps

    We will publish regular updates to our work in these areas.