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The Dudley Group NHS Foundation Trust was rated as an outlier in the National Early Inflammatory Arthritis Audit (NEIAA) in 2019. The Trust quickly put in place several initiatives to drive forward the number of patients seeing a rheumatologist within the three-week NICE guideline, going from 26% in the first year of the audit to 57% just a year later.


Dr Ravinder Sandhu, consultant rheumatologist at the Dudley Group NHS Foundation Trust, explains how the team transformed referral rates so rapidly and gives advice to other services seeking improvements.


Analysing the service

When we first received the news that we were outliers, we acted on the alert promptly and involved the whole team. We analysed the data, assessed our service and reviewed our care pathway. Through a brainstorming session, we identified where the specific delays were that resulted in patients with suspected inflammatory arthritis (SIA) not being seen in a timely manner.


Building on previous work

Before the audit we had already developed:

  • a pro forma for GPs so it was easier for them to refer SIA patients, detailing the information we need to be able to appropriately triage them

  • specific SIA appointments which open a month before to accommodate patients in a timely manner.


We determined that there weren’t enough of these appointments for the number of patients that were being referred. We increased the number of slots for SIA patients by 50%. It was a balance between SIA and routine appointments, but we knew that these patients needed to be prioritised as this group can particularly benefit from early treatment and intervention.


How do you triage patients?

We identified that many of these SIA slots were inappropriately used for patients referred with non-inflammatory conditions, which meant SIA patients were losing out as result.


Previously our outpatient booking team were allocating these appointments. We introduced a robust triage system for our SIA slots to ensure these appointments were used correctly. The consultant team took the responsibility of triage and patient allocation into SIA appointments. 


Getting support from our admin team has been crucial, our secretarial team leader now has responsibility to ensure all SIA slots are filled appropriately each week. Referrals categorised as routine are allocated to any empty clinic slots.


How do you monitor ongoing performance?

As well as submitting data to the BSR, every six months we conducted Plan, Do, Study, Act cycles. This was to review our referral data and specifically the time between referral of patients with SIA and when they were first seen in rheumatology.


Regular monitoring is incredibly important and allows us to make sure we’re maintaining our progress. Our trust board and medical director have been very supportive. They've been keen to understand our learning as a result of this outlier alert, how we’re driving quality improvement and how we're monitoring our performance.


What's your advice to others?

Ensure you're sharing information not just with your team, but with wider management. Tackling improvements is a team effort and you need everyone on board to support you. Sit down with the team and carefully go through and assess what processes you have within the clinical pathway. Identify where the sticking points are and prioritise two or three action points that you can take forward. 


Change is always difficult, but if you can determine specific and achievable actions, it gives you confidence to drive change and make a difference. Regular monitoring of the changes made is crucial to identify whether your actions have resulted in any quality improvement and that they are maintained.


Find out more about the audit