Rheumatology Advance Access originally published online on June 14, 2007
Rheumatology 2007 46(8):1219-1220; doi:10.1093/rheumatology/kem083
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EDITORIALS |
30 million, around 10 000 ... and 18 ... Figuring out the optimal treatment for musculoskeletal conditions in the National Health Service
Centre for Rheumatology Research, University College London,
Division of Medicine, Room 331, 3rd Floor, 46 Cleveland Street,
London W1T 4JF, UK.
Correspondence to: D. A. Isenberg. E-mail: d.isenberg{at}ucl.ac.uk
The Independent newspaper published in the UK is fond of printing front pages consisting mostly of numbers that highlight particular aspects of the story they are covering. It certainly catches the readers’ attention. I would urge that any rheumatologist in the UK to bear in mind the figures 30 million, around 10 000 and 18 when they practice their subspecialty.
The figure of 30 million—pounds—was the number given to members of the Executive Committee of the British Society for Rheumatology involved in discussions with officials from the Department of Health in drawing up the ‘Musculoskeletal Services Framework—A Joint Responsibility: Doing It Differently’ [1]—and refers to the weekly cost to the UK of disability benefit due to musculoskeletal diseases. This huge figure, apart from being second only to psychiatric conditions amongst the subspecialties, also fails to take into account the cost of lack of productivity amongst those affected. Figures like this and, another one provided to us that 70% of patients with back pain who have failed to return to work within 3 months remain out of work for at least 5 yrs, attract the attention of the Department of Health. They have certainly been responsible for rheumatology's ‘ante being upped’ within the Department, as it struggles to contain the rising cost of running the National Health Service. The Musculoskeletal Services Framework is a very useful document for rheumatologists in the UK because it provides a useful basis on which to focus discussion and optimize treatment for musculoskeletal conditions in the next decade. Its core messages are that in order to improve the quality of care we offer our patients, more needs to be done at the level of primary care whilst acknowledging that there will be a remaining need for hospital-based rheumatology services.
The figure of around 10 000—again pounds—represents both the hope for the future and the cost of realizing that hope. Following the introduction of corticosteroids for the treatment of rheumatoid arthritis in the late 1940s, until the mid 1990s, the treatment of patients with serious autoimmune rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus, vasculitis, etc. was based upon immunosuppressive drugs working in a variety of ways, affecting many organs and systems with numerous side-effects. The palpable excitement generated in rheumatological circles with the development of the tumour necrosis factor-
(TNF-) blockers (led principally by Professors Maini and Feldmann) was driven by the fact that through a substantial amount of careful analytical work, two key pro-inflammatory molecules, interleukin 1 and TNF-, were demonstrated to be critical in the development of rheumatoid arthritis (reviewed in [2]). By blocking these specific molecules it was reasoned that clinical benefit may be derived, and certainly in the case of the TNF- blockers this hypothesis has unquestionably been confirmed. The same incidentally can be said of the blocking of B lymphocytes using rituximab, as shown initially by the work of Edwards and Cambridge [3]. There is surely great intellectual satisfaction in knowing that careful analysis of the aetiopathogenesis of individual diseases, coupled with the rapid advances in molecular biology, has led to major therapeutic advance with the reasonable prospect that subsequent work focusing on other critical molecules is likely to be just as successful. Unfortunately, as a former Rolling Stones manager once pointed out in relation to the cost of running a tour by the group in the US ... ‘It's only rock & roll ... but it's expensive’. By analogy the initial costs of around £10 000 per patient per year for each of the three established TNF- blockers reminds us that therapeutic advance will come at a significant cost. It is to hoped, especially given the obsession of the National Institute for Clinical Excellence for demonstrating health economic benefits as well as clinical benefit, that the use of TNF- and, B lymphocyte blockade (and which ever other therapeutic advances come our way in the next few years) will be shown to cut the overall cost of treating patients with rheumatoid arthritis and the other autoimmune diseases. This objective should be achieved by substantially reducing the requirement for synovectomy, joint replacement, tendon transplant, etc. as well as reducing the large concomitant costs of the side-effects of drugs like corticosteroids, methotrexate, cyclophosphamide and ciclosporin amongst others.
Looming increasingly large in the mind of all rheumatologists (and for that matter other physicians) in the UK is a keen sense that the Department of Health has set a target that by 2008, patients referred for specialist care should not be waiting more than 18 weeks for the initiation of definitive treatment. In an accompanying article in this volume of the Journal, David Walsh and his colleagues [4] review what is proposed in great detail. Clearly any attempt by the Department to speed up the process of improving the musculoskeletal health of the nation should be warmly welcomed. This said, we in rheumatology are clearly going to face a challenging period during the shake-up that will inevitably follow the proposals now coming out of the Department of Health. The greater emphasis on delivery of rheumatological healthcare at the primary level invoking the use of triage systems, independent clinical assessment and treatment service centres (CATS) and the greater use of general practitioners with a special interest (and formal training in) musculoskeletal diseases—the GpwSIs—is clearly going to happen. We should not be Luddite about these changes or resort to placing our heads firmly in the sand. Our subspecialty has grown enormously in terms of recognition amongst our peers. Thus within the past 5 yrs John Halsey was named doctor of the year by the Hospital Doctor Journal, Carol Black has been the President of the Royal College of Physicians and Mark Walport has become the Director of the Wellcome Trust. Rheumatologists are now to be found at virtually every level of hospital and academic practice (though we do need to provide some professors of medicine in our medical schools). This increased recognition of the importance of rheumatology will not be of much help to us unless we react to the proposed changes in an intelligent and constructive fashion. To give a few simple examples. It seems to be essential that rheumatologists should be offering themselves to serve on the primary care triage panels to help ensure that patients with musculoskeletal diseases do get directed appropriately at presentation. The numbers of general practitioners who were likely to become musculoskeletal GPwSIs will, I suspect, remain rather modest, but let us as rheumatologists ensure that they are adequately trained and make a significant contribution to this. Finally, although the language and potential bureaucracy of the 18-week patient pathway, as clearly evidenced in the article by David Walsh and colleagues, is daunting, it seems appropriate that we help to produce good and straightforward care packages (with appropriate documentation to be supplied to patients) to manage many of the common musculoskeletal disorders including neck pain, back pain, epicondylitis, carpal tunnel syndrome, a single swollen joint, polyarthritis or muscle weakness.
Whilst trying to accentuate the positive, we must also be aware of those difficulties that we are bound to face. Tensions between primary care trusts and local hospitals, as already evidenced at Newham General Hospital in East London, may mean that in some circumstances hospital-based rheumatologists could face a fight for survival. Here the Musculoskeletal Service Framework, which clearly states the need to retain hospital services should be invaluable. It will, however, be incumbent upon all rheumatology units to keep a very close watch on the levels of service, staffing levels and overall costs. To act as a ‘guide to the perplexed’ the British Society for Rheumatology has produced a ‘tool kit’, which comes strongly recommended for those who need help in working out their units running costs (available via the BSR website). It is also evident that there is a potential dichotomy between the notion of ‘choose and book’, which envisages patients being offered up to five different options for their treatment and the triage systems now rapidly developing up and down the country, which ostensibly appear to be directing patient management into a single pathway. This conflict has not yet been resolved and adds to the general difficulties associated with choose and book.
In summary, figuring out the optimal treatment for managing musculoskeletal diseases is not going to be easy. The notion of reducing the time our patients have to wait for their treatment is perfectly valid, but there are clearly practical problems about ensuring the success of the proposed approach. Hospital-based rheumatologists are likely to get drawn into spending at least part of their time in a primary care setting, but the need for hospital-based services remains essential. Getting this balance right is going to be the critical challenge facing rheumatology in the UK within the next decade.
The author has declared no conflicts of interest.
References
- The Musculoskeletal Services Framework. (2006) 270211 London: Department of Health Publications.
- Maini RN, Feldmann M. The immunopathogenesis of rheumatoid arthritis. In: The Oxford Textbook of Rheumatology—Isenberg DA, Maddison PJ, Woo P, Glass D, Breedveld FC, eds. (2004) 3rd. Oxford: Oxford University Press. 677–96.
- Edwards JCW, Cambridge G. Sustained improvement in rheumatoid arthritis following a protocol designed to deplete B cells. Rheumatology (2001) 40:205–11.
[Abstract/Free Full Text] - Walsh D, Kelly C, Bosworth A, Price C, Burbage G. Provisional guidelines for applying the United Kingdom Department of Health 18 week patient pathway to specialist rheumatology care. Rheumatology (2007) 46:1200–06.
[Abstract/Free Full Text]
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