Rheumatology Advance Access originally published online on June 11, 2007
Rheumatology 2007 46(8):1380-1381; doi:10.1093/rheumatology/kem128
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Rheumatology nurse specialists—do we need them?
Litchdon MedicalCentre, Devon EX32 9BZ
Correspondence to: S. M. Oliver. E-mail: susan.oliver{at}bigfoot.com
SIR, I respond to the Editorial by Hill [1] and agree wholeheartedly with the views expressed.
As outlined in the Hill's article, much of the focus on the value of all specialist services rests almost entirely on cost savings rather than quality indicators. The challenge for us all, but particularly the Rheumatology Nurse Specialist (RNS) is that of ensuring that the ‘real’ clinical data reviewed by Commissioners and Finance Directors, demonstrates activity related to these roles and is seen in the context of improved outcomes. Equally in many cases if RNS activity is collected the relevant codes and ultimately costs are either not collected or not submitted for national collection/review and dissemination. Such a flawed level of data can be seen in the analyses undertaken by Dr Foster's Intelligence (www.doctorfosterintelligence.co.uk).
Telephone support provided by specialist teams is a perfect example of this issue. A recent patient survey prepared by the National Rheumatoid Arthritis Society (NRAS) in collaboration with the Royal College of Nursing Rheumatology Forum and posted on the open access section of the NRAS website outlined the views of the 964 respondents who completed the survey (www.rheumatoid.org.uk).
Respondents were asked if they did not have access to telephone advice line service how they would resolve their problem; 54% stated that they would seek a GP appointment and 35% would call the hospital secretary or clinic for an out-patient appointment. This concurs with the Hughes et al. [2] 2002 paper showing that without the telephone advice line 60% of patients would seek a GP appointment costing the primary care trust (PCT) £15 100 annually.
The NRAS survey shows that respondents found that the services were responsive to their needs with 93% saying that they found the RNS support helpful; equally 68% of patients reported receiving a response in relation to a bad flare or what they perceived as an emergency within 24 h.
As Hill outlined there are some excellent models of care that have focused on using telephone support to reduce follow up appointments but the future now rests with PCTs recognizing the value of this work by contracting such services.
However, some activities that RNS are involved in, will not be considered in the same light - for example, in some Trusts a short term financial ‘gaming’ approach to retrieving funds from the PCT has been that of the charges for day case activity with the ability to be coded creatively resulting in charges as high as £660 perhaps for a day case activity for a joint injection of subcutaneous administration of a treatment. This appears an admirable idea from a secondary care point of view generating additional or higher levels of income but in reality it allows the focus of the PCT's to consider cost management approaches such as exploring non-NHS providers who will deliver the services outside the hospital and be tightly commissioned and controlled to deliver such service [3].
PCTs will consider alternative methods of delivering many components of services if they cannot achieve acceptable terms in negotiation. These will include commissioning telephone follow up services using independent providers, day case interventions such as training patients to administer subcutaneous therapies or administer intravenous infusions and worse still the long-term conditions follow-up model.
I note a recent consultation document issued by the Department of Health is considering options for the future of payment by results (September 2008/9 to November 2010) for a focus on changes to out-patient commissioning data set, which ‘will enable the national currencies to be applied to a wider range of out-patient services, particularly to those services led by allied health professionals and midwives’. The states document that telephone consultations constitute an overhead and ‘we plan, where possible, to start pricing these consultations separately to support their greater use in place of face to face follow up appointments’. Activity data will be collected from October 2007 and will be used to inform the setting of tariff [4].
We need to start selling our services and to look at alternative ways of ensuring patients who require our specialist expertise are provided with the appropriate infrastructure that will point those we really must see in the right direction. The RNS and allied healthcare professionals really need to work constructively with our medical colleagues if we are going to be there to deliver services in the future: we also need to be thinking ‘outside the box’.
The author has declared no conflicts of interest.
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 Top References |
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- Hill J. Rheumatology nurse specialists – do we need them? Rheumatology (2007) 46:379–81.
[Free Full Text] - Hughes RA, Carr MA, Huggett A, Thwaites CEA. Ann Rheum Dis (2002) 61:341–5.
[Abstract/Free Full Text] - Independent Practitioner March 2007.
- Department of Health. Options for the Future of Payment by Results: 2007:1008/09 to 2010/11. London: Department of Health. www.dh.gov.uk/pbr.
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