Objective The rheumatology department at The

Royal Oldham Hospital developed a primary care

service aimed at bridging the gap between primary

and secondary care for patients with potential

rheumatological conditions, and this was given

the name rheumatology Tier 2. The objective of

this study was to evaluate this primary care rheumatology

service (Tier 2)in order to assess its

validity, patient satisfaction and effectiveness.

Design Ten patients participated in individual

semi-structured interviews. Three GPs were interviewed

individually, and two GPs formed a focus

group. Thematic analysis was used to interpret the

findings.

Setting Patients were recruited from seven consecutive

rheumatology Tier 2 clinics. GPs were

recruited from Oldham Primary Care Trust (PCT)

as this was the main source of patient referrals for

the service.

Results The key findings were in relation to the

integration of primary healthcare and hospital services,

i.e. the primary/secondary care interface. This

highlighted the importance of early assessment,

diagnosis and treatment of patients with suspected

inflammatory arthritis.

Conclusion Early diagnosis and treatment with

disease-modifying anti-rheumatic drugs improves

patients’ outcomes. The rheumatology Tier 2 service

built on this evidence and provided a rapid

assessment and referral to secondary care for those

patients with suspected inflammatory arthritis

Ball, E

Critchley, S

English

Objective The rheumatology department at TheRoyal Oldham Hospital developed a primary careservice aimed at bridging the gap between primaryand secondary care for patients with potentialrheumatological conditions, and this was giventhe name rheumatology Tier 2. The objective ofthis study was to evaluate this primary care rheumatologyservice (Tier 2)in order to assess itsvalidity, patient satisfaction and effectiveness.Design Ten patients participated in individualsemi-structured interviews. Three GPs were interviewedindividually, and two GPs formed a focusgroup. Thematic analysis was used to interpret thefindings.Setting Patients were recruited from seven consecutiverheumatology Tier 2 clinics. GPs wererecruited from Oldham Primary Care Trust (PCT)as this was the main source of patient referrals forthe service.Results The key findings were in relation to theintegration of primary healthcare and hospital services,i.e. the primary/secondary care interface. Thishighlighted the importance of early assessment,diagnosis and treatment of patients with suspectedinflammatory arthritis.Conclusion Early diagnosis and treatment withdisease-modifying anti-rheumatic drugs improvespatients’ outcomes. The rheumatology Tier 2 servicebuilt on this evidence and provided a rapidassessment and referral to secondary care for thosepatients with suspected inflammatory arthritis

University of Salford Institutional Repository

Research paperEvaluation of the primary/secondary careinterface in relation to a primary carerheumatology serviceSarah Critchley RGN BA(hons) MScRheumatology Specialist NurseElaine Ball RGN Cert Ed BA(hons) MA PhDLecturer in Adult NursingThe Royal Oldham Hospital, Oldham, UKABSTRACTObjective The rheumatology department at TheRoyal Oldham Hospital developed a primary careservice aimed at bridging the gap between primaryand secondary care for patients with potentialrheumatological conditions, and this was giventhe name rheumatology Tier 2. The objective ofthis study was to evaluate this primary care rheu-matology service (Tier 2) in order to assess itsvalidity, patient satisfaction and effectiveness.Design Ten patients participated in individualsemi-structured interviews. Three GPs were inter-viewed individually, and two GPs formed a focusgroup. Thematic analysis was used to interpret thefindings.Setting Patients were recruited from seven con-secutive rheumatology Tier 2 clinics. GPs wererecruited from Oldham Primary Care Trust (PCT)as this was the main source of patient referrals forthe service.Results The key findings were in relation to theintegration of primary healthcare and hospital ser-vices, i.e. the primary/secondary care interface. Thishighlighted the importance of early assessment,diagnosis and treatment of patients with suspectedinflammatory arthritis.Conclusion Early diagnosis and treatment withdisease-modifying anti-rheumatic drugs improvespatients’ outcomes. The rheumatology Tier 2 ser-vice built on this evidence and provided a rapidassessment and referral to secondary care for thosepatients with suspected inflammatory arthritis.Keywords: primary care development, primary/secondary care interface, rheumatology, Tier 2 serviceHow this fits in with quality in primary careWhat do we know?Early assessment, diagnosis and treatment of patients with suspected inflammatory arthritis has been shownto improve outcomes for these patients.What does this paper add?Evaluation of a new rheumatology service showed that patients and general practitioners felt that it provideda rapid assessment and referral to secondary care for those patients with suspected inflammatory arthritis.Quality in Primary Care 2007;15:33–6 # 2007 Radcliffe PublishingS Critchley and E Ball34IntroductionTraditionally, patients with suspected inflammatoryarthritis are referred directly from their general prac-titioner (GP) to a consultant in secondary care. How-ever, innovations in practice together with recentgovernment policies are proliferating at the primary/secondary care interface, affecting referral pathwaysand resource use.1 The principal motive for suchreorganisation is to move away from reactive carebased in acute systems, towards a systematic patient-centred approach rooted in primary care.Early diagnosis and treatment of inflammatoryarthritis with disease-modifying anti-rheumatic drugs(DMARDs) has been shown to improve patient out-comes.2 A large body of published material suggeststhat DMARDs should be initiated within 3 months ofdisease onset.3,4 In current practice the time fromsymptom onset to commencement of DMARDs is atbest sixmonths.5 It is evident that considerable resourcesare required to enable primary and secondary careservices to deliver DMARDs within the recommendedtime scale.BackgroundResearch has shown that rheumatology services can bemanaged safely within a primary care setting, not-withstanding appropriate support from secondarycare.6 There is evidence that patients seen in a primarycare setting are managed relatively similarly and havethe same treatment outcomes to patients who are seenand treated in secondary care.7 Based on these find-ings, the emergence of new initiatives to manage thedemand for rheumatological disorders occurs largelyat the primary/secondary care interface, rather thansolely within primary care.In May 2003, the rheumatology team at The RoyalOldham Hospital undertook a three-month audit ofnew patient referrals. From the initial audit findingsit was estimated that approximately 40% of the newpatient referrals could be seen and treated in primarycare by a multidisciplinary team. As part of ongoingdevelopments in the management of chronically illpatients, Oldham PCT established a primary care-based rheumatology service (named Tier 2). The aimof the service was to improve care pathways forpatients and reduce waiting times for secondary carerheumatology patients.This study was a nine-month evaluation of therheumatology Tier 2 service; it was commenced 12months after the service began. Because this type ofservicewas new to the specialty of rheumatology, therewas a desire from the outset to combine best practicewith innovation and this was recently recognised whenthe British Society of Rheumatology awarded firstplace to this service. The award ‘Innovation in Rheu-matology’ was designed to highlight innovation andexcellence that has benefited rheumatology medicine.MethodsA qualitative descriptive analysis was used to evaluatepatient and GP responses to their experience of theTier 2 service. The data were analysed and categorisedby frequency, which allowed theories to be developedoffering insight and enhanced understanding of thedata, and provided ameaningful guide of action to theresearch situation.8,9It was hoped that the service users’ perspectivewould provide a patient-led direction, highlight areasfor development and improvement, andmost import-antly, support evidence-based research and confirmthat the rheumatology Tier 2 service was right for thispatient group. The GP sample provided a differentperspective on the service users’ experience – it wasimportant to determine if the service offered a quickerresponse rate of treatment, improved patient out-comes, and changed rheumatology delivery for thebetter.All patients who had a rheumatology Tier 2 ap-pointment on seven consecutive clinic dates were sentan invitation letter, information sheet and reply slipinviting them to attend an interview lasting approx-imately 30 minutes and consisting of semi-structuredquestions, which referred to the rheumatology Tier 2service and their evaluation of it. A total of 32 patientinvitations were sent. Thirteen patients agreed to takepart in this study. Non-responders were not sentreminders due to time constraints of the study. Onepatient was included in a pilot study and two patientswithdrew from the study on the interview date due toprior commitments. The interview was conductedafter the patient’s rheumatology Tier 2 appointmentin an NHS setting.The GP sample was originally intended to form afocus group, and invitations were sent out via email asit was fast and, more importantly, ensured directaccess to all of the GPs. To access the GP populationfor this study, all GPs in the Oldham PCT wereemailed an invitation letter and the research protocol;two weeks later a reminder email was sent. Eighty-seven GPs were invited to attend the focus groupsession. The first six GPs who replied positively tothe email were to be included in the focus group andthe GPs were informed of this in their invitation. TwoGPs agreed to attend the focus group on the datearranged, however, six GPs expressed an interest butcould not attend, as it was difficult to organise amutually agreeable time.Rheumatology service and the primary/secondary care interface 35Due to the small number of participants for the GPfocus group, it was decided to interview individualGPs, as they would be less constrained by a rigid time.The most expedient process to gain access for theindividual interviews was to repeat the process ofemailing the previous six GPs who could not attendthe focus group due to time constraints. The emailasked if they would consider being interviewed abouttheir experiences of the rheumatology Tier 2 serviceon an individual basis at their own GP practice at aconvenient time for them. Three of the six GPs repliedpositively to this invitation and were interviewedindividually.The setting for the GP focus group was a quiet,relaxed room in the education centre at The RoyalOldham Hospital. The individual GP interviews wereheld in private in the GP’s own surgery.Written informed consent was obtained from allparticipants. All interviews and the focus group weretape-recorded and transcribed. The data were storedin a locked filing cabinet in a locked office and weredestroyed after the completion of the study.ResultsBefore the Tier 2 service, patients had to wait up to13 weeks for an initial assessment in secondary care.After introduction of the new service this was nolonger the case; because of the rapid-assessment pro-cess, patients now had access to valuable medicationsooner. DMARDs are generally effective, but they takeup to 12 weeks before they exert a therapeutic effect;and this was another reason to prescribe them early.2The difference between primary and secondary carein the delivery of rheumatological care was evident.The primary care service hadmore direct care pathways –patients were seen, treated and discharged with a planof care, usually within four weeks of receiving the GPreferral. The effectiveness of the service in terms of itsability to discharge patients was a crucial factor in theservices’ success. However, if patients had a suspectedinflammatory disease, their investigations were carriedout before they were referred on to secondary care.Thismeant that when they had a hospital consultationmuch of their diseasemanagement had started. There-fore as one GP observed, the Tier 2 service provideda bridge in the hiatus between early diagnosis andtreatment:‘We don’t want to leave it too late to refer if they are goingto be rheumatoid because they need aggressive treatmentbut we don’t want to send them in too early before it’sclear as to what is going on.’Given that 90% of patients with rheumatoid arthritishave some form of disability within two decades ofonset,10 early diagnosis and treatment is of paramountimportance. Early diagnosis and treatment dramat-ically improve patients’ long-term outcomes,2 andfindings showed that the Tier 2 service saw patientsearly on in the disease process and started DMARDsquickly. This was important also if the patient was toreturn to a productive way of life, and was certainly aconsideration for the GPs:‘What is the final outcome for these individuals, does itreally change their quality of life, do they stay in work andcan they be a productive member of society?’Healthcare resources are finite.11 Therefore infor-mation about costs and effectiveness were essentialwhen making decisions about the Tier 2 service. Oneconsideration from a GP was that if primary careservices are more cost-effective and treatment is offeredin the community then financially the service is moreviable. On the other hand, another GP observed thatcost would be the same as the servicewas the samewithonly a different setting.‘Economically if it can be delivered much more speedilyand the likelihood is that the cost to theNHS is going to beconsiderably less.’In respect of setting, however, the patient findingsshowed that this change had the greatest impact:‘For some people it’s probably less threatening thanhaving to go to the hospital, you know it’s more of afamiliar sort of surrounding.’Patients stated some concerns regarding attending aprimary care rheumatology service, but there was ashift in opinion after their appointment where theyexpressed a preference for the primary care serviceinstead of one based at the hospital. One explanationgiven for this change in opinion was the similarity ofthe assessment in primary care compared to secondarycare:‘I mean the interview that I’ve had was very thorough andI wouldn’t have thought it would have been any morethorough at the hospital.’The development of the Tier 2 service helped both thepatient and the healthcare professional to better definethe patients’ care pathway and ensure a quickerresponse of evidence-based care. The shift from sec-ondary- to primary-based care in the treatment ofrheumatology helped to respond to the local popu-lation’s needs and provide a service that was asaccessible as possible,1 while being cost-effective atthe same time.S Critchley and E Ball36DiscussionFindings revealed that GP and patient satisfaction wasachieved. However, it would be unfair to provide thiswell-evaluated service if it were only for an interimperiod. Whether these services are sustainable over along period of time remains to be seen, due to issuessurrounding cost-effectiveness and continuing changesin healthcare politics. Yet, the general principle ofmoving chronically ill patients from secondary to aprimary care setting reflects current changes in health-care provision.From the data findings, participants felt that themost effective way to deliver care for patients withpotential rheumatological conditions was at the inter-face of primary/secondary care as provided by this newservice. Careful consideration has been given to thesefindings, as they have the potential to impact signifi-cantly on chronic disease services. Further larger studiesare needed in order to develop sustainable services forchronically ill patients.ConclusionPatients with suspected inflammatory arthritis requirerapid assessment, diagnosis and treatment. The com-mencement of appropriate medication has beenproven to slow down disease progression and main-tains quality of life. Unfortunately, current rheuma-tology services struggle to provide treatment within aset time period, thus leaving patients without therequired drug therapy. The rheumatology Tier 2 servicehas improved not only care pathways thus reducinginappropriate secondary care referrals but more im-portantly the speed of the initial assessment, diagnosisand treatment.ETHICS COMMITTEEEthical approval was gained from Oldham LocalResearch Ethics Committee and The University ofSalford.REFERENCES1 Department ofHealth. Supporting Peoplewith LongTermConditions. An NHS and social care model to support localinnovation and integration. London: HMSO, 2005.2 Arthritis and Musculoskeletal Alliance. Standards ofCare for People with Musculoskeletal Conditions. Avail-able at: www.arma.uk.net (accessed 24November 2006).3 QuinnMA,Conaghan PG and Emery P. The therapeuticapproach of early intervention for rheumatoid arthritis:what is the evidence? Rheumatology 2001;40:1211–20.4 Hochberg MC. Early aggressive DMARD therapy: thekey to slowing disease progression in rheumatoid arth-ritis. Scandinavian Journal of Rheumatology 1999;28:3–7.5 Irvine S,Munro R and Porter D. Early referral, diagnosisand treatment of rheumatoid arthritis: evidence for achanging practice. Annals of Rheumatic Disease 1999;58:510–13.6 Hewlett S, Mitchell K, Haynes J et al. Patient-initiatedhospital follow-up for rheumatoid arthritis. Rheuma-tology 2000;29:990–7.7 Hetthen J and Helliwell PS. A comparison betweenprimary care-led rheumatology services and secondarycare provision. Rheumatology 1999;38:1294–5.8 Strauss A and Corbin J. Basics of Qualitative Research:techniques and procedures for developing grounded theory(2e). Thousand Oaks: Sage, 1998.9 Artinian BA. Qualitative modes of inquiry. WesternJournal of Nursing Research 1998;10:138–49.10 Buckley CD. Science, medicine and the future. Treat-ment of rheumatoid arthritis. British Medical Journal1997;315:236–8.11 The University of York. Cost Effectiveness Matters: TheNHS Economic Evaluation Database. 2002:6(1).CONFLICTS OF INTERESTNone.ADDRESS FOR CORRESPONDENCESarah Critchley, Rheumatology Department, Out-patients B, The Royal Oldham Hospital, RochdaleRoad, Oldham OL1 2JH, UK. Tel: +44 (0)161 2957280; email: Sarah.Critchley@pat.nhs.ukReceived 18 July 2006Accepted 8 November 2006

Evaluation of the primary/secondary care interface in relation to a primary care rheumatology service

A comparison between primary care-led rheumatology services and secondary care provision. Rheumatology

Basics of Qualitative Research: techniques and procedures for developing grounded theory (2e). Thousand Oaks: Sage,

Cost Effectiveness Matters: The NHS Economic Evaluation Database.

Early aggressive DMARD therapy: the key to slowing disease progression in rheumatoid arthritis.

Early referral, diagnosis and treatment of rheumatoid arthritis: evidence for a changing practice. Annals of Rheumatic Disease 1999;58:

Patient-initiated hospital follow-up for rheumatoid arthritis. Rheumatology

Qualitative modes of inquiry.

Science, medicine and the future. Treatment of rheumatoid arthritis.

Standards of Care for People with Musculoskeletal Conditions. Available at: www.arma.uk.net (accessed 24November

Supporting Peoplewith LongTerm Conditions. An NHS and social care model to support local innovation and integration.

The therapeutic approach of early intervention for rheumatoid arthritis: what is the evidence? Rheumatology

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