Backhouse, MR

Ndosi, ME

Oliver, S

White Rose Research Online

eLetter on: Global Health Inequities in Rheumatology

This is a repository copy of eLetter on: Global Health Inequities in Rheumatology.White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/100827/Version: Accepted VersionArticle:Backhouse, MR, Ndosi, ME orcid.org/0000-0002-7764-3173 and Oliver, S (2016) eLetter on: Global Health Inequities in Rheumatology. Rheumatology. ISSN 1462-0324 eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version - refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher’s website. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. eLetter on: Global Health Inequities in Rheumatology Michael R Backhouse, Mwidimi E Ndosi and Sue Oliver Leeds Institute of Rheumatic and Musculoskeletal Medicine  Sir,  We read with interest the recent editorial by Kumar [1] highlighting the large unmet needs of people with rheumatic and musculoskeletal diseases (RMDs) across the developing world and commend him for raising an important, but often over looked issue. Few would argue with the importance of rapidly increasing care for RMDs in developing countries where the burden risks further hampering economic development. Whilst we agree with much of the author's plan to improve the treatment of RMDs, we do however note a key omission: developing the non-medical healthcare workforce. Kumar highlights the examples of sub-Saharan Africa where there are <20 rheumatologists serving a population >800 million, and India where ~100 rheumatologists serve 1.1 billion people. This is inadequate by any measure. With the burden of preventable communicable diseases o high in such countries [2], it is challenging to move RMDs up the public health agenda. Although some of the care gap can be closed by increasing health spending, it is unlikely that sufficient health resources will be found to enable universal healthcare through traditional service models, o scarce healthcare resources must be used in new ways. Indeed the challenge of finite resources, greater patient need, and rising treatment costs is ne that faces health systems across the world, not just in developing countries. Yet, this i  a challenge that we must all meet if  we are to reduce the personal and economic burden RMDs place on individuals, their families, and wider society. Although, on a much-reduced scale, some countries such as theUK have also been challenged by a health system, which has struggled to meet the changing demands of the population. The growing shortage of doctors in the 1990s meant that the roles of nurses and allied health professionals (AHPs) had to expand to fill the gap through new extended scope roles, conducting tasks that were traditionally the preserve of doctors. This change did not occur overnight, and much work was required to change legislative frameworks to allow such roles to develop safely and effectively. Nurses were the first to pioneer advanced roles. Now highly trained nurse specialists have a range of skills such as joint injections and prescription rights [3]. As care for people with RMDs evolves sodo these roles and there is now evidence from high quality multicentre randomised controlled trials which demonstrates that nurse led care is cost effective, safe and patients report higher levels of satisfaction than they do in traditional medically led models of care [4]. Such has been the success of nurse specialists, that they are now an essential part of every rheumatology services n the UK and elsewhere in Europe [5, 6], where they work collaboratively with rheumatologists, within the framework of a multidisciplinary team, rather than in competition. Much has been achieved by offering early access, regular disease assessment and patient education using a strong team approach, with nurses and AHPs advancing their skills to enhance the care provided by the medical team. Crucially, this allowed for a larger volume of patients to be seen and managed safely. This team approach has served to optimise the role of the rheumatologist, and enable the services to deliver more cost effective care. For example, some clinics now use specialist nurses to undertake routine patient monitoring, freeing the rheumatologist's time to deal with new and more complex cases. We suggest such an approach represents animportant part of the solution i developing countries where non-physician providers such asmedical assistants and assistant medical officers have been used to great effect for many years [7]. eLetter on: Global Health Inequities in Rheumatology Advanced nursing practice is established in the UK but in different stages of development internationally [6]. In other parts of the world such as in Asia, nurses are now starting this journey and have recently endorsed rheumatology nurses as a pecialist area of practice with appropriate training [8]. Training nurse and AHP workforces to meet this clinical need requires changes in legislation, investment, and a cultural change from all within healthcare. Developing services in such a way does not happen overnight and needs to be managed in a stepwise approach and although individuals are key to the process, it cannot be achieved alone. In conclusion whilst we agree with much that Kumar proposes, failing to utilise the non-medical workforce would be an important omission. Each country must develop it's own solution to meet the specific challenges it faces with differing resources at it's disposal, but the principle of up-skilling nurses and AHPs to enable more patients o access appropriate treatment appears transferable and safe. Disclosure statement: The authors have declared no conflicts of interest 1 Kumar B. Global health inequities in rheumatology: addressing anurgent and largely unmet need of the developing world. Rheumatology 2016. Published online March 24, 2016 doi:10.1093/rheumatology/kew064. 2 Naghavi M, Wang HD, Lozano R, et al. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-71. 3 Oliver S, Leary A. Return on investment: workload, complexity and value of the CNS. Br J Nurs 2012;21:32, 4-7. 4 Ndosi M, Lewis M, Hale C, et al. The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Ann Rheum Dis 2014;73:1975-82. 5 Sorensen J, Primdahl J, Horn HC, Horslev-Petersen K. Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial. Scand J Rheumatol 2015;44:13-21. 6 van Eijk-Hustings Y, van Tubergen A, Bostr?m C, et al. EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis 2012;71:13-19. 7 Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? A systematic review. PLoS ONE 2013;8(2):e54978. 8 Wong FK, Chung LC. Establishing a definition for a nurse-led clinic: structure, process, and outcome. J Adv Nurs 2006;53(3):358-69.  Suggested citation:  Backhouse MR, Ndosi ME, Oliver S. E-letter on: Global health inequities in rheumatology. Rheumatology (Oxford), 7 June 2016.  Available online: http://rheumatology.oxfordjournals.org/content/early/2016/03/24/rheumatology.kew064.extract/reply#rheumatology_el_224  

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eLetter on: Global Health Inequities in Rheumatology

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