Agenda Item 4 (ii): BSR Strategic Goals

1. Agenda Item 4 (ii): BSR Strategic Goals

2. Rheumatology Strategic goals Context QIPP Goals Rheumatology Long Term Conditions

3. BSR – Strategic Goals over the next 5 yearsinformed by members survey, focus groups and partners Key Partners • Individuals with rheumatic diseases and relevant patient support groups • Government(s), nationally and internationally • Other medical and clinical colleagues in primary care and allied health professions nationally and internationally • Professional bodies, academic community and university sector and medical research charities • Policy makers • Commissioners • The general public • The NHS

4. Context: Rheumatology Conditions Major health problem for England • High disability Levels; A previously unseen and comparatively unrecognised cohort of conditions in the U.K. 2nd ranked cause of disability. Will further increase NHS expenditure unless measures are taken • Very common conditions; Musculoskeletal conditions affects 10 million people in the UK (ARUK, 2010), with inflammatory arthritis affecting about 10% of these (around a million people) (RCP, 2011), many of whom are young and of working age • High costs for the U.K. NHS costs rising rapidly; Very expensive conditions: The cost of RA alone to the UK economy is almost £8 billion a year (DH drug costs 2011, NRAS, 2010) • Care is variable There is significant variation in the quality of care and patient experience in all aspects of management (e.g. Kings Fund report 2010, Joint Matters ARMA 2012, National Audit Office report on the management of rheumatoid arthritis, 2009) • There is a need for better commissioning and needs assessment data commissioning contract activity and measurement needs to reflect the Long Term Condition nature of rheumatology

5. Context: QIPP and Rheumatology Conditions There is potential for key QIPP initiatives; Quality improvement through addressing variation in treatment and care; Innovation through implementing best practice; and in Prevention of unnecessary disability and improvements in Productivity. For example: • Care lags behind much of Western Europe; disease activity levels are higher than in the Netherlands and Scandinavia , leading to irreversible damage and incurring significant cost to the NHS and society • Early effective treatment with cheaper drugs is needed; delays in treatment can result in a more aggressive course to the disease, e.g. i) NHS spends £0.5B on biologic agents ii) Costs are increasing by 10 -20% per year, around £100m per year, long way to go to reach levels of Western Europe and USA • Major National Variations in Care i)There is existing wide variation in treatment and outcomes. For example, only 10% of patients are put onto DMARDs within 3 months of symptom onset in spite of NICE guidelines. ii) Only 63% of patients in acute trusts provided annual review for RA patients to monitor disease progression and emergence of co-morbidities (NAO, 2009; NICE, 2009)

6. Context BSR: Successes and Challenges • Research focus developed • Some national standards and indicators • HQIP • Conference • Journal • BSR Biologics register and opportunities • Seen as lead for education, although not fully realised • A lack of Rheumatology identity with policy and decision makers • On the cusp of requiring additional development (size) and focus and direction • Declining membership not encompassing all of the consultants and trainees • Declining Income from Pharma • Perceived as inward looking and comfortable, silo working • Devolved countries need more support • Membership under pressure and looking to BSR – particularly how to deal with system reform

7. BSR Strategic GoalsUnderpinned By Raising Profile and Re-energising Membership • Goal 1: Promote best practice and excellence in rheumatology services by: - Support education of individuals with rheumatic diseases about their conditions and promote involvement of individuals in decisions about their care - Provide national audit and guidelines and supporting implementation of research in daily practice - Identify clinical excellence, disseminate learning and strengthen localisation through Regional Clinical Local Networks - Joint web site with Primary Care to promote best practice • Goal 2: Influencing policy makers and commissioners by raising awareness of rheumatology by: - Build clear identity for rheumatology with leading edge service models and patient focused pathways - Dispersed clinical leadership through Regional Chairs - Develop clinical measurements and contract mechanisms best suited for Long Term Conditions - Promote national indicators and performance monitoring for continuous quality improvement • Goal 3: A provider of high quality courses and educational resources accessible to all musculoskeletal professionals (Be the provider of choice for education in rheumatology) by: - Increase media coverage and communications and marketing of rheumatology - Accelerate e-learning needed for revalidation

8. BSR Strategic GoalsUnderpinned By Raising Profile and Re-energising Membership • Goal 4: Diversify membership to reflect multidisciplinary rheumatology by: -Develop closer working with BHPR, BSPAR, PCRS and RATs providing business support services - Strengthen European, Asia and Far East links through International Strategy working group - Strengthen policy input into devolved countries • Goal 5: Diversify income streams to reduce reliance on any one source by: - Developing a financial management strategy with a broader portfolio - Review external opportunities through education, training and similar initiatives - Attract new funding (eg grants from external bodies like Health Foundation) • Goal 6: Promote interactive communication with members and the public optimising the use of technology by: - More interactive web site, use smart technology, regular updates to members - Increase press coverage, further develop regions to enable local input

9. A multidisciplinary branch of medicine that deals with the investigation, diagnosis and management of patients with arthritis and other musculoskeletal conditions. This incorporates over 200 disorders affecting joints, bones, muscles and soft tissues, including inflammatory arthritis and other systemic autoimmune disorders, vasculitis, soft tissue conditions, spinal pain and metabolic bone disease. A significant number of musculoskeletal conditions also affect other organ systems. Rheumatology is in the midst of a period of exponential growth in knowledge of the mechanisms of rheumatological and auto-immune disease, knowledge which is transforming and advancing our treatment options. There is untapped potential for Quality improvement through addressing variation in treatment and care; Innovation through implementing best practice; Prevention of unnecessary disability and improvements in Productivity. Defining Rheumatology for Policy Makers and Commissioners

10. Rheumatologic Long Term Conditionswithin musculoskeletal services The framework is a vehicle to inform policy makers and commissioners and to frame research and consists of 5 domains underpinned by pathways: • Collaborative pathways span the whole patient pathway, involve all clinicians, and are also referred to in health policy as an integrated care pathway. • The pathway methodology enables the differing contributions of various clinicians along a patient pathway to be reflected along a continuum of care.

11. Rheumatologic Long Term Conditions Framework Domains and Pathways Domain Inflammatory Conditions Connective Tissue Conditions Rare Conditions Diagnostics and Pain management Rheumatology Bone conditions Rheumatoid Arthritis and juvenile idiopathic arthritis Systemic lupus erythematosus /Antiphospholipid Syndrome Osteoarthritis Osteoporosis Hereditary recurrent fevers SeronegativeSpondarthritis disorders Sjogrens Sarcoidosis Regional pain (back pain, limb pain, etc.) Paget's disease Pathway Gout and crystal disease Myositis Relapsing polychondritis Fibromyalgia Regional bone disorder Infection-related arthritis (reactive and septic) Scleroderma Amyloidosis Hypermobility Other metabolic bone disease Vasculitis and Behcets Rare arthropathies Other polyarthralgias Bone dysplasias Polymyalgia and temporal arteritis British Society for Rheumatology Dec 2011.

12. Rheumatologic Long Term Conditions Framework Domains and Pathways Rare Conditions Connective Tissue Diseases Inflammatory Arthritis /Disease Diagnostics and Pain management Bone Conditions Domains Hereditary recurrent fevers Systemic lupus erythematosus Rheumatoid Arthritis Osteoporosis Osteoarthritis Sarcoidosis Sjogrens Seronegative Arthritis Back Pain Paget's disease Pathways Relapsing polychondritis Myositis Reactive/Septic arthritis Regional pain (upper and lower limb pain) Regional bone disorder Scleroderma Amyloidosis Gout/Crystal Arthritis Fibromyalgia Osteomalacia Rare arthropathies Vasculitis Polymyalgia Hypermobility Other metabolic bone disease Mainly secondary care Mainly primary care

13. Patient based pathways evidence based: Rheumatoid arthritis – example only 1ry and 2ry Prevention Diagnosis Treatment Case management Joint Protocol with care plan • Anti-CCP positive arthralgias • Early aggressive treatment with DMARDs • Smoking prevention • Obesity and exercise • History and examination • Blood tests, inflammatory markers, serology • Joint imaging, x-rays, ultrasound • Early use of DMARDs and monitoring • Short term steroids • Pain relief • Access to specialist physiotherapy, podiatry and OT • Monitoring of CRP and DAS28 monthly until stable • Patient education and self care • Prompt treatment of early flares • Keeping people in work and CVD risk assessment • Shared care for established DMARDs • Annual review and monitoring for co-morbidities • Protocols for when rapid access to specialist care is needed • Indicators - examples • Symptom onset to DMARD treatment within 3 months • Aim for remission or at leastDAS28 under 3.2 • Annual review by a specialist MDT including HAQ • CVD risk assessment undertaken each year Health system level patient pathway British Society for Rheumatology Dec 2011.

14. Regionalisation Next Steps

15. Ruth Richmond - Scotland England Philip Gardiner – Northern Ireland Clive Kelly 2012 Election 2012 Vacant ; Election 2012 BSR elected Council Representative/RCP&RSA Rep RCP RSA Representatives Elections to vacancies 2012 Mersey Mano George Peter Lanyon 2012 Jonathan Packham Richard Watts 2012 J Camilleri - Wales 3 Regions Joel B David 2012 Gerald George Nick Viner

16. RegionsBSR members have asked for more activity at regional local level and BSR support to local groups to enable discussion with commissioners. Part of the BSR support requested is through service models and pathways. Full Regionalisation in 2012 • Elections to the remaining BSR Regions will be made by May 2012 at which point all 16 regions will have a Regional representative. • BSR central office can offer administration support and travel expenses for speakers Communication • BSR can send personalised e-mails to all members in a region from a named individual on the Regional Group • BSR central office can set up e-groups for each region to facilitate communication • Each region is encouraged to set up its own page on the BSR web site which might include details of Regional chairs, local events

17. Question: Should the Regional Representatives also have RSA responsibility ? It has been agreed that Regional Representatives are developed into Regional Chair roles; what should this cover?

18. Regional GroupsRoles and Responsibilities Regional Groups • Act as local professional focus for BSR members • Provide a forum for identifying and sharing best practise • Provide a forum for two way communication between BSR central office and members • Enhance membership engagement • Clinical Focus CPD • Two meetings a year, actual or virtual Regional Chair • Preside over all group meetings at which he or she is present and is a member of the BSR Council • The Chair is the main contact with BSR central office • The Chair is responsible collating a programme of activities for the year and reports to the BSR council • The Chair is responsible for ensuring that communications are circulated to all group members

19. Regional Local Clinical Networks;National Context • Implementation in England prescribed by the NHS Commissioning Board of an overarching Strategic Clinical Network supported by around 14 Local Clinical Networks to be announced in March 2012 likely to include cardiac and cancer • These are seen as ‘engines ‘ for change and pathway co-ordination across complex systems or pathways of care’ and improving quality outcomes • They will bring together primary , secondary clinicians together with patients to define evidence based best practice pathways. The Chair will be a Lead Clinician. • They will advise the commissioners who will be: 1) NHS Commissioning Board and 4 devolved regions ; specialist commissioning and primary care (GP GMS contract) commissioning 2) CCG level ; all other commissioning

20. Question: The new NHS Commissioning Board (NCB) through Medical Director Bruce Keogh is introducing Strategic Clinical Networks, these are mandated by the NCB but there is also opportunity to set up informal clinical networks. What would BSR Regional Local Clinical Networks look like?

21. BSR Regions Local Clinical Networks Next Steps • Outputs of regional discussions to inform a paper on general Regional roles and responsibilities • Circulate paper for comments • Agree at Executive • Ask which regions would be interested in being a pilot for a Local Clinical Network