Agenda Item 4 (ii): BSR Strategic Goals Status(pink): This paper is for Discussion and Approval Explanation: The rapidly changing economic environment.

Agenda Item 4 (ii): BSR Strategic GoalsStatus(pink): This paper is for Discussion and Approval

Explanation:

The rapidly changing economic environment and NHS structures has resulted in the need to review the BSR Strategy every year to reflect change. These goals support this strategy

Finance, implications and Risk:

There is a risk that the Society could become less relevant to members if unable to support them and deliver the tools necessary for them to manage in this environment

Recommendation:

The Trustees are asked to discuss and approve the strategy

Prepared by and Queries to:

Laura Guest: [email protected]

RheumatologyStrategic goals

ContextQIPPGoals

Rheumatology Long Term Conditions

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

BSR – Strategic Goals over the next 5 years

informed by members survey, focus groups and partners

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

Context: 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)

Context: QIPP and Rheumatology Conditions

• 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

Context BSR: Successes and Challenges

• 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

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

BSR Strategic GoalsUnderpinned By Raising Profile and Re-energising Membership

Defining Rheumatology for Policy Makers and Commissioners

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.

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.

Inflammatory Conditions Inflammatory Conditions

Rheumatoid Arthritis and juvenile idiopathic arthritis

Rheumatoid Arthritis and juvenile idiopathic arthritis

Systemic lupus erythematosus /Antiphospholipid Syndrome

Systemic lupus erythematosus /Antiphospholipid Syndrome

Gout and crystal diseaseGout and crystal disease MyositisMyositis

Seronegative Spondarthritis disorders

Seronegative Spondarthritis disorders

SjogrensSjogrens

Infection-related arthritis (reactive and septic)

Infection-related arthritis (reactive and septic)

SclerodermaScleroderma

Connective Tissue Conditions Rare Conditions Rare Conditions

Diagnostics and Pain managementDiagnostics and Pain management

Hereditary recurrent feversHereditary recurrent fevers

Osteoarthritis Osteoarthritis

SarcoidosisSarcoidosis

Relapsing polychondritisRelapsing polychondritis

Regional pain (back pain, limb pain, etc.)

Regional pain (back pain, limb pain, etc.)

FibromyalgiaFibromyalgia

AmyloidosisAmyloidosis Other metabolic bone diseaseOther metabolic bone disease

HypermobilityHypermobility

Rheumatologic Long Term Conditions Framework

Domains and Pathways

DomainDomain

PathwayPathway

Rheumatology Bone conditionsRheumatology Bone conditions

Osteoporosis Osteoporosis

Paget's disease Paget's disease

Regional bone disorderRegional bone disorder

Vasculitis and Behcets Vasculitis and Behcets Rare arthropathiesRare arthropathies Other

polyarthralgiasOther polyarthralgias Bone dysplasiasBone dysplasias

British Society for Rheumatology Dec 2011.

Polymyalgia and temporal arteritis

Systemic lupus erythematosus Systemic lupus erythematosus

MyositisMyositis

SjogrensSjogrens

SclerodermaScleroderma

Connective Tissue Diseases

Diagnostics and Pain managementDiagnostics and

Pain management

OsteoarthritisOsteoarthritis

Back PainBack Pain

Regional pain (upper and lower

limb pain)

Regional pain (upper and lower

limb pain)

OsteomalaciaOsteomalaciaFibromyalgiaFibromyalgia

Rheumatologic Long Term Conditions Framework Domains and Pathways

DomainsDomains

PathwaysPathways

Bone ConditionsBone Conditions

OsteoporosisOsteoporosis

Paget's diseasePaget's disease

Regional bone disorder

Regional bone disorder

Vasculitis Vasculitis Polymyalgia Polymyalgia Other metabolic bone disease

Other metabolic bone disease

Inflammatory Arthritis /Disease

Inflammatory Arthritis /Disease

Rheumatoid Arthritis

Rheumatoid Arthritis

Gout/Crystal Arthritis

Gout/Crystal Arthritis

Seronegative Arthritis

Seronegative Arthritis

Reactive/Septic arthritis

Reactive/Septic arthritis

Rare Conditions Rare Conditions

Hereditary recurrent fevers

Hereditary recurrent fevers

SarcoidosisSarcoidosis

Relapsing polychondritis

Relapsing polychondritis

AmyloidosisAmyloidosis

Rare arthropathiesRare arthropathies HypermobilityHypermobility

Mainly secondary care

Mainly secondary care

Mainly primary care

Mainly primary care

Patient based pathways evidence based: Rheumatoid arthritis – example only

1ry and 2ry Prevention 1ry and 2ry Prevention

•

• Anti-CCP positive arthralgias

•Early aggressive treatment with DMARDs

•Smoking prevention

•Obesity and exercise

•

• Anti-CCP positive arthralgias

•Early aggressive treatment with DMARDs

•Smoking prevention

•Obesity and exercise

Diagnosis Diagnosis Treatment Treatment Case management Case management

Joint Protocol with care plan

Joint Protocol with care plan

• History and examination

• Blood tests, inflammatory markers, serology

•Joint imaging, x-rays, ultrasound

• 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

•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

• 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

• Shared care for established DMARDs

• Annual review and monitoring for co-morbidities

• Protocols for when rapid access to specialist care is needed

Health system level patient pathway

Indicators - examples• Symptom onset to DMARD treatment within 3 months• Aim for remission or at least DAS28 under 3.2• Annual review by a specialist MDT including HAQ• CVD risk assessment undertaken each year

British Society for Rheumatology Dec 2011.

Regionalisation Next Steps

England

J Camilleri - Wales

Ruth Richmond - Scotland

Philip Gardiner – Northern Ireland

Gerald George

Jonathan Packham

Nick Viner

MerseyMano George

BSR elected Council Representative/RCP&RSA Rep RCP RSA Representatives

Elections to vacancies 2012

Peter Lanyon 2012

Joel B David 2012

Richard Watts 2012

Vacant ; Election 2012

Clive Kelly 2012

Election 2012

3 Regions

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

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.

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?

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 virtualRegional 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

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

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?

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