Workforce and job planning
The number of rheumatologists recorded in the 2018–19 census of consultants and higher specialty trainees in the UK is:
Proportion working less than full time (LTFT)
Higher specialty trainee (HST)
*HST LTFT percentages are calculated from JRCPTB data to give overall figures which may differ from those in the census
These figures relate to physicians who work substantively for the NHS.
It is possible to provide an estimate for the number of consultant programmed activities (PAs) required to provide a secondary care service for a population of 500,000, based on epidemiological, needs-based assessments of the number of incident and prevalent cases of musculoskeletal conditions likely to present to primary care, and the estimated proportion of these cases that would benefit from assessment, treatment and follow-up in secondary care. Using these estimates we calculate that approximately one WTE consultant is required per 86,000 population (5.8 WTE per 500,000).
The data assume that a consultant provides 4.5 clinics a week for 42 weeks per year, giving a total of 189 clinics per year. These data will obviously change depending on regional variations in patient demographics and models of care. Non-inflammatory conditions such as back pain, osteoarthritis, osteoporosis and regional musculoskeletal conditions have greater unit variations and depend on local commissioning, availability of other services and specialist interests. Local commissioning must take into consideration incident cases of inflammatory arthritis and provision for follow-up in accordance with NICE guidance. Units providing a large component of complex tertiary care are likely to need a higher level of staffing, depending on the population served.
The job plan below is included as guidance and not intended to be prescriptive. Activities will vary according to population served, demographics and location. For further information, see the BMA/NHS Employers guidance from 2011.
Rheumatology is mainly an outpatient-based specialty. The number of clinics provided per consultant will vary, depending on casemix, involvement in acute medicine, provision of community clinics, academic interests and other duties including teaching and management. The expected workload is based on recommendations of best practice from the British Society for Rheumatology. A full-time consultant rheumatologist would be expected to undertake 4–5 clinics a week and those who perform general internal medicine (GIM) 3–4 clinics a week. These would include routine clinics, specialist clinics (eg lupus clinics and fracture prevention clinics) and combined clinics (eg with orthopaedic surgeons). Some consultants now undertake musculoskeletal ultrasound and report bone density scans and sufficient time needs factoring into job plans for these activities.
The recommended workload is as follows:
- New patients: 6–7 new patients per clinic depending on casemix, with one slot for urgent cases (30 minutes per patient)
- Review clinics: 10–15 patients per clinic (15 minutes per patient)
- Mixed clinics: one new patient takes the time of two review patients, but this depends on the casemix
- Specialised clinics for patients with complex disorders eg early rheumatoid arthritis, systemic lupus erythematosus, vasculitis and paediatric rheumatology; numbers of patients seen in clinics need to be reduced from the recommendations above.
The number of patients seen in consultant clinics needs to be reduced from the recommendations above if the consultant is supporting and training junior staff (by about 20%) or supervising nurse-led clinics.
The number of patients seen in consultant clinics needs to be reduced from the recommendations above if the consultant is undertaking undergraduate and postgraduate teaching (by about 25%).
Clinic workload planning also needs to factor in time for administrative tasks such as dictating letters and reviewing blood tests and other investigations. This is likely to require at least 30 minutes of a 4-hour clinic.
As patient evaluation becomes more complex (eg completion of disease activity scores and initial and annual review data collection according to NICE guidance) these times are likely to be insufficient. In Sweden, for example, it is routine to allocate 1 hour for a new inflammatory arthritis patient appointment and 30 minutes for a follow-up patient. Similarly for patients with complex connective tissue diseases/vasculitis a longer appointment time is more typical.
Casemix and ratio of new patients to follow-up patients
Commissioners in the NHS in England have often tried to impose reductions in follow-up workload (usually expressed in terms of ratios of new patients to follow-ups) in the belief that more follow-up work and chronic disease management can be undertaken in primary care. Most rheumatologists would consider that people with non-inflammatory disorders can and should be discharged once a diagnosis and management plan are in place. However, some of the most crucial components of rheumatological care of chronic and systemic rheumatological disease are delivered via outpatient review, which often needs to be intensive and frequent, especially in early disease. This is recognised in NICE guidelines on rheumatoid arthritis which recommend more frequent follow-up for patients with active disease, as well as rapid access and annual review, and are incorporated in the Best Practice Tariff for early inflammatory arthritis.
It is therefore important that rheumatology units are actively involved in discussions with commissioners in developing appropriate care pathways and community services.
The number of patients managed in day-case units is increasing. Depending on casemix, procedures undertaken (such as ultrasound), rheumatologists will need 0.5–1 PAs per week for this type of activity.
As noted above, improved management has resulted in a significant reduction in rheumatology inpatient admissions. Only a minority of units (usually those providing specialised services) have dedicated inpatient beds. However, patients admitted by acute medical teams, often have complex disease with life-threatening complications and require prolonged lengths of stay. Consultant rheumatologists need to work closely with the medical teams to provide ongoing care, and provide input on a regular, sometimes daily, basis. Patients admitted with acute hot joints, osteoporotic fractures, pyrexia of unknown origin (PUOs) and undiagnosed multisystem disease will also require rheumatological assessment. At least one PA per week needs to be allocated to supporting inpatient work.
Non-contact clinical work
A significant amount of rheumatology clinical work does not involve direct patient contact but consists of activities such as liaising and discussing cases with the MDT and processing results of investigations and communicating results and management plans to patients and other clinicians. Most rheumatologists also provide formal or informal discussion of patients with GPs and other clinicians by telephone or email (sometimes formalised into ‘virtual clinics’). Sometimes this will be about patients known to the rheumatology service, but sometimes advice and guidance will be requested about patients previously unknown to the rheumatology service, which may replace the need for a face to face appointment. This requires careful governance and may take some time to process. Rheumatologists are also increasingly involved in triage of musculoskeletal referrals. This kind of activity has often been considered as ‘administration’ and regarded as less important than clinical work involving patient contact (particularly if this work does not attract any Payment by Results tariff). However, it should be regarded as core clinical work, and needs to be recognised as such by both commissioners and provider organisations. It may significantly reduce the need for patients to attend hospital, which is not only largely more acceptable to patients, but also to commissioners. Depending on work patterns, 0.5–1.5 PAs may be required for this type of activity. Arrangements for shared care for disease modifying drugs vary widely from locality to locality, with a recent trend for more prescribing and monitoring to be undertaken in the rheumatology service. This also needs to be recognised in job planning.