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National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis2nd Annual Report 2016(Data collection: 1 February 2015 – 29 January 2016)

Contents

1. Acknowledgements 2

2. Foreword 3

3. Future of the audit 4

4. Executive Summary 5

Data collection and methodology 5

Key findings from the 2nd year 6

Recommendations 6

5. Introduction 8

6. Methodology 9

Scope and data collection 9

Audit standards 11

Definition of outliers 12

Data quality 12

Local engagement 14

Project governance 15

7. Analyses and interpretation 16

Recruitment and participation 16

Staffing levels and access to service provision models 18

Demographics 21

National performance against key standards and indicators 23

NICE Quality Standards, RAID, DAS, work 23

Recommendations 43

Local performance against key standards and indicators 45

NICE Quality Standards, RAID, DAS, work, staffing levels 45

8. Outlier providers – NICE Quality Standard 2 138

9. Use of data in research 139

10. Appendices 142

Appendix 1 – Report on data quality 142

Appendix 2 – Participating providers in England and Wales 158

Providers whose case ascertainment was not sufficient to provide robust benchmarking at trust level 162

Providers not participating in the audit 162

Appendix 3 – Committee structure and membership 163

Appendix 4 – List of tables and figures 163

Appendix 5 - Glossary 167

National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis 2nd Annual Report 2016

Prepared by the editorial team

Dr Jo Ledingham BSR Clinical Audit Director

Zoe Ide Patient representative, Project Working Group

Dr Neil Snowden Chair of Project Working Group

Karen Jameson MRC Statistician

Dr James Galloway Consultant Rheumatologist, King’s College London

Dr Peter Lanyon BSR President

Ali Rivett BSR Director of Clinical Affairs

Dr Elizabeth MacPhie Consultant Rheumatologist, Minerva Health Centre

Prof. Elaine Dennison MRC Professor of Musculoskeletal Epidemiology

Prof. Alex MacGregor Chair of BSR Research Committee

Dr Jill Firth BHPR President

Dr Ian Rowe Former Chair of BSR Clinical Affairs Committee

National clinical audit for rheumatoid and early inflammatory arthritis 2nd Annual Report 2016

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1. Acknowledgements

We would particularly like to thank rheumatology teams and patients across England and Wales for their time and effort in participating in the audit.

In addition to the project working group and steering committee members (listed in appendix 3), thanks is also extended to Prof. Cyrus Cooper from the MRC Lifecourse Epidemiology Unit, Prof. Simon Bowman from the BSR and to James Thomas, Ian Mulcahy and Shrirang Desai from Northgate for their involvement in this audit.

HQIP

The national audit for rheumatoid and early inflammatory arthritis is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme (NCA). HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the NCA Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.

Northgate Public Services

Northgate Public Services is a software and outsourcing business and its health division is one of the leading providers of audit, registry and screening services, including some of the largest services of its kind in the world. For this audit, it is responsible for the provision and hosting of the IT audit tool and the helpdesk, along with the overall contract management with HQIP. The IT solution is hosted within Northgate Public Services’ secure data centre and made available to clinicians in NHS Rheumatology units via a browser over the N3 network.

MRC Lifecourse Epidemiology Unit, University of Southampton

The MRC Lifecourse Epidemiology Unit, University of Southampton is a major MRC University-Unit Partnership, which houses around 90 clinical, epidemiological and statistical researchers addressing the aetiology and prevention of musculoskeletal and metabolic disorders throughout the lifecourse. The unit undertakes the statistical analysis of the annual report.

2. Foreword

On behalf of the British Society for Rheumatology, I am delighted to share with you the 2nd annual report of the national clinical audit for rheumatoid and early inflammatory arthritis (EIA) in England and Wales.

Providing multidisciplinary care for people living with inflammatory arthritis is one of the core activities of our work as rheumatology teams. This is why engaging with this audit has been so important for every trust and health board, as evidenced by the fact that 97% in England and Wales have participated.

But the importance of this audit is much wider. We all know the severe impact, both personal and financial, that inflammatory arthritis can have on people’s lives, including their ability to work, highlighted by two thirds of the audit participants being of working age. Over the last 15 years, we have seen that care can be transformed by use of biologic drugs, particularly when disease is severe or unresponsive to conventional treatment. However, new drugs have introduced significant new NHS costs. Whilst it is likely that this is offset by the gains of better disease control, we also know that rapid assessment and diagnosis allows us the best opportunity for earlier intervention and better disease control, and potentially reduces the need for escalation to biologic therapy.

The National Institute for Health and Clinical Excellence (NICE) has drawn up seven key quality standards that identify the most important goals for us to meet in delivering high quality care to our patients. This audit enables us to identify how we are performing against these quality improvement standards.

The 1st annual report highlighted variation, particularly in achievement of NICE Quality Standard 2 – whether people who have suspected EIA are seen within 3 weeks of their GP referral. Whilst this was achieved in 55% of patients in London, elsewhere this varied from 28% to 39%.

What progress and new information has been gained in this second year?

Importantly, our community has continued to show sustained and increasing commitment to the audit. Overall, recruitment increased by 5%, with over 5,000 new patients recruited. The range of data quality also improved significantly, as did our patients’ experience, with 95% reporting this as ‘good’, compared to 78% in year one. However, achievement of NICE Quality Standard 2 remained unchanged at 37%, although this is perhaps not surprising given the timescales required to make service redesigns. So what are the implications of these results?

It’s now very clear from the consistency of the data, that important variations in standards for people living with inflammatory arthritis still exist. This has implications for both primary and secondary care clinicians and commissioners. We all have a role to play in working towards reducing this unwarranted variation, at local, regional and national level.

I would urge you all to read the report in detail, and reflect on the results, and decide individually and in your respective teams, what the implications are and how you will take action.

Finally, I need to acknowledge that this first ever national audit has only succeeded because of the hard work and dedication of every rheumatology team member across all the units, the contribution of our patients, and the leadership and support of the BSR team.

On behalf of the BSR, I would like to thank everyone for this remarkable achievement, of which we should all be proud. Please share your plans and progress with us.

Dr Peter Lanyon BSR President

2 Foreword1 Acknowledgements


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3. Future of the audit

It is recognised that national audits have had a significant impact of driving quality improvement, both in terms of benchmarking services and the results of treatment but also to allow data capture that can be used to develop levers to improve both the provision of services as well as improved patient outcome. This aligns closely with NHS England’s primary aim to deliver high quality care for all, through enabling evidence-based practice.

Whilst the current audit has drawn to a close, planning for commissioning the next stage of the audit will commence shortly. This gives an opportunity for all stakeholders (providers, commissioners and the broader NHS) to address the recommendations. Many of these will only lead to improvements if there are significant structural changes to medical education and service planning across the NHS. These improvements will take time and the pause in the project will maximise the opportunity for real and meaningful change in the provision of rheumatology services. The next phase should capture the impact and scale of these changes and continue to push towards further improvements.

As we move towards this next stage, we will review the scope of the data collection and ensure that it provides data which can be used by the rheumatology community to drive service improvements. Some of the improvements that the audit has already generated are provided as case studies in this report.

As National Clinical Director, I will be working with rheumatologists, patients and NHSE supporting this process, as I believe it is vitally important that we continue to collect and use data in the field of rheumatology and MSK disease generally, given the global burden of disease and the importance of early and effective treatment in these long term conditions that have such profound effect on individuals, those around them and society in general.

Prof. Peter Kay National Clinical Director Musculoskeletal Services, NHS England

Case study 1

Following receipt of the year 1 data, we developed an action plan to improve the management of patients with rheumatoid and early inflammatory arthritis. Since January 2016, the following has been achieved:

• We have instituted urgent slots to see patients with suspected EIA within 3 weeks of the GP referring. We have also developed an EIA clinic with direct referral from GPs.

• We have implemented an EIA referral proforma and direct access pathway to guide GPs on making appropriate referrals, and importantly to ensure that these patients can be triaged to an urgent appointment.

• We have developed and implemented an educational programme for local GPs and GP trainees to educate them and highlight the indication for urgent referrals of patients with suspected IA. During the audit data collection period, a number of local GPs were referring EIA patients as routine and were not therefore identified for an early appointment.

• We have developed treatment protocols to ensure a standardised approach to early initiation of treatment, drug education and appropriate review.

• We are developing the skills of our nursing team and agreeing revised workforce plans to better balance our capacity and demand.

We believe that the changes we have made and a more robust approach to data completeness will show significant improvement and we look forward in future audit participation to demonstrate this.”

(North of England trust provider)

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4. Executive Summary

There are four key audiences for the annual report:

• Those who receive care, including patients and the public

• Those who deliver care, including clinicians and trust boards

• Those who commission care, including NHS England, Welsh Government, Clinical Commissioning Groups and Commissioning Support Units

• Those who regulate care, including CQC, Monitor and clinical audit and improvement professionals

The content has been tailored to apply to each of these groups, with the exception of patients and the public for whom a separate report has been produced. This is available on the BSR website.

Data collection and methodology

Patients aged 16 and over who presented for the first time in rheumatology departments were recruited where early inflammatory arthritis was suspected, following an assessment within the clinic. This included patients with:

• Rheumatoid arthritis

• Psoriatic arthritis

• Spondyloarthropathy with peripheral arthritis

• Undifferentiated arthritis

Data were collected at presentation to NHS rheumatology services and for the first 3 months of subsequent follow up appointments. Care received by these patients was assessed against the NICE Quality Standards for Rheumatoid Arthritis (QS33)1 and patient reported measures of experience and outcome, including data on ability to work. Data were also collected on the staffing and service models of each rheumatology service to explore the relationships between performance and organisational factors.

Data presented in this report are for patients recruited from 1 February 2015 to 30 October 2015. Recruitment was shortened to a 9-month period to ensure the analysis could be completed before the end of the contract. 97% of NHS rheumatology providers in England and Wales were registered to participate in the 2nd year of the audit and data from 5,002 patients were available. Over a 12 month period, this shows a 5% increase in patient recruitment. Overall, 11,356 patients were recruited in the two year data collection period, amounting to 38,311 records in total.

Benchmarking at provider level is only published for those identified by our methodology as having an adequate case submission rate to underpin robust comparison with others. In addition, provider level data have not been reported for any provider supplying data for 5 or fewer patients to protect patient confidentiality, according to HQIP guidance.

1 National Institute for Health and Care Excellence. Rheumatoid Arthritis: NICE Quality Standard [QS33]. https://www.nice.org.uk/guidance/qs33 [accessed August 2015] 2013 [accessed August 2015].

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Key findings from the 2nd year

• The quality and range of data have increased significantly, with 124 (88%) providers providing sufficient data to allow robust benchmarking, up from 100 (70%) in year 1. In addition, the number of patients returning follow-up data increased by 50%.

• 95% of patients agreed that they had a good experience of care, up from 78% in year 1. 1% of patients disagreed, which remains unchanged from year 1 even with the increase in sample size.

• 68% of patients received DMARDs within 6 weeks of referral (NICE Quality Standard 3), up from 53% in year 1.

• There was a strong correlation between nurse staffing levels and compliance with treatment initiation within 6 weeks (NICE Quality Standard 3) and delivery of treatment targets (NICE Quality Standard 5).

• The percentage of patients who recalled being asked about work in the course of their consultation increased to 66%, up from 42% in year 1.

• As in year one, the national findings disguised considerable variation at a local level. Compliance with NICE Quality Standard 2 for example ranged from 47% in London to 22% in Wales.

Recommendations

This 2nd annual report is published only six months after the first report. Therefore, after a shortened second year, it is appropriate to restate the recommendations arising from year one of the audit, in addition to making further recommendations for clinicians and health services prompted by the second year of data collection:

Review of recommendations from year one

• For educators: reduce referral times by improving educational input to primary care about the presentation and early management of inflammatory arthritis. Enhance rheumatology and musculoskeletal training at undergraduate level.

• For the public: raise awareness of the need to seek professional help swiftly for early signs of inflammatory arthritis in order to improve outcomes.

• For providers: review capacity and processes to improve waiting times and deliver intensive treatment.

• For commissioners: commission and monitor according to best practice.

• For patients: enhance the power of service users to provide feedback on outcomes and experience.

• For the NHS: develop better systems for collecting, coding and using information for outpatient services.

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Further recommendations from year two

Commissioners, primary and secondary care and the broader rheumatological community

Analyse and understand variation in performance against key standards, facilitated by peer support between clinical services and dissemination of best practice, with a view to developing plans for service improvement.

Rheumatology services and providers

Review the adequacy of specialist nurse provision, given the strong association between staffing levels and timely delivery of intensive treatment.

Review the level of non-clinical support to the audit, in light of wide variation and clear links to the impact on engagement with and recruitment to the audit.

Consider ongoing data collection on waiting times, treatment initiation and measures of patient outcome and experience, for local use and pending the launch of the new audit.

Rheumatology providers and patients

Work together to improve systems for collecting and using data on patient outcomes and experience, as a part of routine clinical care.

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9 6 Methodology

National clinical audit for rheumatoid and early inflammatory arthritis 2nd Annual Report 2016National clinical audit for rheumatoid and early inflammatory arthritis 2nd Annual Report 2016

8 5 Introduction

5. Introduction

In 2009, the UK National Audit Office (NAO) reported the cost effectiveness of early aggressive treatment of RA, as well as acknowledging significant geographical variation in RA care across the UK.2 In the same year, the UK National Institute for Health and Care Excellence (NICE) published clinical guidance (CG79) for the treatment of Rheumatoid Arthritis (RA)3 emphasising the importance of early diagnosis and treatment of RA and subsequently published Quality Standards (QS) for the treatment of RA (QS33) in 2013.4

The national audit for rheumatoid and early inflammatory arthritis was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and launched in February 2014. The audit aimed to assess the early management of patients referred to English and Welsh rheumatology services with suspected inflammatory arthritis and to enable patients to provide feedback on the services provided to them and on the impact of their arthritis on their lives. The audit enabled rheumatology services to measure their performance against NICE Quality Standards, benchmarked to regional and national comparators for the first time.

The 1st clinician and patient report, published in January 2016, highlighted wide variation in compliance against the NICE Quality Standards. This led the report to publish a series of recommendations for those responsible for medical education, rheumatology services and providers, CCGs, service users, NHS England and the wider research community within the specialty. We are aware of a large number of examples where the data have been used to address these recommendations and drive local service improvements. Some of these are given as case studies in this document.

Since the publication of the 1st report, the results have been:

1. publicised within national, international and regional rheumatology conferences, at primary care meetings and in peer-reviewed journal publications

2. presented at commissioning events organised by the BSR

3. raised in parliament by a range of MPs and Peers

4. presented at a parliamentary summit on work and musculoskeletal disease, jointly hosted by the BSR and Fit for Work Coalition

5. fed into BSR training workshops on the importance of raising work issues in the course of consultations

The 2nd report provides an analysis of data collected between 1 February 2015 and 29 January 2016. The data collection, analysis processes and the IT platform remained unchanged during this time. This shortened data collection period was implemented in order to enable the analysis to be completed before the close of the contract. It did however mean that providers did not have an opportunity to act on the findings of the 1st report, aside from a few weeks for those which had been identified as outliers. The shortened time period meant that whilst the absolute number of participants in year was numerically lower (5,002 patients against 6,354 in year 1), the recruitment rate actually increased. There was also a considerable increase in the follow up data collection, which was completed at the end of January 2016.

For this report, new analyses have been provided in a number of areas, including the relationship between nurse staffing levels and NICE Quality Standards 3 and 5, along with provider -level staffing data.

2 National Audit Office. Services for people with rheumatoid arthritis. http://www.nao.org.uk/report/services-for-peoplewith-rheumatoid-arthritis; 2009.

3 National Institute for Health and Clinical Excellence. Rheumatoid arthritis: The management of rheumatoid arthritis in adults. https://www.nice.org.uk/guidance/cg79 2009 [accessed August 2015].

4 National Institute for Health and Care Excellence. Rheumatoid Arthritis: NICE Quality Standard [QS33]. https://www.nice.org.uk/guidance/qs33 [accessed August 2015] 2013 [accessed August 2015].

6. Methodology

This section explains how data from the audit were analysed and reported back to providers and patients. Where possible, methods used remain consistent with the 2015 annual report.

All primary analyses are presented at national level with breakdown by geographical region (reflecting NHS rather BSR divisions). Individual provider level data are also presented in secondary analysis tables for providers that returned data on sufficient numbers of patients. Centres returning data on 5 or fewer patients were excluded from the provider level tables to protect patient confidentiality.

Scope and data collection

All patients aged 16 and over with suspected early inflammatory arthritis were eligible for inclusion in the audit. This included both patients referred with a suspected diagnosis of inflammatory arthritis as well as patients who were ultimately diagnosed with an inflammatory arthritis. Follow up information was requested only for those people who were diagnosed with rheumatoid arthritis, were positive for anti-cyclic citrillunated peptide (CCP) antibodies or patients with inflammatory polyarthritis affecting 5 or more joints. For the second year of recruitment, providers were invited to update their organisation data if changes had occurred in staffing levels, service provision or structure.

The questionnaires used to capture performance against the key standards are available at: http://rheumatology.org.uk/resources/audits/national_ra_audit/information_pack.aspx

Information was collected from both clinicians and patients at presentation, and for eligible patients at each follow up visit for the first 3 months of care. Data were entered at unit level directly into an electronic data capture tool.

The data extracted from the online tool were transferred to the MRC Lifecourse Epidemiology Unit at the University of Southampton for analysis.

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National clinical audit for rheumatoid and early inflammatory arthritis 2nd Annual Report 2016 National clinical audit for rheumatoid and early inflammatory arthritis 2nd Annual Report 2016

Case study 2

We have undertaken detailed analysis in the department, and felt that the quality of the GP referrals we receive was a major contributing factor. We discussed the first year’s results at our Trust’s Divisional Governance and Risk Meeting last November and our outline action plan.

We note the annual report published in January 2016 and welcome the recommendations made on the basis of the national data, which resonate with our own analysis and experiences.

We feel this issue reflects our wider local health landscape more than our own departmental processes. To this end, we have highlighted the need for detailed referral information, and the use of the previously agreed referral proforma, in order to allow prioritisation of suspected early inflammatory arthritis, to our commissioners and GPs.

Most significantly, a meeting is planned shortly with our CCG and GP leads, to discuss configuration of local services and pathways, at which we will share the results of this national audit, and subsequently plan to develop better pathways for early inflammatory arthritis as well as other musculoskeletal conditions, as we believe achieving ‘best person, place and time’ for all MSK disorders will improve outcomes and experience for all our patients, will use resources most effectively, and is critical to identifying and treating early inflammatory arthritis promptly. We have since made available at least 2 further urgent outpatient appointments per week in the department, for suspected early inflammatory arthritis, to be used at consultants' discretion if a referral for suspected EIA is identified.

We have increased capacity in our weekly early arthritis clinic and now have a dedicated musculoskeletal radiologist in the clinic, allowing access to diagnostic ultrasound where necessary. 2 of our consultants are undertaking training in MSK ultrasound which will further increase diagnostic capacity. A re-audit of NICE Quality Standard 2 is planned to establish if these measures have led to any improvement.”


Audit standards

The table below describes which metric or metrics were used to address each quality standard and whether these are presented as a proportion of patients or at provider level. In addition, details on the measurements used for the Rheumatoid Arthritis Impact of Disease (RAID), Disease Activity Score (DAS) and work are provided.

Table 6.1 metrics used to address NICE Quality Standards

NICE Quality Standard Metric used

Quality Standard 1 GP referral time

Patients referred within 3 days as assessed by time between date of first presentation to GP and date of referral receipt in rheumatology unit.

Data presented as a proportion of all patients.

Quality Standard 2 Waiting time

Patients seen in rheumatology within 3 weeks as assessed by time between date referral received and date patient first seen by clinician.

Data presented as a proportion of all patients.

Quality Standard 3 Time to DMARD

Treatment initiation (DMARD monotherapy, DMARD combination therapy and steroids) within 6 weeks of referral as assessed by clinician reported documentation at baseline or follow-up.

Data presented as a proportion of patients with rheumatoid arthritis.

Quality Standard 4 Education & self-management

Patient education and self-management service within 1 month of diagnosis as assessed by clinician reported documentation at follow-up.


Quality Standard 5 Treat to target

Setting and agreement of treatment target assessed using data from clinician baseline form. Achievement of treatment target assessed using data from clinician follow-up form.


Quality Standard 6 Urgent access

Availability of urgent access to rheumatology assessed using response on clinician baseline form. Cross referenced by organisational data of provision of a telephone advice service. Data provided at provider level.

Quality Standard 7 Annual Review

Availability of annual review assessed from data provided at provider level.

Explanatory analyses were also conducted for NICE Quality Standard 2 to help understand factors influencing adherence, including whether the referral letter raised the possibility of an inflammatory arthritis. These data were obtained from the clinician baseline form. In addition, organisational factors including whether departments had a dedicated early inflammatory arthritis clinic were analysed. Consultant provision was determined from data provided at provider level regarding number of whole time equivalent consultants and catchment population.



The RAID scores at baseline are presented for all patients and separately for patients with rheumatoid arthritis. The mean change in reduction in RAID score was calculated for patients with rheumatoid arthritis and for this same group the proportion of patients achieving a 50% reduction in RAID was assessed.

The average DAS at baseline is reported for all patients with rheumatoid arthritis, where this can be calculated. The proportion of patients with high (DAS >5.1), intermediate (DAS 3.2-5.1) and low (DAS <3.2) disease activity has been presented. The proportion of patients with a reduction in DAS of at least 1.2 has also been reported.

The main experience measure analysed from the PREM questionnaire was the response to the question “overall in the past 3 months I have had a good experience of care for my arthritis?” Due to the small numbers in each category, 'strongly disagree' was combined with 'agree' and 'strongly disagree' with 'disagree' to form four categories: 'agree', 'neither agree' or 'disagree', 'disagree' and 'not answered'.

Impact on a patient’s ability to work was assessed from information provided by patients at follow-up. Data have only been presented on patients of working age i.e. 16-65. The proportion of patients not working and of patient’s frequently, occasionally and rarely needing time off work because of their arthritis has been presented. Data have also been presented on whether patients reported that they were asked about their working ability.

Definition of outliers

Providers were identified as potential outliers based on reporting of NICE Quality Standard 2. National guidance on outlier management was adhered to and limits around expected values were derived statistically to define if a provider was a potential outlier.

The national average, having excluded data from providers where recruitment had been below the minimum expected, was used as the target against which individual providers proportions were compared.

The definition of the limits of acceptable performance was based on statistical criteria. Two-sided significance levels of 0.05 and 0.002 were used to define limits of acceptable performance for NICE Quality Standard 2. These limits were considered as the thresholds for an ‘alert’ or an ‘alarm’, respectively. Initially it was considered whether a performance indicator was statistically different from the target at a two-side significant level of 0.05. 95% of all providers were expected to perform within this range, set as 2 standard deviations from the target (alert). In considering a two-sided significance level of 0.002, 99.8% of all providers were expected to lie within this range, i.e. set as 3 standard deviations from the target (alarm).

Data quality

It is important to consider three aspects of data quality for this audit - the gap between predicted and actual recruitment, the fall-off in recruitment between baseline and follow up and missing data fields on the submitted forms. To some extent, all three reflect the complexity of this prospective outpatient audit.

An expected annual incidence rate of 15 cases per 100,000 of adult population has been calculated. Good progress has been made towards this level of recruitment nationally, especially in the second year of a complex audit, and we thank our clinical colleagues for their hard work in making this possible. However, this overall figure masks considerable heterogeneity at local level, with a significant minority of registered trusts recruiting very small numbers of patients.

Although there may be some minor local variation in incidence, we do not believe this can account for the very low levels of recruitment in some providers. Overall, significant progress has been made in the second year of the audit with engagement.

Continued data capture at follow up presents particular challenges because of the audit design. It should be noted, however, that there will always be some fall off in data collection between baseline and follow up. The clinical picture may evolve and the patient may no longer be eligible for data capture, and also patients will fail to attend follow up appointments for a variety of reasons. Arguably, the most important outputs for this audit are those setting national benchmarks for waiting times before and after referral (NICE Quality Standards 1 and 2) and these are unaffected by absent follow up data. Figure 6.2 shows the number of forms that were provided at each stage of the audit and for which patients.

Figure 6.2 number of forms provided at each stage in year 2 by patient diagnosis

5,002 patients recruited at

baseline

257 patients without baseline diagnosis and at least 1 follow up

record

2,162 RA patients with at least one follow

up record

1,244 RA patients with >1 follow up visit record

1,118 patients with non-RA diagnosis

699 patients without diagnosis

at baseline

3,185 RA patients

at baseline



Attempts were made to mitigate missing data by creating as many mandatory fields as possible in the online data tool. However, not all data fields can be made mandatory (for example, most patient-supplied data). Most of the missing data fields were in follow up forms, and as noted above, this does not affect NICE Quality Standards 1 and 2.

Despite efforts to mitigate these issues, it is inevitable with any audit requiring significant input from busy clinicians that some information will be missing at analysis. Throughout this report, the proportion of cases for whom information on any particular variable is not available is presented. No attempt has been made to impute missing values in this audit. While this can be a valuable statistical tool in some settings, it was not felt appropriate for this project. Where information is missing, this may be by chance or may be biased. For some variables, there is a considerable proportion of missing data, particularly if the information was due to be collected at follow up, and especially if it is extracted from the patient completed follow up form. This reflects the fact that patients were asked to complete and return this independently to ensure that they gave honest feedback to the unit where they were being treated.

In providers where low numbers of patients were recruited, there must be some uncertainty around the confidence limits of performance for that trust, and findings should be interpreted with caution. However, outlying providers have performed outside the usual range in the cases reported to us, and have had the opportunity to verify their data. There are many reasons for outlying recruitment and performance, but staffing levels appear to be a recurring theme and preliminary analyses would support this as a reason for many providers experiencing difficulty in recruitment and waiting times relative to other trusts. We have chosen to present data for all providers who have entered data to this audit although the reader should consider carefully the number of patients entered by each provider, as we would expect less uncertainty around a provider’s performance if their results reflect the experience of many patients, compared with (for example) fewer than ten. For this reason, we would encourage all providers to explore mechanisms for improved patient data capture in the second wave of the audit in the anticipation that this will lead to greater confidence in the results reported.

In future, the CQC intends to maximise the use and accessibility of national clinical audit data to help facilitate the CQC regulatory process and to support quality improvement measures at provider level. As part of this, key metrics from national audits will be incorporated into CQC inspections, including a consideration on the quality of data that has been provided. The BSR has provided a report to the CQC on data quality from participating providers, which can be found at appendix 1.

Local engagement

The 1st annual report was published on 22 January 2016 and launched at the King’s Fund in London. The event was attended by a range of representatives from trusts, health boards, patient groups, Department of Health, NHS England, HQIP and other charities. On the same day, the clinician and patient reports were sent to all participating trusts and health boards, along with CCG quality leads. The reports and the accompanying press release were noted in a number of publications, including the BMJ and Huffington Post. Data from the report were presented at the BSR annual conference, local meetings and BSR commissioning networks.

Throughout the data collection period, the BSR has provided participants with regular updates through quarterly newsletters and notifications relating to data collection deadlines. In addition, the wider rheumatology community has been kept informed through newsletters distributed by the BSR to members and other organisations. Presentations were also made regularly at national and local meetings to discuss progress with the project and plans for the future.

An extensive engagement exercise was undertaken with providers which had been identified as outliers in year 1. The 1st report identified 29 providers whose data showed a much lower than expected proportion of patients seen within the NICE-recommended 3 weeks of referral. The clinical leads of these providers were written to by the BSR in June 2015 to ask them to review their data and provide potential reasons for the results, in line with the DH policy on the management of outliers.

The review of data revealed a small number of inaccuracies which were amended and the analysis re-run, in order to confirm the status of these providers and whether they would be named in the report as outliers. In September, the BSR sent letters to the respective CEOs and Medical Directors of these providers, copied to the clinical leads, to notify them of their performance to date and to seek assurance that plans would be put in place to address the issues that had been highlighted. Many replied with detailed plans to improve their service and some of these are included as case studies in this report.

In addition, 43 providers did not provide sufficient data to allow for robust benchmarking of their service. A similar process was followed as for outliers, although data for these providers were not published in the report. Each provider was however provided with their data, following the publication of the report.

This process was followed in relation to the year 2 data and the results are presented in this report.

Project governance

Three working groups were involved in this project:

• Editorial Group

• Project Working Group

• Steering Group

These groups consisted of a range of clinicians, nurses and allied health professionals, academics and patient representatives. Patient representatives were involved in each group and contributed to the draft and approval of this report. The membership is outlined in appendix 3.

16 17 7 Analyses and interpretation7 Analyses and interpretation


7. Analyses and interpretation

Recruitment and participation

In year 2, 146 providers were eligible to participate in the audit. Of these, 5 did not register to participate and 12 returned no patient level data. The remaining 129 providers recruited patients to the audit (table 7.1). This represents a drop in the number of providers that were able to recruit patients in comparison to year 1. The providers that were unable to recruit, along with those whose case ascertainment was not sufficient to publish provider-level data are listed in appendix 2. Providers were approached to provide support with the audit and to understand reasons for not returning data, with the overwhelming majority citing lack of resources.

Table 7.1 participation by NHS region and Wales

Region Number of eligible and registered providers

N (%) of eligible and registered providers submitting data

National 141 129 (91%)

London 19 17 (89%)

Midlands & East of England 39 35 (90%)

North of England 42 41 (98%)

South of England 35 30 (86%)

Wales 6 6 (100%)

Table 7.2 Anticipated recruitment by NHS regions and Wales

Region Adult population (≥16 yrs) Expected cases

National 46,550,257 5,237

London 6,806,412 766

Midlands & East of England 13,256,698 1,491

North of England 12,292,531 1,383

South of England 11,657,421 1,311

Wales 2,537,195 285

Baseline data for the year two report were collected from 1 February 2015 until the end of October 2015 (i.e. for 9 rather than 12 months) to allow time for complete data analysis before the close of the contract. Therefore, although the absolute number of participants in year 2 was numerically lower (5,002 versus 6,354), the recruitment rate actually increased. Follow up data capture was completed at the end of January 2016. It is important to note that year two baseline data collection was completed several months before the report on the first year’s data had the required approvals for publication. As such there was no potential for actions to be implemented in response to year one data to have impact on the year two data, aside from a very short window of opportunity for outlying trusts. The data collection and analysis processes and the IT platform remained unchanged during the second year of data collection.

Recruitment date (February 2014 – October 2015)

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Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Based upon the audit data, it is possible to estimate the incidence of suspected inflammatory arthritis and of rheumatoid arthritis within England and Wales. It should be noted that the RA incidence reflects the case definition described in the methods section (as opposed to a stricter ACR/EULAR definitions). In addition, acknowledging that the audit will not have captured all cases, the rate is likely to be an underestimate of the true incidence. The variation in rate across regions is likely to reflect uptake of the audit, as well as regional variation in disease incidence and local referral pathways.

Nationally, the estimated annual incidence of early inflammatory arthritis was 15/100,000, and when limited to those with a confirmed diagnosis of rheumatoid, 9/100,000 (Table 7.4).

Recruitment continued to rise throughout the audit time period as shown in figure 7.3. In year 2, recruitment ranged from 455 patients per month (April 2015) to 675 patients per month (June 2015). Throughout the course of the audit, the highest number of patients was recruited in July 2014, with 728 patients. In the weeks preceding this, there was an extensive exercise undertaken by BSR to work with providers to help them recruit and overcome any barriers they were facing. It is notable that engagement with the audit remained strong throughout the data collection period with no evidence of end-of-audit fatigue, which is relevant for consideration of future audits.

Figure 7.3 cumulative number of patients recruited over the 2-year data collection period

Num

ber

of p

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Table 7.4 – recruitment and annualised adult incidence by NHS regions and Wales

Region Adult population (≥16 yrs)

Number of patients recruited over 9 months (all cases)

Annual incidence / 100,000 persons all cases (95% CI)

Number of RA patients recruited over 9 months

Annual incidence / 100,000 RA only (95% CI)

National 46,550,257 5,002 14.33 (13.99, 14.68)

3,185 9.12 (8.85, 9.4)

London 6,806,412 587 11.5 (10.71, 12.34)

320 6.27 (5.69, 6.9)

Midlands & East of England

13,256,698 1,391 13.99 (13.36, 14.64)

958 9.64 (9.12, 10.18)

North of England 12,292,531 1,576 17.09 (16.37, 17.84)

992 10.76 (10.19, 11.36)

South of England 11,657,421 1,105 12.64 (12.0, 13.3)

682 7.8 (7.3, 8.32)

Wales 2,537,195 343 18.03 (16.4, 19.74)

233 12.24 (10.93, 13.7)

Although overall recruitment rates to the audit are comparable to year 1, the proportion of RA cases captured has increased (estimated incidence 9 compared to 6 per 100,000 in year 1). This is likely to represent a more concerted focus on the quality standards relevant to the audit, in relation to the assessment of early rheumatoid arthritis, and more selective recruitment of patients. It was apparent in the early stages of year 1, for example, that some providers were overly inclusive in their recruitment and clarification of eligibility criteria helped to address this.

Staffing levels and access to service provision models

The following tables describe the staffing levels and service provision within the 129 rheumatology providers that recruited patients in year 2. The reported number of whole time equivalent consultant rheumatologists in England and Wales was 498, which is a lower figure than reported in the first year of the audit. Similarly, the reported numbers of specialist nurses were lower. The revised figures reflect the correction of supplied information, rather than an actual change in staffing levels. This underlines the fact that the provision of consultant rheumatologists falls significantly below that recommended by the Royal College of Physicians5 of 1 per 86,000 (or 1.09 per 100,000).

5 Royal College of Physicians. Consultant physicians working with patients. 2013;5th Edition:243.

There are no national recommendations for the number of specialist nurses per head of population and it is apparent that there is substantial variation across regions and Wales, although this is the focus of current research activity. Nationally, there is one specialist nurse for every 1.3 WTE consultant, with the range being from 1.2 consultants for the North of England and 1.8 consultants for London.

Table 7.5 numbers of consultants and specialist nurses per 100,000 by NHS region and Wales

Region Catchment population

Total number of consultants

Consultants per 100, 000 population

Total number of specialist nurses

Nurses per 100, 000 population

National 57,931,083 498 0.86 381 0.66

London 8,859,689 75 0.84 41 0.47


15,226,195 138 0.90 107 0.70

North of England 17,100,757 152 0.89 131 0.77

South of England 14,034,442 102 0.72 76 0.54

Wales 2,710,000 32 1.18 26 0.95

Tables 7.6 and 7.7 present access to the wider rheumatology multi-disciplinary team and provide information on the availability of telephone advice lines, educational services, early arthritis clinics and same day ultrasound provision. Access to MDT services was far from universal and there was wide variation across regions. In particular, access to specialist podiatry services was restricted to approximately half of providers. Collectively, these figures remain largely unchanged from year 1.

Case study 3

The reason for being an outlier [in year 1] is the fact that the rheumatology department was seriously understaffed, with 1.7 consultants instead of the recommended 3 WTE consultants for the population of 300 000. The first BSR letter triggered an internal review in the trust, and this issue (which was previously flagged up by ourselves but never acted on) was taken seriously.

We are happy to say that we managed to recruit an additional rheumatology nurse, and have an agreed business case to recruit 1.2 WTE equivalent rheumatologists. However, these positive measures will not have resulted in any performance improvement yet. We hope that the situation will improve dramatically once the 2 new consultants have joined us.”




Table 7.6 proportion of providers within each NHS region and Wales that reported access to other allied health professionals

Region N (%) of providers with access to physiotherapy

N (%) of providers with access to occupational therapy

N (%) of providers with access to podiatry

National 92 (72%) 96 (76%) 65 (51%)

London 8 (47%) 7 (41%) 7 (41%)


27 (79%) 27 (79%) 13 (38%)

North of England 35 (85%) 37 (90%) 27 (66%)

South of England 17 (59%) 20 (69%) 13 (45%)

Wales 5 (83%) 5 (83%) 5 (83%)

Table 7.7 number and proportion of providers reporting availability of service provision models by NHS region and Wales

Region N (%) of providers with a telephone advice line

N (%) of providers with access to patient education and self-management services

N (%) of providers with EIA clinic

N (%) of providers with access to same day ultrasound

National 123 (97%) 55 (43%) 72 (57%) 35 (28%)

London 16 (94%) 6 (35%) 11 (65%) 5 (29%)


33 (97%) 16 (47%) 20 (59%) 7 (21%)

North of England 41 (100%) 20 (49%) 21 (51%) 10 (24%)

South of England 27 (93%) 10 (35%) 18 (62%) 11 (38%)

Wales 6 (100%) 3 (50%) 2 (33%) 2 (33%)

Interestingly, the two regions with the lowest proportion of access to a telephone advice line (London and the South of England) also provided the lowest proportion of access to patient education and self-management services, which may be linked to the low nurse staffing levels recorded. Nationally, 57% of providers reported running early arthritis clinics, which demonstrates a slight increase on the year 1 data, although the proportion was only 33% in Wales. At a national level, same day ultrasound was only available in 28% of providers and was not available in all early arthritis clinics.

Demographics

From 5,002 recruited patients, 64% were female, and 70% were of working age at presentation, which compares equitably with the demographic characteristics of the first year of the audit.

Table 7.8 number and proportion of age and gender of participants

Age group Male [n(%)] Female [n(%)] Total [n(%)]

All 1,815 (36%) 3,187 (64%) 5,002 (100%)

Working age (16 - 65) 1,161 (33%) 2,328 (67%) 3,489 (70%)

Non-working age (>65) 654 (43%) 859 (57%) 1,513 (30%)

The range of ethnicity also remained similar when compared to year 1, with a majority of the population identifying as white (77%). London reported the widest diversity of all regions whilst Wales reported the lowest.

Table 7.9 ethnicity of recruited patients by NHS region and Wales

Ethnicity National [n(%)]

London [n(%)]

Midlands & East of England [n(%)]

North of England [n(%)]

South of England [n(%)]

Wales [n(%)]

All 5,002 (100%)

587 (12%)

1,391 (28%)

1,576 (32%)

1,105 (22%)

343 (7%)

White 3,847 (77%)

295 (50%)

1,110 (80%)

1,232 (78%)

902 (82%)

308 (90%)

Black 89 (2%)

54 (9%)

23 (2%)

6 (0%)

5 (1%)

1 (0%)

Asian 248 (5%)

80 (14%)

78 (6%)

56 (4%)

32 (3%)

2 (1%)

Chinese/ other

27 (1%)

17 (3%)

2 (0%)

7 (0%)

0 (0%)

1 (0%)

Mixed 55 (1%)

24 (4%)

10 (1%)

12 (1%)

6 (1%)

3 (1%)

Not provided 736 (15%)

117 (20%)

168 (12%)

263 (17%)

160 (15%)

28 (8%)



Diagnosis at presentation

Table 7.10 presents the diagnosis of patients at baseline. Out of 5,002 patients, 3,943 (79%) had a confirmed inflammatory arthritis diagnosis, of which 2,568 had RA. It is relevant to mention that during follow up some patients initially diagnosed with undifferentiated arthritis were subsequently classified with RA as well. In total 3,185 patients in the audit were ultimately diagnosed with RA.

Psoriatic arthritis was the baseline diagnosis in 524 (11%) of patients, and a seronegative spondyloarthritis in 155 (3%). The latter group were only included in the audit if peripheral joint involvement was apparent at presentation. Overall fewer patients had a recorded diagnosis of undifferentiated arthritis or ‘other’ in year 2 of the audit, consistent with improved understanding of the processes and inclusion criteria.

Table 7.10 number and proportion of patient diagnosis at baseline

Diagnosis Patients [n(%)]

Rheumatoid arthritis 2,568 (51%)

Psoriatic arthritis 524 (11%)

Seronegative spondyloarthritis 155 (3%)

Undifferentiated arthritis 696 (14%)

Other 315 (6%)

No information provided 744 (15%)

National performance against key standards and indicators

NICE Quality Standard 1

NICE Quality Standard 1 recommends that people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than one joint, are referred to a rheumatology service within 3 working days of presentation.

No clinically meaningful difference in referral time or on the percentage achieving this target was observed between year 1 and 2. Small differences were apparent and largely reflect a subtle change in reporting as in year 1, the audit reported delay in ‘days’, whilst year 2 reports ‘working days’. This explains the apparent improvement in performance with the overall standard. It is worth noting however that the percentage achievement rate when using ‘days’ was unchanged in year 2 (17%) when compared to year 1. The median time between presentation and referral nationally did reduce slightly (from 23 to 20 working days) and data quality was good with very low levels of missing data.

A striking observation is that the performance in Wales was significantly better than in other NHS regions in years 1 and 2, with 46% of patients referred within the target of 3 working days and a median referral delay of 5 days. It is also notable that the referral delay reduced in Wales from 19 working days in year 1 to just 5 working days in year 2. There was less dramatic improvement in waiting time in the Midlands and East of England region, along with London, but waiting times were unchanged in the North and South of England regions. We cannot explain the reasons for these differences from the audit data, but this may reflect the fact that some regions have been more successful that others in raising awareness in primary care of the importance of early referral.

Table 7.11 number (%) of patients referred to rheumatology within 3 working days of presentation to their GP by NHS region and Wales

Region Number of patients at baseline

N (%) referred within 3 working days of presentation to GP

Median (IQR) time between presentation to GP and referral (working days)

N (%) missing

National 5,002 1,020 (20%) 20 (5, 54) 13 (0%)

London 587 111 (19%) 15 (5, 50) 0 (0%)


1,391 190 (14%) 24 (8, 63) 3 (0%)

North of England 1,576 354 (23%) 19 (4, 51) 6 (0%)

South of England 1,105 206 (19%) 22 (6, 62) 4 (0%)

Wales 343 159 (46%) 5 (1, 25) 0 (0%)



Figure 7.12 time to referral in days by NHS region and WalesM

edia

n de

lay

in r

efer

ral (

days

)

60

40

20

National London Midlands & East of England

North of England

South of England

Wales0

NHS regions and Wales

Case study 4

Thank you for the report detailing our trust performance against NICE Quality Standard 2. We recognise this to be a vital standard of delivery and welcome the opportunity to analyse the data in detail.

We have recognised that the waiting times for an appointment in the early arthritis clinic have been longer than we would like due to capacity constraints at consultant level. We have in the last two weeks welcomed an additional 50% WTE consultant colleague and increased the number of early arthritis clinic slots across three sites as a consequence.

Following a review, we will be proposing revisions to the referral pathway to this service. The current requirement is for GPs to direct all MSK referrals through the triage system in the local intermediate provider service and the delay in this pathway breaches NICE guidelines before the referral is received in the hospital. The Choose and Book service does also not comply and so this will be discussed at the MSK Redesign Group and Reforming Elective Care meeting with the aim of initiating a direct access referral pathway for patients with suspected early inflammatory arthritis.”

(South of England trust provider)


NICE Quality Standard 2 recommends that people with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.

Nationally 37% of patients were seen within 3 weeks of referral and this statistic is essentially unchanged from year 1 of the audit. This highlights that specialist units across England and Wales were still struggling to find ways to meet this standard. Data quality was good, with very low levels of missing data.

Med

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50

60

30

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North of England

South of England

Wales0

As highlighted in the year 1 report, this standard is important because early assessment allows for early diagnosis, maximises the chances of early initiation of appropriate treatment and minimises the chance of irreversible joint damage and disability.

Table 7.13 number (%) of patients seen in a rheumatology service within 3 weeks of referral by NHS region and Wales

Region Number of patients recruited

N (%) seen within 3 weeks

Median (IQR) waiting time (days)

N (%) missing

National 5,002 1,844 (37%) 29 (16, 49) 4 (0.1%)

London 587 276 (47%) 23 (14, 42) 0 (0%)


1,391 472 (34%) 33 (17, 54) 0 (0%)

North of England 1,576 591 (38%) 29 (16, 48) 2 (0.1%)

South of England 1,105 430 (39%) 28 (16, 48) 2 (0.2%)

Wales 343 75 (22%) 34 (23, 48) 0 (0%)

As in year 1, the London region was best able to meet this standard, achieving this for 47% of patients, and Wales was least able to meet this standard, achieving this for only 22%. Both these regions achieved this standard in a lower proportion of patents than for year 1, when they had achievement rates of 55% and 28% respectively. Both these regions also had the lowest numbers of patients recruited. The regions that improved their achievement rates were the South of England, increasing from 35% to 39%, and the Midlands and East of England, increasing from 32% to 34%.

Figure 7.14 median time from referral to first specialist appointment nationally and for each NHS region and Wales, along with the interquartile ranges for NICE Quality Standard 2




Of concern is the fact that achievement rates for this crucial standard have not improved nationally, but it is important to acknowledge that the year 1 results were not available until year 2 data capture was complete. Many of the factors that could influence ability to meet this standard would need time to alter, e.g. the education of GPs on information to provide in letters to enable appropriate allocation of patients to urgent appointments, establishing new EIA clinics, alteration in systems for clinician review of referral letters and for using Choose and Book. Approval for additional consultant staff will also generally be a lengthy process, particularly with the current financial constraints of the NHS. It is noteworthy that consultant levels remain well below those recommended by the Royal College of Physicians (1.16 per 100,000 population).

Case study 5

The trust had been aware of capacity issues in rheumatology prior to the national audit; actions were underway to address this. The non-compliance with NICE Quality Standards relating to the management of early inflammatory arthritis was actually highlighted on the Trust risk register with actions agreed to resolve this via increase in capacity and information technology solutions.

It must be noted that the service has seen a significant rise in referrals which impacted on the ability to maintain the waiting time for the period identified in the audit within 3 weeks. The analysis of activity over the last 3 financial years demonstrated a notable year on year increase in new referrals with an increase of around 26.5% (from 2012/13 to 2014/15) in new consultant appointments. This is despite paper triage of all rheumatology referrals at an intermediate care level (hub). Indeed, the hub triage has experienced a 50% increase in rheumatology referrals from 2012 to 2015.

The following action points have been developed since starting data collection for the audit to improve patient access to early assessment and commencement of DMARDs:

1. Patients are fast-tracked through paper triage of letters where early inflammatory arthritis is suspected.

2. Implementation of the Best Practice Tariff (BPT) for rheumatoid arthritis on 6th May 2015.

This is an incentive to provide high quality care for early RA. As part of the BPT, patients are seen in the clinic within 3 weeks of referral, and given a prescription by the rheumatologist to ensure early treatment with DMARDs in confirmed cases. There is a structured pathway for the first year of management and uses data from the audit. This schedule has been developed to attract a higher remuneration and support funding the service. It has been estimated that when fully implemented, the service will require 10 new consultant appointments per week, 8 consultant follow-up 14 clinical nurse specialist and 5 annual review appointments per week.

3. A business case for the post of rheumatology consultant has been agreed and recruitment of a locum consultant is underway.

We are pleased to confirm that since the implementation of the BPT in May 2015, all patients with suspected inflammatory arthritis have been offered an appointment within three weeks.”

(South of England trust provider)

In year 1, the presence of an EIA clinic was associated with the ability to meet this standard. In year 2, there has been no major increase in the number of departments offering EIA clinics (57% from 54%). Exactly how these clinics impact on ability to meet this standard warrants further exploration.


NICE Quality Standard 3 recommends that people with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs (DMARDs) by a rheumatology service within 6 weeks of referral.

This standard deals with treatment pathways specific to RA (rather than other forms of polyarthritis) and hence the analysis for NICE Quality Standard 3 has been applied only to those patients with a clinician-confirmed diagnosis of RA (this diagnosis being made either at baseline or follow-up).

Performance against this standard is reported as the percentage of patients with RA commencing any DMARD within 6 weeks of receipt of referral, the percentage treated with steroids (by any route) at baseline or at any time during follow up, and the percentage treated with combination DMARDs at any point during the 3 month audit. Data quality was again generally good, with low levels of missing data.



Table 7.15 number (%) of patients starting DMARDs within 6 weeks of referral by NHS region and Wales

Region National London Midlands & East of England

North of England

South of England

Wales

Number of RA patients

3,185 320 958 992 682 233

N (%) commence DMARDs ≤6wks

2,170 (68%)

227 (71%)

572 (60%)

704 (71%)

492 (73%)

175 (75%)

N (%) missing for commence DMARDs ≤6wks

14 (0%)

2 (1%)

5 (1%)

2 (1%)

4 (1%)

1 (0%)

N (%) combination DMARDs at any time

1,400 (46%)

134 (44%)

424 (46%)

422 (45%)

296 (45%)

124 (55%)

N (%) missing for combination DMARDs at any time

135 (4%)

12 (4%)

43 (5%)

45 (5%)

29 (4%)

6 (3%)

N (%) steroids at any time

2,494 (86%)

240 (83%)

743 (86%)

800 (87%)

521 (84%)

190 (90%)

N (%) missing steroids at any time

286 (9%)

32 (10%)

97 (10%)

75 (8%)

61 (9%)

21 (9%)

Number of patients with RA at baseline

2,495 255 795 745 534 166

N (%) steroids at baseline

1,937 (78%)

188 (74%)

605 (76%)

618 (83%)

392 (73%)

134 (81%)

N (%) missing for steroids at baseline

1 (0%)

1 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

Nationally, about two thirds of patients with RA started on DMARDs within 6 weeks of referral. This is a higher figure than reported from year one of the audit where 53% started DMARDs within 6 weeks, although this increase may be attributable in part to differences in coding of DMARD usage between years 1 and 2. As noted above, performance against QS2 was virtually identical in year 2 to year 1, with 37% of patients seen within 3 weeks of referral, a median time to first appointment of just over 4 weeks, and 25% of patients waiting 7 weeks. This suggests that most rheumatology services were able to offer timely treatment once the patient had their first appointment and received a working diagnosis. It should be emphasised that starting DMARD therapy within 6 weeks may not be appropriate for every patient, for clinical reasons and because of patient choice.

The proportion of patients treated with combination DMARDs was also higher in the second year of the audit (46% against 36% in year one). The proportion of patients treated with steroids at any time (86% year 2 against 82% year 1) was only slightly higher. Again, the differences between years 1 and 2 are due in part to differences in coding and should not be over-interpreted.

There was less regional and local variation for performance against NICE Quality Standard 3 than NICE Quality Standards 1 and 2 in year 2, but the improvements in comparison with year 1 in performance were seen across all regions.

Table 7.16 shows odds ratio and confidence intervals for the relationship between nurse numbers and the three components of this standard. For the first component of the analysis, which looks at patients being treated within 6 weeks of referral, no association was found with nursing staff numbers. This may be because DMARDs were initiated at the initial appointment with a doctor to meet this standard or because there were waiting times to see a specialist nurse in some services. Treatment with combination DMARDs was significantly associated with nursing staff numbers and this is likely to reflect a potential escalation approach to treatment involving nurse-led appointments. The association between nurse staffing levels and prescription of steroids is smaller, albeit still statistically significant, and is likely to reflect treat to target approaches from nurse-led clinics.

Table 7.16 number of specialist nurses per 100,000 population as an explanatory variable for NICE Quality Standard 3


N Odds ratio 95% CI p-value

Commencing DMARDs within 6 weeks of referral

3,149 1.29 (0.77, 2.18) 0.335

Combination DMARDs at any time

3,030 2.06 (1.18, 3.60) 0.011

Steroids at any time

2,881 1.67 (1.02, 2.73) 0.041


NICE Quality Standard 4 recommends that patients with rheumatoid arthritis are offered educational and self-management activities within 1 month of diagnosis.

Clinicians were asked whether patients were offered a structured patient education and self-management service within 1 month of diagnosis when the patient returned for follow up.

The results for achievement of this standard are presented in table 7.17 and figure 7.18. Data quality was again good, with very low levels of missing data. Clinicians submitting data for rheumatoid arthritis patients attending for follow up reported that two thirds of patients nationally were offered education within 1 month of diagnosis. There was an increase in reported achievement rates of this NICE Quality Standard to 67% from 59% in year 1.

Variation in achievement rates are again shown within NHS regions, with lowest rates in Wales (52%) and highest rates in the North of England (74%) for year 2, compared to lowest rates in London (38%) and highest rates in the North of England (63%) for year 1. Achievement rates improved in all regions and most substantially in London, from 38% to 59% in year 2.



Table 7.17 number (%) of RA patients offered education and self-management within 1 month of diagnosis by NHS region and Wales

Region Number of RA patients at follow-up

N (%) RA patients offered educational support

N (%) missing data

National 2,162 1,438 (67%) 13 (1%)

London 209 123 (59%) 2 (1%)


645 412 (64%) 4 (1%)

North of England 697 513 (74%) 6 (1%)

South of England 439 300 (69%) 1 (0%)

Wales 172 90 (52%) 0 (0%)

Figure 7.18 number (%) of RA patients offered education and self-management within 1 month of diagnosis by NHS region and Wales

% p

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e


60

70

80

50

40

30

20

10

0National level North of

EnglandLondon South of

EnglandMidlands &

East of EnglandWales

As for year 1, there were discrepancies between access to education reported via clinician follow up forms when compared to data collected via the annual organisational data collection form. The latter provided data indicating that 43% of providers nationally provided education services to patients, with only 35% of providers within the South of England and 50% of providers within Wales being able to provide this service. These discrepancies, as discussed in the year 1 annual report, are likely to reflect differences in interpretation of the term 'education and self management'.

Data were not collected on the format of any education and self management activities provided to patients and so no further comment can be made on this. Neither can comment be made on whether failure to achieve this standard was through lack of availability of such services altogether or whether this was through lack of timely supply of these services. There is a high likelihood that these services would primarily be provided by nursing staff. The North of England region have consistently performed the best for this standard, as measured via clinician data supplied from follow up forms in year 1 and 2, and also reported the highest nursing staff ratios in England for both years. However, Wales have achieved this standard in the lowest proportion of patients in year 2, despite similarly high number of nurses ratios. The numbers of patients for whom data have been submitted for Wales were small and so firm conclusions are difficult to draw. Likewise numbers were also small for London but compared to year 1, there was a substantial improvement in reported achievement rates for this quality standard from 38% in year 1 to 59% in year 2. This is despite having the lowest reported number of nurses per head of population in year 2.


NICE Quality Standard 5 recommends that people who have active rheumatoid arthritis should be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

The audit has reported achievement of this standard through assessment of whether or not treatment targets have been set and agreed with RA patients and on whether or not pre-set treatment targets have been met at follow up. National and NHS regional data are shown in table 7.19 and figure 7.20.

Table 7.19 - number and proportion of patients for whom a treatment target was set by NHS region and Wales

Region Number of RA patients

N (%) with a treatment target set at baseline

N (%) with a treatment target set and agreed

National 3,185 2,831 (89%) 2,614 (92%)

London 320 275 (86%) 254 (92%)


958 876 (91%) 816 (93%)

North of England 992 837 (84%) 776 (93%)

South of England 682 630 (92%) 582 (92%)

Wales 233 213 (91%) 186 (87%)



Figure 7.20 number and proportion of patients for whom a treatment target was set by NHS region and Wales

% p

erce

ntag

e


100

95

90

85

80



EnglandMidlands &


Nationally, at the time of presentation to secondary care services, clinicians reported that they set a treatment target for 89% of their RA patients, and that they agreed this target with 92% of these patients. This compares to figures of 91% and 90% respectively in year 1 and therefore remains essentially unchanged.

Across NHS regions and Wales, the variation reduced a little compared to year 1; the range in year 2 being 84% in the North of England to 92% in the South of England, compared to 82% in Wales to 97% in the South of England and Midlands and East of England region in year 1. Numbers were again small for Wales, but rates of treatment target setting increased in year 2 to 91% from 82%.

Clinician reported agreement of treatment targets with patients also remained stable, with a small improvement to 92% in year 2; 87% in Wales and 93% in the North of England and in the Midlands and East of England.

Data were also collected and analysed for achievement rates on a previously set treatment target and are shown in table 7.21 and figure 7.22.

Table 7.21 Number and percentage of RA patients who achieved their treatment target at follow-up by NHS region and Wales


Number with treatment target achieved*

Number with no follow up data on targets achieved

National 2,162 840 (52%) 544

London 209 93 (62%) 60


645 220 (46%) 169

North of England 697 263 (52%) 186

South of England 439 183 (54%) 100

Wales 172 81 (57%) 29

*Denominator based on available data

Figure 7.22 percentage of RA patients who achieved their treatment target at follow-up by NHS region and Wales

% p

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e


60

70

50

40

30

20

10



EnglandMidlands &


Nationally, when looking at achievement rates of previously set treatment targets, these were achieved in 52% of RA patients for whom data were available. This compares to an achievement rate of 49% nationally in year 1 for those with available data. Treatment targets were achieved in year 2 for the highest proportion of RA patients in London (62%) and for lowest proportion in the Midlands and East of England (46%). Numbers were again low in London but achievement rates increased from 46% in year 1 to 62% in year 2 and reduced from 49% in year 1 to 46% in year 2 for the Midlands and East of England.

As discussed in the 1st annual report, the majority of clinicians reported setting treatment targets, and agreeing these with their patients from the initial consultation; however no verification of this information was undertaken. It is of interest that clinicians continued to set treatment targets without agreeing them with patients for a small proportion of patients and the reasons for this are not apparent from the audit data.

Nationally, the data show that treatment targets were achieved within 3 months of specialist care for just over half the patients, with a small increase from just under half the patients in year 1. Whilst acknowledging the short follow up period of the audit, it remains of some concern that such a high proportion of patients aren’t achieving previously set treatment targets within the early stages of specialist care. There are multiple factors that may be influencing these results. In addition, the absence of follow up data on 25% of patients makes us less confident of the accuracy of this estimate. Individual providers have access to details they have provided on the type of treatment targets set for their patients, on treatments offered to patients and on reasons why treatments have not been initiated to allow them to further explore these aspects of care and their potential impact on treatment target achievement rates.

Table 7.23 shows the relationship between nursing numbers and compliance with achievement of pre-set treatment targets. This is statistically significant and is likely to reflect the fact that the delivery of treat to target care through shared decision-making will primarily be through nurse-led clinics.



Table 7.23 number of specialist nurses per 100,000 population as an explanatory variable for achieving pre-set treatment targets


N Odds ratio 95% CI p-value

Treatment target achieved at follow-up

1600 1.58 (1.02, 2.46) 0.043


NICE Quality Standard 6 states that people with rheumatoid arthritis and disease flares or possible drug related side effects should receive advice within 1 working day of contacting the rheumatology service.

Data feeding into this standard are available from two sources and both are detailed in table 7.24.

Table 7.24 number and proportion of patients with access to urgent advice by NHS region and Wales

Region Number of patients N (%) of patients with access to urgent advice

N (%) of providers with a telephone advice line1

National 5,002 4,597 (92%) 123 (97%)

London 587 526 (90%) 16 (94%)


1,391 1,305 (94%) 33 (97%)

North of England 1,576 1,421 (90%) 41 (100%)

South of England 1,105 1,027 (93%) 27 (93%)

Wales 343 318 (93%) 6 (100%)

1 Data were missing for 2 trusts - one in the Midlands & East region and one in the South of England region

Data supplied via the clinician follow up forms for year 2 showed that nationally 92% of patients had access to urgent advice, with a fairly narrow range of availability reported across NHS regions; 90% of patients having this service available in the North of England and in London compared to 94% of patients in the Midlands and East of England.

There was, however, a drop in reported availability of this service from all NHS regions when compared to year 1 data. In year 1, this service was reported to be available to 99% of patients nationally with a range of 98% in the South of England to 100% in Wales. The reasons for this change are not apparent from the audit data and are a concern as this suggests a retrograde step in care for patients with RA. It is possible that there is a problem with availability of specialist nurses to man telephone advice lines but the reasons for this reduced access to urgent advice are unclear from the audit data.

However, other data relevant to this standard collected from the annual organisational form have not changed in any major way from the year 1 data. 97% of providers reported that they had a telephone advice line; ranging from 93% in the South of England to 100% in the North of England and Wales. This service would be one of the main potential mechanisms available for patients to access urgent advice. Whilst it is reassuring that the vast majority of providers provide this service to patients the absence of such a service in some providers is of concern. It should also be recognised that the existence of a telephone advice line does not necessarily guarantee access to urgent advice and the details on how each service is run within individual providers have not been collected via this audit.


NICE Quality Standard 7 recommends that people with rheumatoid arthritis should have a comprehensive annual review that is coordinated by the rheumatology service.

Table 7.25 shows the breakdown of annual review availability across geographical regions. Nationally 82% of providers reported a structured annual review process. The provision of annual review services varied across geographical region. Whilst Wales reported the lowest percentage, this is based upon a small number of health boards (4 out of 6 in Wales report annual review services).

NICE Quality Standard 7 recommends comprehensive annual review and further details are outlined in NICE CG79. This audit has not assessed individual patient level data but simply the reported provision of annual review service.

The provision of annual review services is lower than was reported in the annual report for the first year of the audit. There was an error within the coding of the annual review question leading to inaccuracy for the year one report. The revised performance data for year two reflects a correction rather than an actual change in the provision of annual review services.

Table 7.25 number and proportion of providers with an annual review process by NHS region and Wales

Region N (%) of providers with an annual review process1

National 104 (82%)

London 16 (94%)

Midlands & East of England 29 (85%)

North of England 33 (81%)

South of England 22 (76%)

Wales 4 (67%)

1 Data were missing for 2 trusts - one in the Midlands & East region and one in the South of England region



Rheumatoid Arthritis Impact of Disease (RAID) score

The Rheumatoid Arthritis Impact of Disease (RAID) score is the primary patient reported outcome measure in this audit. The domains assessed include pain, function, fatigue and well-being. There is currently no validated PROM for use across all diseases captured in this audit. However, it was felt appropriate to present baseline RAID for all patients, as well as baseline and follow up results for patients with RA. Scores provide a measure of the impact of inflammatory joint disease at the point of presentation to secondary care. RAID scores range from 0-10 with 10 indicating more severe symptoms. A Minimum Clinically Important Difference (MCID) for RAID is defined as a reduction of 3 points or more or a percentage reduction of 50% from the baseline score6.

RAID scores were available for 87% of patients at their baseline visit, irrespective of their diagnosis. The mean score was 5.8 for all patients at baseline, as outlined in table 7.26. As outlined in table 7.27, the mean RAID score was higher at 6.1 for RA patients and RAID scores for RA were comparable across geographical regions, with the lowest being 5.7 in the South of England and the highest being 6.5 in Wales.

Table 7.26 breakdown of RAID scores for all patients at presentation by NHS region and Wales

Region Number of patients at baseline

N (%) of patients with RAID at baseline

Mean (SD) RAID at baseline

National 5,002 4,324 (86%) 5.8 (2.3)

London 587 474 (81%) 5.5 (2.4)


1,391 1,254 (90%) 5.8 (2.3)

North of England 1,576 1,334 (85%) 5.9 (2.3)

South of England 1,105 949 (86%) 5.5 (2.3)

Wales 343 313 (91%) 6.2 (2.3)

Table 7.27 provides a breakdown of RAID scores for RA patients only at presentation by NHS region and Wales

Region Number of RA patients N (%) of RA patients with RAID at baseline

Mean (SD) RAID at baseline

National 3,185 2,767 (87%) 6.1 (2.2)

London 320 264 (83%) 6.0 (2.3)


958 874 (91%) 6.0 (2.2)

North of England 992 837 (84%) 6.2 (2.2)

South of England 682 579 (85%) 5.7 (2.3)

Wales 233 213 (91%) 6.5 (2.3)

6 Dougados M, Brault Y, Logeart I, van der Heijde D, Gossec L, Kvien T. Defining cut-off values for disease activity states and improvement scores for patient-reported outcomes: the example of the Rheumatoid Arthritis Impact of Disease (RAID). Arthritis Res Ther 2012;14(3):R129.

Baseline and follow-up RAID were available for 933 out of 2,162 RA patients (43%). This represents a significant improvement (more than 100%) in data capture on year 1. The mean RAID at follow-up in RA patients was 4.0, representing a mean change of -2.2. Only 44% of RA patients for whom we had baseline and follow up data achieved an MCID for RAID by their last follow-up visit. Wales had the highest reduction in RAID and MCID for RAID, which may partly reflect their higher baseline scores for this PROM.

Table 7.28 RAID scores at follow-up for RA patients by NHS region and Wales


N (%) of RA patients with RAID at follow-up

Mean (SD) RAID at follow-up in RA patients

Number of RA patients with baseline & follow-up RAID

Mean (SD) change in RAID in RA patients

N (%) RA patients with MCID

National 2,162 1,001 (46%)

4.0 (2.5)

933 -2.2 (2.5)

406 (44%)

London 209 88 (42%)

3.6 (2.4)

84 -2.3 (2.4)

33 (39%)


645 278 (43%)

4.1 (2.5)

268 -2.0 (2.4)

110 (41%)

North of England

697 357 (51%)

4.1 (2.6)

328 -2.2 (2.6)

143 (44%)

South of England

439 190 (43%)

3.6 (2.4)

170 -2.4 (2.2)

78 (46%)

Wales 172 88 (51%)

3.9 (2.2)

83 -2.8 (2.6)

42 (51%)

Disease Activity Score (DAS-28)

DAS-28 is the second validated outcome measure reported in this audit that has a component of patient reporting within it. DAS-28 provides an assessment of RA disease activity using a composite of clinician and patient-derived measures. The DAS-28 can range from 0-9.55. A DAS-28 > 5.1 defines high disease activity, with scores of 3.2-5.1 reflecting intermediate disease activity and scores < 3.2 reflecting low disease activity. A DAS-28 <2.6 indicates remission. A reduction in DAS-28 of >1.2 is considered to be a clinically meaningful response.

In table 7.29, DAS-28 results are presented at baseline for patients with a clinician diagnosis of RA, those with a positive CCP antibody or those with five or more swollen joints. Follow up DAS-28 from the last available returned follow up form are shown in table 7.30.

In comparison to year one of the audit, the return of clinician data on baseline DAS decreased to 80% (from 91% in year 1). The reasons for this are unclear, but suggest time pressures within first appointments impaired clinician ability to collect this important data. Levels of disease activity at baseline were however similar to those recorded in year 1, with approximately half of all patients (48%) presenting with severe disease. 90% had severe or intermediate disease activity at presentation. The mean DAS was 5.0 and this was consistent across all regions at baseline.



Over the follow up period, data on 1,736 RA patients were collected (80%), which is an improvement on data capture in year 1. Just under one third (31%) of patients for whom information was available achieved a state of disease remission, and the proportion of patients with high disease activity at their last follow up was low at 14%. However, it is important to note that for 32% of RA patients recruited to the audit, no follow up data were submitted. This reflects a substantial body of missing information. It is also possible that those patients in whom follow data are absent had different outcomes from the rest of audit population and therefore some degree of bias in the estimate of DAS-28 response is likely.

Table 7.29 number and proportion of rheumatoid arthritis patients nationally and within NHS regions and Wales that had mild, moderate and severe disease activity at their first appointment

Region Number of RA patients at baseline

N (%) RA patients with baseline DAS

Mean (SD) DAS score

Low disease activity

Intermediate disease activity

High disease activity

National 3,185 2,557 (80%)

5.0 (1.4)

249 (10%)

1,080 (42%)

1,228 (48%)

London 320 255 (80%)

5.0 (1.4)

30 (12%)

101 (40%)

124 (49%)


958 821 (86%)

5.0 (1.3)

75 (9%)

369 (45%)

377 (46%)

North of England

992 748 (75%)

5.1 (1.4)

68 (10%)

295 (39%)

385 (52%)

South of England

682 517 (76%)

5.0 (1.4)

54 (11%)

227 (44%)

236 (46%)

Wales 233 216 (93%)

5.0 (1.3)

22 (10%)

88 (41%)

106 (50%)

Table 7.30 number and proportion of rheumatoid arthritis patients nationally and within NHS regions and Wales that had mild, moderate and severe disease activity at their follow-up appointment


North of England

South of England

Wales

Number of RA patients at follow-up

2,162 209 645 697 439 172

N (%) RA patients with follow-up DAS

1,736 (80%)

175 (84%)

500 (78%)

541 (78%)

371 (85%)

149 (87%)

Mean (SD) DAS score

3.5 (1.5)

3.3 (1.5)

3.7 (1.4)

3.5 (1.5)

3.5 (1.5)

3.3 (1.4)

Remission 531 (31%)

60 (34%)

129 (26%)

169 (31%)

112 (30%)

61 (41%)

Low disease activity

254 (15%)

31 (18%)

70 (14%)

79 (15%)

55 (15%)

19 (13%)


703 (41%)

65 (37%)

222 (44%)

219 (41%)

143 (39%)

54 (36%)


248 (14%)

19 (11%)

79 (16%)

74 (14%)

61 (16%)

15 (10%)

Mean (SD) change in DAS score

-1.7 (1.6)

-1.8 (1.7)

-1.6 (1.5)

-1.7 (1.7)

-1.5 (1.7)

-1.9 (1.7)

N (%) with reduction in DAS score of >1

849 (60%)

94 (64%)

249 (59%)

251 (62%)

158 (54%)

97 (67%)



Patient Reported Experience Measures (PREMs)

PREM data were collected after 3 months of specialist care via a confidential data collection process. In the absence of a validated composite score for the PREM, the responses are reported to the overarching question ‘overall in the past 3 months I have had a good experience of care for my arthritis?’. Data were available on 926 rheumatoid arthritis patients attending for follow up appointments and are presented in the table below.

Table 7.31 number and proportion of rheumatoid arthritis patients providing responses to the question ‘overall in the past 3 months, I have had a good experience of care for my arthritis?’ by NHS region and Wales


N (%) agreed or strongly agreed

N (%) neither agree nor disagree

N (%) disagreed or strongly disagreed

N (%) not applicable

N (%) missing

National 2,162 888 (95%)

26 (3%)

12 (1%)

14 (2%)

1,222 (57%)

London 209 78 (95%)

3 (4%)

0 (0%)

1 (1%)

127 (61%)


645 247 (90%)

16 (6%)

5 (2%)

7 (3%)

370 (57%)

North of England

697 315 (97%)

3 (1%)

6 (2%)

2 (1%)

371 (53%)

South of England

439 168 (95%)

4 (2%)

1 (1%)

4 (2%)

262 (60%)

Wales 172 80 (100%)

0 (0%)

0 (0%)

0 (0%)

92 (54%)

% refers to proportion of data available

The large majority (95%) of patients answering this question reported that they 'agreed' or 'strongly agreed' that they had had a good experience of care in the 3 months since they first presented to their rheumatology service. This has increased significantly from year 1, where the comparative figure was 78%. The range of data for this indicator between NHS regions and Wales has slightly decreased to 10% in year 2, against 13% in year 1. There were almost identical figures (1% in both years) for patients who did not have a good experience of care. These data are encouraging and suggest that most patients were happy with the care that they received but we need to acknowledge the limitations of using a single question to judge patient experience, alongside the 57% of patients who did not return data.

Overall, the number of patients answering this question increased by over 60% when compared to year 1. This suggests an improvement in the way that providers have managed their data collection processes, such as ensuring that follow-up forms are routinely available to be completed at the appointment and can be returned anonymously through the clinical audit department. However, there remained a large proportion of patients who did not provide a response and so we are unable to publish provider-level data. Further work is required to address this and this needs consideration in the development of the new audit.

Work status

Information was collected at the first appointment and in subsequent follow-up appointments in relation to the work status of patients and the impact of their condition on ability to work. There were 2,068 RA patients of working age (i.e. <66). Of these, data on employment status at baseline were missing for 327 (16%). Of the remaining 1,741, 956 (55%) were working in full-time paid employment, 322 (19%) were working in part-time paid employment and 463 (27%) were not in paid employment.

A total of 1,430 RA patients of working age returned a follow up form and the data are presented in table 7.32.

Table 7.32 number and proportion of RA patients <66 years returning a patient follow-up form and reporting impact of their arthritis on their ability to work by NHS region and Wales


North of England

South of England

Wales

Number of RA patients of working age at follow-up

1,430 149 439 464 267 111

N (%) not working in paid employment because of arthritis

51 (8%)

1 (2%)

13 (7%)

24 (11%)

8 (8%)

5 (9%)

N (%) frequently take time off because of arthritis

38 (6%)

4 (7%)

11 (6%)

15 (7%)

7 (7%)

1 (2%)

N (%) occasionally take time off because of arthritis

109 (17%)

11 (19%)

37 (19%)

36 (16%)

17 (16%)

8 (14%)

N (%) rarely take time off because of arthritis

256 (40%)

23 (40%)

74 (39%)

89 (39%)

42 (40%)

28 (49%)

N (%) other1 187 (29%)

19 (33%)

56 (29%)

65 (28%)

31 (30%)

16 (28%)

N (%) missing 789 (55%)

91 (61%)

248 (57%)

235 (51%)

162 (61%)

53 (48%)

1 Other = not working in paid employment but not because of arthritis, no longer volunteering but not because of arthritis or volunteering but may need to take time off because of arthritis



70% of patients recruited in year 2 were of working age. Established inflammatory arthritis has severe implications on work capacity and there is also evidence from the audit that a significant minority of patients struggled with their work even in the early stages. Table 7,32 shows a small increase on the year 1 data in the number of patients not working, or needing frequent time off due to their arthritis. As such, work-related interventions are important at this stage, in order to ensure that patients can remain in work. Robust interpretation is hampered by the low number of returned forms, although it is clear that this area merits further research.

Asking patients about their work in the course of their consultation is a key driver for managing effective interventions and preventing long-term incapacity. Table 7.33 outlines whether patients recall being asked about work.

Table 7.33 number and proportion of RA patients <66 years returning a patient follow-up form and responding to whether they were asked about work in the course of their consultation by NHS region and Wales

Region Number of RA patients of working age at follow-up

N (%) no N (%) yes N (%) can't recall or N/A

N (%) missing

National 1,430 89 (18%)

319 (66%)

75 (16%)

947 (66%)

London 149 6 (17%)

24 (67%)

6 (17%)

113 (76%)


439 28 (20%)

86 (63%)

23 (17%)

302 (69%)


129 (69%)

29 (16%)

278 (60%)


58 (67%)

10 (12%)

180 (67%)

Wales 111 8 (22%)

22 (60%)

7 (19%)

74 (67%)

66% of patients recalled being asked about work, which is a significant increase on the year 1 data. This aspect of the 1st annual report has been one of the most widely used by participants and other organisations and we believe that this focus has driven improvements in the composition of patient consultations. To further improve this area, the BSR is providing training courses in 4 regions in 2016.

The interpretation of these data is hampered by the high number of missing values. It is not possible to know if people for whom we lack data are inherently different with respect to the impact of their disease upon work. However, it is clear that inflammatory arthritis has a very significant impact on work and further research on the impact in early disease is now indicated. Clinicians are reminded of the need to consider this aspect of good clinical care when seeing patients of working age and of enquiring about impact on work within consultations.

Recommendations

This second annual report is published only six months after the first report. There are some important differences between outcomes reported in years one and two, but this is too short a time interval for major changes to have been achieved in performance against many of the audit standards Therefore, after a shortened second year, it is timely and appropriate to restate the recommendations arising from year one of the audit, in addition to making further recommendations for clinicians and health services prompted by the second year of data collection. It is also important to consider how the audit project might be most usefully advanced into future years.

Review of recommendations from year one

• For educators: reduce referral times by improving educational input to primary care about the presentation and early management of inflammatory arthritis. Enhance rheumatology and musculoskeletal training at undergraduate level

• For the public: raise awareness of the need to seek professional help swiftly for early signs of inflammatory arthritis in order to improve outcomes

• For providers: to review capacity and processes to improve waiting times and deliver intensive treatment

• For commissioners: commission and monitor according to best practice

• For patients: enhance the power of service users to provide feedback on outcomes and experience

• For the NHS: develop better systems for collecting, coding and using information for outpatient services

Further clinical recommendations from year two

Recommendation: Analyse and understand variation in performance against key standards, facilitated by peer support between clinical services and dissemination of best practice, with a view to developing plans for service improvement

For commissioners, primary and secondary care and the broader rheumatological community (including BSR): there is now a richness and depth of audit data at a local level for most health economies, with evidence of considerable variation in performance against all audit standards. This should be of value for all providers, but should be a particular focus for providers with outlying performance. All those involved with provision of rheumatology services should examine their local data, benchmarked against national performance and against the performance of similar services both locally and nationally. Services may find local reasons for variation, such as socioeconomic factors or variation in local funding. However, there may also be much to be learned from peer health economies in terms of service improvement. BSR should consider how to facilitate peer support between clinical services and how to disseminate examples of good practice using case studies and other methods. It should be emphasised that many providers achieved good levels of performance. For the key metric against NICE Quality Standard 2, nearly 40% offered first appointments within 3 weeks, and the median waiting time was only 4 weeks. However, this overall figure masked a wide spread of providers with much longer waiting times. While all providers can potentially learn and improve from the audit, the greatest benefits to the public health are likely to come from a focus on the providers with longer waits, understanding variation, and using peer support where appropriate.



Providers should review the adequacy of their provision of specialist nursing

For rheumatology services: fewer patients experience delays in starting and escalating DMARD treatment in year two compared to year one. However, there was still wide variation nationally and improvements need to be made around drug education and initiation and escalation of treatment- allowing patients to start appropriate treatment in the shortest possible time, while recognising the importance of informed shared decision making. The year 2 data, and further analysis of the year 1 data, suggests a strong association between specialist nurse staffing levels and timely delivery of intensive treatment.

Recommendation: Provider organisations need to review the level of non-clinical support to the audit

For trusts and health boards: The non-clinical support provided for the audit by provider organisations has varied considerably across the NHS, with some organisations providing adequate audit department support, and others leaving all aspects of the audit to clinical services. This variation has had a clear impact on engagement with and recruitment to the audit.

Recommendation: Providers and patients need to work together to improve systems for collecting and using data on patient outcomes and experience as a part of routine clinical care

For patients and providers: consideration needs to be given to how patient support groups, at a local and national level, can be used to support both the audit practice and service improvement.

Recommendation: During the hiatus in the audit project, rheumatology services should give strong consideration to continuing to collect data on waiting times, treatment initiation and measures of patient outcome and experience, for use in their own service

Most of the measures used in the audit can contribute usefully to routine clinical care, although not all of these are collected by clinical services. Continued data collection would maintain momentum for the next phase of the audit project. The Care Quality Commission intends to use some of the key metrics from the audit as part of their assessment of rheumatology services which should provide further incentive for local data collection.

Finally, it should be emphasised that the outcomes of this audit demonstrate some positive aspects of NHS rheumatology practice in England and Wales. Audit reports tend to focus on what can be learnt and improved - and there is, indeed, much to be done, as detailed in the recommendations. However, there are also things to celebrate as the audit shows that almost two thirds of patients are offered disease modifying treatment within 6 weeks of referral, which is a huge improvement from historical waiting times. Acknowledgement should also be made of the high degree of engagement and support from the rheumatological community for this complex audit. These successes set the scene for further service improvements and the long term viability of the audit.

Local performance against key standards and indicators

Provider performance is measured against NICE Quality Standards 1-7. This chapter presents individual provider results from the year 2 data collection period for NICE Quality Standards 1 to 7, the patient and clinician reported outcome measures and staffing numbers for each NHS region and Wales. It should be noted that compliance with each NICE Quality Standard is measured at 100%.

Benchmarking at provider level is only published for providers which have been identified by our methodology as having an adequate case submission rate to underpin robust comparison with others. In addition, provider level data have not been reported for any trust providing data for 5 patients or fewer, in order to protect patient confidentiality.


NICE Quality Standard 1 recommends that people with suspected persistent synovitis affecting the small joints of the hands or feet, or more than one joint, are referred to a rheumatology service within 3 working days of presentation.

Table 7.34 provider compliance with NICE Quality Standard 1 in the London region

Provider name Number of patients at baseline



National 5,002 1,020 (20%) 20 (5, 54)

London region 587 111 (19%) 15 (5, 50)

Barking, Havering and Redbridge University Hospitals NHS Trust

28 ≤5 (-%) 18.5 (4.5, 63)

Chelsea and Westminster Hospital NHS Foundation Trust

24 ≤5 (-%) 15.5 (7, 38.5)

Croydon Health Services NHS Trust 81 36 (44%) 4 (0, 20)

Ealing Hospital NHS Trust 27 0 (0%) 24 (12, 57)

Epsom & St Helier University Hospitals NHS Trust

25 8 (32%) 7 (3, 20)

Guy's and St Thomas' NHS Foundation Trust

42 ≤5 (-%) 49 (10, 110)

Homerton University Hospital NHS Foundation Trust

35 10 (29%) 9 (2, 20)

Imperial College Healthcare NHS Trust

14 6 (43%) 12 (1, 22)

King's College Hospital NHS Foundation Trust

103 12 (12%) 17 (9, 47)

Kingston Hospital NHS Foundation Trust

54 ≤5 (-%) 45 (12, 115)

Lewisham and Greenwich NHS Trust

28 8 (29%) 8 (2.5, 36)



Table 7.34 continued




North West London Hospitals NHS Trust

52 ≤5 (-%) 18.5 (6.5, 50)

Royal Free London NHS Foundation Trust

20 ≤5 (-%) 24.5 (3, 63)

St George's Healthcare NHS Trust, London

13 ≤5 (-%) 14 (5, 50)

University College London Hospitals NHS Foundation Trust

33 ≤5 (-%) 22 (12, 36)

Table 7.35 provider compliance with NICE Quality Standard 1 in the Midlands and East of England region




National 5,002 1,020 (20%) 20 (5, 54)

Midlands & East of England region 1,391 190 (14%) 24 (8, 63)

Basildon & Thurrock University Hospitals NHS Foundation Trust

28 ≤5 (-%) 43 (19, 59)

Burton Hospitals NHS Foundation Trust

29 ≤5 (-%) 36 (11, 93)

Cambridge University Hospitals NHS Foundation Trust

57 10 (18%) 18 (6, 39)

Chesterfield Royal Hospital NHS Foundation Trust

6 0 (0%) 14.5 (7, 38)

Derby Hospitals NHS Foundation Trust 83 14 (17%) 29 (10, 78)

Dudley Group NHS Foundation Trust 64 7 (11%) 31 (10.5, 82.5)

East and North Hertfordshire NHS Trust

115 14 (12%) 22 (9, 59)

George Eliot Hospital NHS Trust 9 ≤5 (-%) 10 (2, 41)

Gloucestershire Hospitals NHS Foundation Trust

15 0 (0%) 22 (16, 38)

Heart of England NHS Foundation Trust 43 7 (17%) 16.5 (5, 31)

Hinchingbrooke Health Care NHS Trust 24 7 (32%) 12 (2, 26)

Ipswich Hospitals NHS Trust 59 30 (51%) 1 (0, 24)





James Paget University Hospital Foundation NHS Trust

29 ≤5 (-%) 42 (6, 123)

Luton and Dunstable University Hospital NHS Foundation Trust

28 0 (0%) 93 (32.5, 149.5)

Norfolk and Norwich University Hospital NHS Foundation Trust

57 8 (14%) 13 (5, 39)

Northampton General Hospital NHS Trust

41 7 (17%) 14 (5, 30)

Nottingham NHS Treatment Centre 122 9 (7%) 29.5 (11, 66)

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

59 ≤5 (-%) 42 (17, 142)

Royal Wolverhampton Hospitals NHS Trust

70 8 (11%) 29 (10, 80)

Sandwell and West Birmingham Hospital NHS Trust

39 ≤5 (-%) 38 (13, 97)

Sherwood Forest Hospitals NHS Foundation Trust

25 ≤5 (-%) 16 (5, 35)

South Warwickshire NHS Foundation Trust

34 ≤5 (-%) 24 (10, 69)

Southend University Hospital NHS Foundation Trust

57 13 (23%) 21 (4, 46)

Staffordshire and Stoke on Trent Partnership NHS Trust

30 10 (33%) 9 (2, 28)

University Hospitals Birmingham NHS Foundation Trust

72 ≤5 (-%) 29 (11, 98)

University Hospitals Coventry and Warwickshire NHS Trust

14 0 (0%) 35 (22, 97)

University Hospitals of Leicester NHS Trust

47 ≤5 (-%) 43 (23, 90)

Walsall Healthcare NHS Trust 12 ≤5 (-%) 27 (11.5, 72.5)

West Hertfordshire Hospitals NHS Trust

17 0 (0%) 41 (21, 64)

West Suffolk NHS Foundation Trust 18 ≤5 (-%) 24.5 (7, 65)

Worcestershire Acute Hospitals NHS Trust

45 ≤5 (-%) 20 (9, 45)

Wye Valley NHS Trust 30 6 (20%) 14.5 (4, 29)



Table 7.36 provider compliance with NICE Quality Standard 1 in the North of England region




National 5,002 1,020 (20%) 20 (5, 54)

North of England region 1,576 354 (23%) 19 (4, 51)

Aintree University Hospital NHS Foundation Trust

63 12 (19%) 15 (6, 31)

Airedale Hospital NHS Foundation Trust 22 ≤5 (-%) 18 (9, 42)

Barnsley Hospital NHS Foundation Trust 48 16 (33%) 10 (2, 28.5)

Blackpool Teaching Hospitals NHS Foundation Trust

22 ≤5 (-%) 30.5 (14, 51)

Bolton NHS Foundation Trust 62 ≤5 (-%) 45 (22, 81)

Bradford Teaching Hospitals NHS Foundation Trust

18 ≤5 (-%) 20.5 (8, 43)

Central Manchester University Hospitals NHS Foundation Trust

26 ≤5 (-%) 23 (11, 57)

City Hospitals Sunderland NHS Foundation Trust

59 11 (19%) 13 (5, 53)

Countess of Chester Hospital NHS Foundation Trust

36 ≤5 (-%) 32.5 (13.5, 149)

County Durham and Darlington NHS Foundation Trust

18 ≤5 (-%) 8 (2, 82)

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

44 7 (16%) 20.5 (6, 59)

East Cheshire NHS Trust 25 ≤5 (-%) 30 (19, 62)

East Lancashire Healthcare Trust 50 6 (12%) 18.5 (7, 40)

Gateshead Health NHS Foundation Trust

16 6 (38%) 15 (1, 35.5)

Harrogate and District NHS Foundation Trust

7 ≤5 (-%) 15 (1, 33)

Hull and East Yorkshire Hospitals NHS Trust

31 10 (32%) 22 (1, 61)

Lancashire Care NHS Foundation Trust 51 14 (28%) 18 (1, 52)

Leeds Teaching Hospitals NHS Trust 46 29 (66%) 1 (0, 12.5)

Mid Cheshire Hospitals NHS Foundation Trust

27 ≤5 (-%) 32 (8, 63)

Mid Yorkshire Hospitals NHS Trust 31 6 (19%) 26 (9, 54)





Newcastle upon Tyne Hospitals Foundation Trust

75 36 (48%) 5 (0, 37)

North Cumbria University Hospitals NHS Trust

11 ≤5 (-%) 7 (1, 22)

Northern Lincolnshire and Goole NHS Foundation Trust

13 0 (0%) 58 (22, 86)

Northumbria Healthcare NHS Foundation Trust

42 10 (24%) 13.5 (4, 59)

Pennine Acute Hospitals NHS Trust 46 8 (17%) 26 (7, 63)

Pennine Musculoskeletal Partnership 96 38 (40%) 7 (0, 30)

Rotherham NHS Foundation Trust 24 15 (63%) 1 (0, 7)

Royal Liverpool & Broadgreen University Hospitals NHS Trust

21 8 (38%) 8 (0, 25)

Salford Royal NHS Foundation Trust 40 ≤5 (-%) 29 (7, 88.5)

Sheffield Teaching Hospitals NHS Foundation Trust

47 8 (17%) 17 (6, 43)

South Tees Hospitals NHS Foundation Trust

95 9 (10%) 16 (5, 35)

Southport & Formby District General Hospital

28 ≤5 (-%) 36.5 (13.5, 57)

St Helens and Knowsley Teaching Hospitals NHS Trust

42 ≤5 (-%) 41.5 (13, 109)

Stockport NHS Foundation Trust 10 ≤5 (-%) 22 (13, 33)

Tameside Hospital NHS Foundation Trust

44 6 (14%) 41 (20.5, 164.5)

University Hospital of South Manchester NHS Foundation Trust

40 6 (15%) 30.5 (10, 114)

University Hospitals of Morecambe Bay NHS Foundation Trust

91 14 (15%) 23 (6, 54)

Warrington and Halton Hospital NHS Trust

20 0 (0%) 56.5 (25.5, 322.5)

Wirral University Teaching Hospital NHS Foundation Trust

47 10 (21%) 7 (4, 20)

Wrightington, Wigan and Leigh NHS Foundation Trust

28 15 (54%) 3 (1, 10.5)

York Teaching Hospitals NHS Foundation Trust

14 ≤5 (-%) 19 (4, 24)



Table 7.37 provider compliance with NICE Quality Standard 1 in the South of England region




National 5,002 1,020 (20%) 20 (5, 54)

South of England region 1,105 206 (19%) 22 (6, 62)

Ashford & St Peter's Hospitals NHS Foundation Trust

32 6 (19%) 13 (5, 72)

Buckinghamshire Healthcare NHS Trust 51 ≤5 (-%) 44 (20, 102)

East Kent Hospitals University NHS Foundation Trust

23 6 (26%) 12 (3, 58)

Frimley Park Hospital NHS Foundation Trust

19 ≤5 (-%) 12 (5, 70)

Great Western Hospital NHS Foundation Trust

17 ≤5 (-%) 12 (5, 67)

Hampshire Hospitals NHS Foundation Trust

35 7 (20%) 13 (6, 43)

Heatherwood and Wexham Park Hospitals NHS Foundation Trust

8 ≤5 (-%) 33.5 (8.5, 44.5)

Isle of Wight NHS Trust 28 6 (21%) 27.5 (8, 64)

Maidstone and Tunbridge Wells NHS Trust

37 ≤5 (-%) 65 (13, 183)

Medway NHS Foundation Trust 44 ≤5 (-%) 54 (18, 105)

North Bristol NHS Trust 49 ≤5 (-%) 27 (9, 53)

Northern Devon Healthcare NHS Trust 32 ≤5 (-%) 40 (8.5, 116.5)

Oxford University Hospitals NHS Trust 79 9 (11%) 31 (14, 53)

Plymouth Hospitals NHS Trust 59 14 (24%) 21 (4, 55)

Portsmouth Hospitals NHS Trust 110 17 (16%) 28.5 (9, 69)

Royal Berkshire NHS Foundation Trust 14 ≤5 (-%) 17.5 (5, 56)

Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

71 23 (32%) 14 (2, 36)

Royal National Hospital for Rheumatic Disease NHS Foundation Trust

30 8 (27%) 14.5 (3, 122)

Salisbury NHS Foundation Trust 36 12 (33%) 15.5 (2, 33.5)

Surrey and Sussex Healthcare NHS Trust

57 39 (68%) 2 (1, 8)

Sussex Community NHS Trust 20 ≤5 (-%) 8 (3, 31)

Taunton and Somerset NHS Trust 45 ≤5 (-%) 21 (10, 33)





University Hospital Southampton NHS Foundation Trust

77 ≤5 (-%) 23.5 (12.5, 42)

University Hospitals Bristol NHS Foundation Trust

18 ≤5 (-%) 31.5 (12, 75)

Western Sussex Hospitals NHS Foundation Trust

33 ≤5 (-%) 32 (13, 79)

Weston Area Health NHS Trust 48 8 (17%) 16 (7, 71)

Yeovil District Hospital NHS Foundation Trust

21 ≤5 (-%) 81 (10, 273)

Table 7.38 provider compliance with NICE Quality Standard 1 in Wales




National 5,002 1,020 (20%) 20 (5, 54)

Wales 343 159 (46%) 5 (1, 25)

Abertawe Bro Morgannwg University Health Board

51 24 (47%) 5 (2, 12)

Aneurin Bevan University Health Board 30 ≤5 (-%) 33.5 (18, 66)

Betsi Cadwaladr University Health Board 131 97 (74%) 1 (0, 4)

Cardiff and Vale University Health Board 24 ≤5 (-%) 13 (5, 33.5)

Cwm Taf University Health Board 71 24 (34%) 9 (2, 30)

Hywel Dda University Health Board 36 7 (19%) 20 (4, 65)




NICE Quality Standard 2 recommends that people with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.


Provider name Number of patients recruited



National 5,002 1,844 (37%) 29 (16, 49)

London region 587 276 (47%) 23 (14, 42)


28 ≤5 (-%) 57.5 (34, 87.5)


24 16 (67%) 13.5 (9, 31.5)

Croydon Health Services NHS Trust 81 54 (67%) 19 (12, 25)

Ealing Hospital NHS Trust 27 15 (56%) 19 (14, 36)


25 6 (24%) 35 (23, 42)


42 17 (41%) 25.5 (13, 51)


35 22 (63%) 19 (10, 38)

Imperial College Healthcare NHS Trust 14 ≤5 (-%) 46.5 (24, 65)


103 55 (53%) 21 (13, 36)


54 19 (35%) 30 (19, 42)

Lewisham and Greenwich NHS Trust 28 20 (71%) 16.5 (13.5, 23)


52 14 (27%) 38 (18.5, 56.5)


20 12 (60%) 18 (12.5, 38)


13 ≤5 (-%) 24 (20, 44)


33 16 (49%) 22 (13, 36)





National 5,002 1,844 (37%) 29 (16, 49)

Midlands & East of England region 1,391 472 (34%) 33 (17, 54)


28 ≤5 (-%) 51 (29, 79)

Burton Hospitals NHS Foundation Trust 29 19 (66%) 18 (6, 27)


57 11 (19%) 42 (29, 65)


6 ≤5 (-%) 59 (23, 81)

Derby Hospitals NHS Foundation Trust 83 56 (68%) 15 (12, 31)

Dudley Group NHS Foundation Trust 64 25 (39%) 30.5 (11.5, 51)

East and North Hertfordshire NHS Trust 115 44 (38%) 25 (19, 36)


15 ≤5 (-%) 36 (12, 64)

Heart of England NHS Foundation Trust 43 8 (19%) 50 (24, 69)

Hinchingbrooke Health Care NHS Trust 24 10 (42%) 29.5 (15.5, 83.5)

Ipswich Hospitals NHS Trust 59 53 (90%) 15 (12, 20)


29 6 (21%) 54 (38, 64)


28 6 (21%) 36.5 (22, 66.5)


57 8 (14%) 36 (28, 45)


41 14 (34%) 31 (18, 50)

Nottingham NHS Treatment Centre 122 49 (40%) 26 (17, 41)


59 ≤5 (-%) 49 (33, 70)


70 20 (29%) 40.5 (18, 63)


39 8 (21%) 40 (24, 47)


25 ≤5 (-%) 59 (47, 64)


34 7 (21%) 41 (24, 63)








57 13 (23%) 41 (22, 56)


30 14 (47%) 26.5 (10, 33)


72 27 (38%) 35 (11.5, 63.5)


14 ≤5 (-%) 53 (28, 62)


47 15 (32%) 40 (19, 61)

Walsall Healthcare NHS Trust 12 ≤5 (-%) 87.5 (42, 109)

West Hertfordshire Hospitals NHS Trust 17 ≤5 (-%) 38 (26, 55)

West Suffolk NHS Foundation Trust 18 14 (78%) 16.5 (13, 20)


45 8 (18%) 47 (32, 66)

Wye Valley NHS Trust 30 7 (23%) 38.5 (22, 49)





National 5,002 1,844 (37%) 29 (16, 49)

North of England region 1,576 591 (38%) 29 (16, 48)


63 23 (37%) 27 (19, 36)

Airedale Hospital NHS Foundation Trust 20 6 (30%) 33.5 (17, 42)

Barnsley Hospital NHS Foundation Trust 48 21 (44%) 30.5 (12.5, 46.5)


22 13 (59%) 15 (8, 33)

Bolton NHS Foundation Trust 62 ≤5 (-%) 48.5 (33, 60)


18 ≤5 (-%) 32 (21, 44)


26 11 (42%) 22.5 (11, 49)


59 20 (34%) 30 (19, 40)


36 8 (22%) 35 (22, 50.5)


18 6 (33%) 71 (17, 92)


44 35 (80%) 16 (12, 20)

East Cheshire NHS Trust 25 11 (44%) 23 (20, 46)

East Lancashire Healthcare Trust 50 8 (16%) 50.5 (33, 86)


16 ≤5 (-%) 35 (30.5, 41.5)


7 ≤5 (-%) 21 (13, 33)


31 25 (81%) 13 (10, 21)

Lancashire Care NHS Foundation Trust 51 17 (33%) 38 (18, 60)

Leeds Teaching Hospitals NHS Trust 46 ≤5 (-%) 35.5 (27, 53)


27 8 (30%) 31 (21, 39)

Mid Yorkshire Hospitals NHS Trust 31 19 (61%) 21 (8, 33)


75 51 (68%) 18 (8, 25)








11 ≤5 (-%) 39 (12, 49)


13 ≤5 (-%) 38 (18, 48)


42 17 (41%) 32 (11, 41)

Pennine Acute Hospitals NHS Trust 46 ≤5 (-%) 55.5 (42, 70)

Pennine Musculoskeletal Partnership 96 56 (58%) 19.5 (14, 29)

Rotherham NHS Foundation Trust 24 8 (33%) 29.5 (15, 34)


21 ≤5 (-%) 37 (34, 54)

Salford Royal NHS Foundation Trust 40 7 (18%) 43 (31, 66.5)


47 38 (81%) 13 (8, 21)


95 41 (43%) 26 (16, 49)


28 ≤5 (-%) 54 (34, 74)


42 29 (69%) 15 (7, 32)

Stockport NHS Foundation Trust 10 ≤5 (-%) 22 (18, 26)


44 6 (14%) 39 (28.5, 71)


40 11 (28%) 29.5 (20.5, 47.5)


91 24 (26%) 35 (20, 47)


20 ≤5 (-%) 61.5 (49.5, 65)


47 10 (21%) 43 (23, 77)


28 12 (43%) 28 (16.5, 42)


14 6 (43%) 24.5 (18, 39)





National 5,002 1,844 (37%) 29 (16, 49)

South of England region 1,105 430 (39%) 28 (16, 48)


32 14 (44%) 26.5 (11, 42.5)

Buckinghamshire Healthcare NHS Trust 51 11 (22%) 34 (25, 43)


23 13 (57%) 20 (11, 41)


19 ≤5 (-%) 31 (13, 52)


17 7 (41%) 31 (18, 42)


35 13 (37%) 29 (17, 48)


8 ≤5 (-%) 24 (16, 40)

Isle of Wight NHS Trust 28 7 (25%) 33 (21, 49)

Medway NHS Foundation Trust 44 13 (30%) 38 (16, 63)

North Bristol NHS Trust 49 13 (27%) 47 (20, 74)

Northern Devon Healthcare NHS Trust 32 17 (53%) 20.5 (14.5, 27)

Oxford University Hospitals NHS Trust 79 60 (76%) 14 (7, 21)

Plymouth Hospitals NHS Trust 59 16 (27%) 28 (21, 47)

Portsmouth Hospitals NHS Trust 110 73 (66%) 19 (12, 28)

Royal Berkshire NHS Foundation Trust 14 ≤5 (-%) 26.5 (21, 77)


71 33 (47%) 24 (13, 39)


30 10 (33%) 25 (18, 40)

Salisbury NHS Foundation Trust 36 18 (50%) 21.5 (15, 30.5)


57 9 (16%) 39 (26, 56)

Sussex Community NHS Trust 20 ≤5 (-%) 39 (25, 49.5)

Taunton and Somerset NHS Trust 45 26 (58%) 19 (12, 31)


77 40 (52%) 21 (15, 29)


17 ≤5 (-%) 68 (36, 94)








33 ≤5 (-%) 70 (49, 93)

Weston Area Health NHS Trust 48 ≤5 (-%) 53 (42, 62)


21 6 (29%) 35 (21, 83)





National 5,002 1,844 (37%) 29 (16, 49)

Wales 343 75 (22%) 34 (23, 48)


51 16 (31%) 31 (21, 41)

Aneurin Bevan University Health Board

30 ≤5 (-%) 33 (27, 49)

Betsi Cadwaladr University Health Board

131 38 (29%) 30 (18, 42)

Cardiff and Vale University Health Board

24 ≤5 (-%) 97 (28.5, 170)

Cwm Taf University Health Board 71 14 (20%) 35 (26, 50)

Hywel Dda University Health Board 36 ≤5 (-%) 42 (33.5, 49)


NICE Quality Standard 3 recommends that people with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.


Provider name Number of RA patients






National 3,185 2,170 (68%) 1,400 (46%) 2,494 (86%) 2,495 1,937 (78%)

London region 320 227 (71%) 134 (44%) 240 (83%) 255 188 (74%)


18 ≤5 (-%) ≤5 (-%) 12 (75%) 13 8 (62%)


7 6 (86%) 6 (86%) ≤5 (-%) ≤5 ≤5 (-%)

Croydon Health Services NHS Trust

31 27 (87%) 7 (23%) 24 (77%) 31 24 (77%)

Ealing Hospital NHS Trust 24 20 (83%) 11 (50%) 23 (100%) 19 16 (89%)


19 11 (61%) 6 (32%) 14 (88%) 16 10 (63%)


10 ≤5 (-%) 0 (0%) 7 (70%) 8 6 (75%)


15 12 (80%) ≤5 (-%) 15 (100%) 12 12 (100%)


9 6 (67%) ≤5 (-%) ≤5 (-%) 9 ≤5 (-%)


80 55 (70%) 40 (53%) 57 (86%) 56 40 (71%)


14 10 (71%) ≤5 (-%) 12 (86%) 14 12 (86%)


12 11 (92%) 10 (83%) 7 (78%) 6 ≤5 (-%)


30 18 (60%) 15 (52%) 23 (82%) 29 22 (76%)


17 16 (94%) ≤5 (-%) 14 (88%) 15 12 (80%)


9 9 (100%) 8 (89%) 7 (78%) 8 6 (75%)


19 16 (84%) 11 (58%) 13 (81%) 9 7 (78%)










National 3,185 2,170 (68%) 1,400 (46%) 2,494 (86%) 2,495 1,937 (78%)

Midlands & East of England region

958 572 (60%) 424 (46%) 743 (86%) 795 605 (76%)


23 16 (70%) 7 (37%) 21 (96%) 20 16 (80%)


24 23 (96%) 11 (46%) 15 (79%) 19 10 (53%)


18 10 (56%) 10 (56%) 12 (86%) 8 ≤5 (-%)


6 ≤5 (-%) ≤5 (-%) ≤5 (100%) 6 ≤5 (-%)

Derby Hospitals NHS Foundation Trust

62 40 (65%) 23 (38%) 53 (87%) 56 48 (86%)

Dudley Group NHS Foundation Trust

45 30 (67%) 17 (41%) 40 (89%) 39 32 (82%)


33 27 (82%) 19 (58%) 14 (45%) 31 14 (45%)

George Eliot Hospital NHS Trust

8 ≤5 (-%) ≤5 (-%) ≤5 (-%) 6 ≤5 (-%)


12 ≤5 (-%) ≤5 (-%) 7 (87.5%) 8 ≤5 (-%)

Heart of England NHS Foundation Trust

38 26 (68%) 28 (74%) 32 (89%) 36 31 (86%)

Hinchingbrooke Health Care NHS Trust

16 15 (94%) 10 (63%) 15 (100%) 12 11 (92%)

Ipswich Hospitals NHS Trust 19 6 (33%) ≤5 (-%) 15 (79%) 14 10 (71%)


29 10 (35%) 22 (82%) 24 (92%) 26 20 (77%)


26 26 (100%) 23 (89%) 18 (78%) 20 13 (65%)


43 31 (72%) 28 (65%) 39 (93%) 42 36 (86%)


39 33 (85%) 31 (84%) 27 (87%) 33 22 (67%)

Nottingham NHS Treatment Centre

80 70 (90%) 16 (22%) 65 (100%) 57 50 (88%)


50 15 (30%) 13 (27%) 25 (74%) 41 20 (49%)


40 25 (63%) 34 (85%) 32 (82%) 39 31 (80%)









33 10 (30%) 7 (22%) 24 (78%) 29 18 (62%)


24 13 (54%) 17 (77%) 23 (96%) 22 20 (91%)


28 6 (21%) 7 (30%) 22 (96%) 15 12 (80%)


42 15 (36%) 9 (21%) 34 (81%) 37 29 (78%)


18 10 (56%) ≤5 (-%) 16 (94%) 12 11 (92%)


42 15 (36%) ≤5 (-%) 34 (94%) 34 23 (68%)


11 ≤5 (-%) ≤5 (-%) 10 (100%) 9 6 (67%)


41 22 (54%) 15 (40%) 29 (76%) 29 23 (79%)

Walsall Healthcare NHS Trust 12 ≤5 (-%) 8 (67%) 11 (92%) 11 10 (91%)


15 9 (60%) ≤5 (-%) 11 (73%) 15 11 (73%)

West Suffolk NHS Foundation Trust

6 6 (100%) ≤5 (-%) 6 (100%) ≤5 ≤5 (100%)


38 16 (42%) 18 (49%) 30 (88%) 32 28 (88%)

Wye Valley NHS Trust 27 24 (89%) 17 (63%) 23 (96%) 22 20 (91%)










National 3,185 2,170 (68%) 1,400 (46%) 2,494 (86%) 2,495 1,937 (78%)

North of England region 992 704 (71%) 422 (45%) 800 (87%) 745 618 (83%)


57 55 (97%) 53 (93%) 48 (91%) 41 38 (93%)

Airedale Hospital NHS Foundation Trust

11 6 (55%) 7 (78%) 11 (100%) ≤5 ≤5 (100%)

Barnsley Hospital NHS Foundation Trust

25 16 (64%) ≤5 (-%) 16 (84%) 18 13 (72%)


18 16 (89%) ≤5 (-%) 14 (82%) 16 13 (81%)

Bolton NHS Foundation Trust 34 15 (44%) ≤5 (-%) 31 (91%) 24 22 (92%)


14 13 (93%) 9 (64%) 14 (100%) 10 10 (100%)


12 7 (58%) ≤5 (-%) 7 (58%) 11 6 (55%)


44 39 (89%) 6 (14%) 34 (94%) 31 25 (81%)


31 21 (68%) 26 (84%) 29 (94%) 30 28 (93%)


17 8 (47%) ≤5 (-%) 16 (94%) 15 14 (93%)


27 20 (77%) 9 (33%) 18 (72%) 20 14 (70%)

East Cheshire NHS Trust 18 14 (78%) 12 (67%) 15 (94%) 15 13 (87%)

East Lancashire Healthcare Trust

37 23 (62%) 10 (29%) 25 (83%) 17 14 (82%)


16 11 (69%) ≤5 (-%) 8 (57%) 12 6 (50%)


19 17 (90%) ≤5 (-%) 11 (65%) 18 11 (61%)

Lancashire Care NHS Foundation Trust

46 26 (57%) 31 (67%) 37 (80%) 41 33 (81%)

Leeds Teaching Hospitals NHS Trust

7 ≤5 (-%) 0 (0%) ≤5 (-%) 7 ≤5 (-%)


19 16 (84%) 18 (95%) 15 (79%) 19 15 (79%)

Mid Yorkshire Hospitals NHS Trust

15 11 (73%) ≤5 (-%) 13 (93%) 10 10 (100%)


56 49 (89%) 18 (35%) 48 (91%) 44 34 (77%)









10 9 (90%) 10 (100%) 9 (90%) 9 8 (89%)


12 10 (83%) ≤5 (-%) ≤5 (-%) 6 ≤5 (-%)


25 18 (72%) 6 (24%) 24 (96%) 25 24 (96%)

Pennine Acute Hospitals NHS Trust

31 16 (52%) 21 (68%) 25 (86%) 27 21 (78%)

Pennine Musculoskeletal Partnership

64 49 (77%) 18 (33%) 54 (95%) 32 28 (88%)

Rotherham NHS Foundation Trust

20 19 (95%) 8 (50%) 17 (100%) 11 10 (91%)


10 8 (80%) 9 (90%) 7 (88%) 8 7 (88%)

Salford Royal NHS Foundation Trust

14 8 (57%) 9 (64%) 14 (100%) 13 13 (100%)


37 35 (95%) 27 (73%) 36 (97%) 30 28 (93%)


60 31 (52%) 17 (30%) 51 (96%) 44 40 (91%)


14 7 (50%) ≤5 (-%) 7 (78%) 8 ≤5 (-%)


24 22 (92%) 20 (83%) 23 (100%) 20 19 (95%)


18 8 (44%) ≤5 (-%) 10 (59%) 12 8 (67%)


23 17 (74%) 8 (35%) 18 (78%) 23 18 (78%)

University Hospitals of Morecambe Bay NHS Foundation trust

31 19 (61%) 18 (58%) 26 (90%) 27 23 (85%)


12 6 (50%) ≤5 (-%) 10 (91%) 11 8 (73%)


28 13 (46%) ≤5 (-%) 23 (89%) 9 7 (78%)


20 18 (90%) 9 (45%) 14 (82%) 15 12 (80%)


9 ≤5 (-%) 0 (0%) 8 (89%) 6 ≤5 (-%)










National 3,185 2,170 (68%) 1,400 (46%) 2,494 (86%) 2,495 1,937 (78%)

South of England region 682 492 (73%) 296 (45%) 521 (84%) 534 392 (73%)


15 ≤5 (-%) 0 (0%) 13 (87%) 15 13 (87%)

Buckinghamshire Healthcare NHS Trust

41 28 (68%) 18 (50%) 36 (97%) 21 16 (76%)


13 13 (100%) 6 (46%) 10 (83%) 13 10 (77%)


9 ≤5 (-%) ≤5 (-%) 6 (67%) 9 6 (67%)


13 10 (77%) ≤5 (-%) 10 (91%) 11 7 (64%)


28 21 (75%) 18 (67%) 22 (100%) 26 21 (81%)


6 6 (100%) 0 (0%) ≤5 (-%) ≤5 ≤5 (-%)

Isle of Wight NHS Trust 18 11 (61%) ≤5 (-%) 17 (94%) 16 14 (88%)


14 9 (64%) 8 (67%) 13 (100%) 9 9 (100%)

Medway NHS Foundation Trust 31 24 (77%) 7 (23%) 28 (90%) 27 24 (89%)

North Bristol NHS Trust 33 25 (76%) 9 (28%) 24 (77%) 24 17 (71%)

Northern Devon Healthcare NHS Trust

27 25 (93%) 10 (37%) 24 (89%) 23 18 (78%)

Oxford University Hospitals NHS Trust

38 36 (97%) 26 (68%) 24 (65%) 35 23 (66%)

Plymouth Hospitals NHS Trust 48 30 (63%) 34 (71%) 26 (55%) 45 23 (51%)

Portsmouth Hospitals NHS Trust

80 58 (75%) 30 (39%) 71 (96%) 51 48 (94%)


66 57 (86%) 29 (45%) 44 (86%) 49 32 (65%)


15 13 (87%) 11 (73%) 10 (77%) 13 9 (69%)

Salisbury NHS Foundation Trust

16 15 (94%) 9 (60%) 16 (100%) 13 12 (92%)


25 13 (52%) ≤5 (-%) 18 (86%) 18 9 (50%)

Sussex Community NHS Trust 7 ≤5 (-%) 0 (0%) ≤5 (-%) 6 ≤5 (-%)

Taunton and Somerset NHS Trust

39 25 (64%) 31 (80%) 29 (88%) 31 21 (68%)









22 14 (64%) 9 (41%) 15 (68%) 19 12 (63%)


11 ≤5 (-%) ≤5 (-%) ≤5 (-%) 7 ≤5 (-%)


22 11 (50%) 8 (44%) 21 (96%) 13 12 (92%)

Weston Area Health NHS Trust 25 18 (72%) 8 (33%) 19 (83%) 19 15 (79%)


11 6 (55%) ≤5 (-%) 6 (67%) 7 ≤5 (-%)








National 3,185 2,170 (68%) 1,400 (46%) 2,494 (86%) 2,495 1,937 (78%)

Wales 233 175 (75%) 124 (55%) 190 (90%) 166 134 (81%)


35 32 (91%) 25 (76%) 32 (94%) 27 24 (89%)


16 9 (56%) 6 (38%) 13 (81%) 12 8 (67%)


83 58 (70%) 26 (32%) 60 (90%) 53 44 (83%)


13 6 (46%) 9 (69%) 9 (75%) 8 6 (75%)

Cwm Taf University Health Board

62 54 (87%) 44 (72%) 59 (97%) 43 39 (91%)

Hywel Dda University Health Board

24 16 (67%) 14 (61%) 17 (77%) 23 13 (57%)




NICE Quality Standard 4 recommends that patients with rheumatoid arthritis are offered educational and self-management activities within 1 month of diagnosis.


Provider name Number of RA patients at follow-up


National 2,162 1,438 (67%)

London region 209 123 (59%)

Barking, Havering and Redbridge University Hospitals NHS Trust 12 11 (92%)

Chelsea and Westminster Hospital NHS Foundation Trust 6 6 (100%)

Ealing Hospital NHS Trust 22 19 (86%)

Epsom & St Helier University Hospitals NHS Trust 17 ≤5 (-%)

Homerton University Hospital NHS Foundation Trust 14 10 (71%)

King’s College Hospital NHS Foundation Trust 71 44 (64%)

Lewisham and Greenwich NHS Trust 9 0 (0%)

North West London Hospitals NHS Trust 10 6 (60%)

Royal Free London NHS Foundation Trust 15 ≤5 (-%)

University College London Hospitals NHS Foundation Trust 18 14 (78%)




National 2,162 1,438 (67%)

Midlands & East of England region 645 412 (64%)

Basildon & Thurrock University Hospitals NHS Foundation Trust 20 14 (70%)

Burton Hospitals NHS Foundation Trust 23 23 (100%)

Cambridge University Hospitals NHS Foundation Trust 18 12 (71%)

Chesterfield Royal Hospital NHS Foundation Trust 6 6 (100%)

Derby Hospitals NHS Foundation Trust 12 10 (83%)

Dudley Group NHS Foundation Trust 31 30 (97%)

George Eliot Hospital NHS Trust 6 6 (100%)

Gloucestershire Hospitals NHS Foundation Trust 10 ≤5 (-%)

Heart of England NHS Foundation Trust 22 22 (100%)

Hinchingbrooke Health Care NHS Trust 15 12 (80%)

Ipswich Hospitals NHS Trust 8 0 (0%)

James Paget University Hospital Foundation NHS Trust 26 24 (92%)




Luton and Dunstable University Hospital NHS Foundation Trust 23 0 (0%)

Norfolk and Norwich University Hospital NHS Foundation Trust 19 18 (95%)

Northampton General Hospital NHS Trust 39 21 (57%)

Nottingham NHS Treatment Centre 71 50 (71%)


39 17 (44%)

Royal Wolverhampton Hospitals NHS Trust 9 7 (78%)

Sandwell and West Birmingham Hospital NHS Trust 26 ≤5 (-%)

Sherwood Forest Hospitals NHS Foundation Trust 17 11 (65%)

South Warwickshire NHS Foundation Trust 27 14 (52%)

Southend University Hospital NHS Foundation Trust 12 9 (75%)

Staffordshire and Stoke on Trent Partnership NHS Trust 9 9 (100%)

University Hospitals Birmingham NHS Foundation Trust 40 22 (55%)

University Hospitals Coventry and Warwickshire NHS Trust 11 11 (100%)

University Hospitals of Leicester NHS Trust 31 7 (23%)

Walsall Healthcare NHS Trust 7 0 (0%)

West Hertfordshire Hospitals NHS Trust 7 ≤5 (-%)

Worcestershire Acute Hospitals NHS Trust 28 20 (72%)

Wye Valley NHS Trust 25 24 (96%)






National 2,162 1,438 (67%)

North of England region 697 513 (74%)

Aintree University Hospital NHS Foundation Trust 52 52 (100%)

Airedale Hospital NHS Foundation Trust 10 8 (80%)

Barnsley Hospital NHS Foundation Trust 20 16 (80%)

Blackpool Teaching Hospitals NHS Foundation Trust 15 0 (0%)

Bolton NHS Foundation Trust 24 8 (35%)

Bradford Teaching Hospitals NHS Foundation Trust 14 ≤5 (-%)

City Hospitals Sunderland NHS Foundation Trust 44 34 (77%)

Countess of Chester Hospital NHS Foundation Trust 21 17 (81%)

Doncaster and Bassetlaw Hospitals NHS Foundation Trust 13 12 (92%)

East Cheshire NHS Trust 16 ≤5 (-%)

East Lancashire Healthcare Trust 37 29 (81%)

Gateshead Health NHS Foundation Trust 10 10 (100%)

Hull and East Yorkshire Hospitals NHS Trust 7 7 (100%)

Lancashire Care NHS Foundation Trust 24 23 (96%)

Mid Yorkshire Hospitals NHS Trust 11 10 (91%)

Newcastle upon Tyne Hospitals Foundation Trust 47 47 (100%)

North Cumbria University Hospitals NHS Trust 6 6 (100%)

Northern Lincolnshire and Goole NHS Foundation Trust 12 11 (92%)

Pennine Acute Hospitals NHS Trust 16 12 (75%)

Pennine Musculoskeletal Partnership 56 42 (76%)

Rotherham NHS Foundation Trust 20 17 (85%)

Royal Liverpool & Broadgreen University Hospitals NHS Trust 7 ≤5 (-%)

Salford Royal NHS Foundation Trust 8 ≤5 (-%)

Sheffield Teaching Hospitals NHS Foundation Trust 32 32 (100%)

South Tees Hospitals NHS Foundation Trust 53 49 (93%)

Southport & Formby District General Hospital 11 11 (100%)

St Helens and Knowsley Teaching Hospitals NHS Trust 23 23 (100%)

Tameside Hospital NHS Foundation Trust 12 0 (0%)

University Hospital of South Manchester NHS Foundation Trust 7 0 (0%)

University Hospitals of Morecambe Bay NHS Foundation Trust 12 6 (50%)

Wirral University Teaching Hospital NHS Foundation Trust 28 ≤5 (-%)

Wrightington, Wigan and Leigh NHS Foundation Trust 10 10 (100%)

York Teaching Hospitals NHS Foundation Trust 6 ≤5 (-%)




National 2,162 1,438 (67%)

South of England region 439 300 (69%)

Buckinghamshire Healthcare NHS Trust 38 9 (24%)

East Kent Hospitals University NHS Foundation Trust 8 ≤5 (-%)

Great Western Hospital NHS Foundation Trust 12 8 (67%)

Hampshire Hospitals NHS Foundation Trust 18 16 (89%)

Isle of Wight NHS Trust 14 0 (0%)

Maidstone and Tunbridge Wells NHS Trust 13 ≤5 (-%)

Medway NHS Foundation Trust 12 ≤5 (-%)

North Bristol NHS Trust 19 14 (74%)

Northern Devon Healthcare NHS Trust 25 16 (64%)

Oxford University Hospitals NHS Trust 7 7 (100%)

Plymouth Hospitals NHS Trust 10 9 (90%)

Portsmouth Hospitals NHS Trust 71 64 (91%)


63 63 (100%)

Salisbury NHS Foundation Trust 14 14 (100%)

Surrey and Sussex Healthcare NHS Trust 20 6 (30%)

Taunton and Somerset NHS Trust 29 23 (79%)

University Hospital Southampton NHS Foundation Trust 8 ≤5 (-%)

Western Sussex Hospitals NHS Foundation Trust 12 ≤5 (-%)

Weston Area Health NHS Trust 19 19 (100%)

Yeovil District Hospital NHS Foundation Trust 8 8 (100%)






National 2,162 1,438 (67%)

Wales 172 90 (52%)

Abertawe Bro Morgannwg University Health Board 33 ≤5 (-%)

Aneurin Bevan University Health Board 7 ≤5 (-%)

Betsi Cadwaladr University Health Board 57 21 (37%)

Cardiff and Vale University Health Board 6 ≤5 (-%)

Cwm Taf University Health Board 54 51 (94%)

Hywel Dda University Health Board 15 12 (80%)


NICE Quality Standard 5 recommends that people who have active rheumatoid arthritis should be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.


Provider name Number of RA patients at baseline




N (%) treatment target achieved

National 3,185 2,831 (89%) 2,614 (92%) 2,162 840 (52%)

London region 320 275 (86%) 254 (92%) 209 93 (62%)


18 18 (100%) 16 (89%) 12 ≤5 (-%)


7 ≤5 (-%) ≤5 (100%) 6 ≤5 (-%)

Croydon Health Services NHS Trust 31 30 (97%) 30 (100%) ≤5 ≤5 (-%)

Ealing Hospital NHS Trust 24 18 (75%) 18 (100%) 22 16 (80%)


19 16 (84%) 13 (81%) 17 11 (69%)


10 7 (70%) 6 (86%) ≤5 0 (0%)


15 10 (67%) 10 (100%) 14 6 (60%)

Imperial College Healthcare NHS Trust 9 9 (100%) ≤5 (-%) ≤5 0 (0%)

King’s College Hospital NHS Foundation Trust

80 71 (89%) 63 (89%) 71 27 (59%)

Kingston Hospital NHS Foundation Trust 14 14 (100%) 14 (100%) ≤5 ≤5 (100%)

Lewisham and Greenwich NHS Trust 12 7 (58%) 7 (100%) 9 ≤5 (-%)







North West London Hospitals NHS Trust 30 25 (83%) 24 (96%) 10 ≤5 (-%)


17 15 (88%) 15 (100%) 15 7 (70%)


9 9 (100%) 8 (89%) ≤5 ≤5 (-%)


19 16 (84%) 16 (100%) 18 10 (71%)







National 3,185 2,831 (89%) 2,614 (92%) 2,162 840 (52%)

Midlands & East of England region 958 876 (91%) 816 (93%) 645 220 (46%)


23 23 (100%) 23 (100%) 20 7 (39%)

Burton Hospitals NHS Foundation Trust 24 24 (100%) 24 (100%) 23 14 (64%)


18 15 (83%) 14 (93%) 18 ≤5 (-%)


6 6 (100%) 6 (100%) 6 ≤5 (-%)

Derby Hospitals NHS Foundation Trust 62 59 (95%) 44 (75%) 12 7 (64%)

Dudley Group NHS Foundation Trust 45 42 (93%) 40 (95%) 31 11 (52%)

East and North Hertfordshire NHS Trust 33 19 (58%) 19 (100%) ≤5 ≤5 (100%)

George Eliot Hospital NHS Trust 8 7 (88%) 7 (100%) 6 ≤5 (-%)


12 ≤5 (-%) ≤5 (100%) 10 ≤5 (-%)

Heart of England NHS Foundation Trust 38 35 (92%) 35 (100%) 22 12 (75%)

Hinchingbrooke Health Care NHS Trust 16 16 (100%) 15 (94%) 15 11 (73%)

Ipswich Hospitals NHS Trust 19 15 (79%) 10 (67%) 8 ≤5 (-%)


29 29 (100%) 28 (97%) 26 ≤5 (-%)


26 26 (100%) 26 (100%) 23 ≤5 (-%)


43 42 (98%) 40 (95%) 19 7 (44%)


39 39 (100%) 35 (90%) 39 18 (62%)









Nottingham NHS Treatment Centre 80 74 (93%) 74 (100%) 71 7 (11%)


50 47 (94%) 47 (100%) 39 22 (69%)


40 37 (93%) 35 (95%) 9 ≤5 (-%)


33 33 (100%) 33 (100%) 26 7 (54%)


24 24 (100%) 24 (100%) 17 14 (100%)


28 22 (79%) 22 (100%) 27 13 (62%)


42 40 (95%) 38 (95%) 12 ≤5 (-%)


18 17 (94%) 16 (94%) 9 ≤5 (-%)


42 31 (74%) 24 (77%) 40 8 (40%)


11 11 (100%) 8 (73%) 11 ≤5 (-%)


41 35 (85%) 30 (86%) 31 6 (38%)

Walsall Healthcare NHS Trust 12 12 (100%) 9 (75%) 7 ≤5 (-%)

West Hertfordshire Hospitals NHS Trust 15 15 (100%) 15 (100%) 7 ≤5 (-%)

West Suffolk NHS Foundation Trust 6 6 (100%) 6 (100%) ≤5 0 (0%)


38 36 (95%) 35 (97%) 28 8 (44%)

Wye Valley NHS Trust 27 26 (96%) 25 (96%) 25 8 (35%)







National 3,185 2,831 (89%) 2,614 (92%) 2,162 840 (52%)

North of England region 992 837 (84%) 776 (93%) 697 263 (52%)


57 57 (100%) 56 (98%) 52 27 (53%)

Airedale Hospital NHS Foundation Trust 11 ≤5 (-%) ≤5 (100%) 10 ≤5 (100%)

Barnsley Hospital NHS Foundation Trust 25 24 (96%) 17 (71%) 20 ≤5 (-%)


18 18 (100%) 16 (89%) 15 12 (80%)

Bolton NHS Foundation Trust 34 27 (79%) 23 (85%) 24 9 (50%)


14 11 (79%) 10 (91%) 14 ≤5 (-%)


12 10 (83%) 10 (100%) ≤5 ≤5 (-%)


44 41 (93%) 40 (98%) 44 13 (34%)


31 28 (90%) 24 (86%) 21 ≤5 (-%)


17 17 (100%) 16 (94%) ≤5 ≤5 (-%)


27 23 (85%) 22 (96%) 13 ≤5 (-%)

East Cheshire NHS Trust 18 18 (100%) 18 (100%) 16 ≤5 (100%)

East Lancashire Healthcare Trust 37 34 (92%) 31 (91.2%) 37 11 (46%)

Gateshead Health NHS Foundation Trust 16 10 (63%) 8 (80%) 10 ≤5 (-%)


19 19 (100%) 19 (100%) 7 ≤5 (-%)

Lancashire Care NHS Foundation Trust 46 46 (100%) 46 (100%) 24 14 (58%)

Leeds Teaching Hospitals NHS Trust 7 ≤5 (-%) ≤5 (100%) 0 -


19 18 (95%) 18 (100%) 0 -

Mid Yorkshire Hospitals NHS Trust 15 11 (73%) 10 (91%) 11 9 (100%)


56 54 (96%) 54 (100%) 47 29 (64%)


10 10 (100%) 10 (100%) 6 ≤5 (-%)


12 12 (100%) 12 (100%) 12 9 (75%)


25 22 (88%) 21 (96%) ≤5 0 (0%)

Pennine Acute Hospitals NHS Trust 31 28 (90%) 24 (86%) 16 ≤5 (-%)









Pennine Musculoskeletal Partnership 64 35 (55%) 30 (86%) 56 15 (58%)

Rotherham NHS Foundation Trust 20 19 (95%) 17 (90%) 20 6 (55%)


10 6 (60%) ≤5 (-%) 7 ≤5 (100%)

Salford Royal NHS Foundation Trust 14 13 (93%) 12 (92%) 8 ≤5 (-%)


37 36 (97%) 36 (100%) 32 20 (69%)


60 56 (93%) 55 (98%) 53 23 (47%)


14 14 (100%) 14 (100%) 11 ≤5 (-%)


24 24 (100%) 23 (95.8%) 23 12 (55%)


18 14 (78%) 14 (100%) 12 ≤5 (-%)


23 20 (87%) 18 (90%) 7 0 (0%)


31 30 (97%) 19 (63%) 12 ≤5 (-%)


12 ≤5 (-%) ≤5 (100%) ≤5 ≤5 (-%)


28 ≤5 (-%) ≤5 (100%) 28 0 (0%)


20 10 (50%) 9 (90%) 10 ≤5 (-%)


9 ≤5 (-%) ≤5 (-%) 6 ≤5 (-%)







National 3,185 2,831 (89%) 2,614 (92%) 2,162 840 (52%)

South of England region 682 630 (92%) 582 (92%) 439 183 (54%)


15 15 (100%) 15 (100%) 0 -

Buckinghamshire Healthcare NHS Trust 41 27 (66%) 18 (67%) 38 ≤5 (-%)


13 13 (100%) 13 (100%) 8 ≤5 (-%)


9 8 (89%) 8 (100%) ≤5 ≤5 (100%)


13 13 (100%) 12 (92%) 12 ≤5 (-%)


28 27 (96%) 26 (96%) 18 7 (47%)


6 6 (100%) 6 (100%) ≤5 0 (0%)

Isle of Wight NHS Trust 18 18 (100%) 18 (100%) 14 ≤5 (-%)


14 11 (79%) 9 (82%) 13 ≤5 (-%)

Medway NHS Foundation Trust 31 28 (90%) 28 (100%) 12 ≤5 (-%)

North Bristol NHS Trust 33 31 (94%) 31 (100%) 19 8 (44%)

Northern Devon Healthcare NHS Trust 27 27 (100%) 27 (100%) 25 9 (64%)

Oxford University Hospitals NHS Trust 38 37 (97%) 36 (97%) 7 ≤5 (-%)

Plymouth Hospitals NHS Trust 48 47 (98%) 42 (89%) 10 ≤5 (-%)

Portsmouth Hospitals NHS Trust 80 73 (91%) 71 (97%) 71 43 (67%)


66 64 (97%) 61 (95%) 63 26 (57%)


15 14 (93%) 14 (100%) ≤5 0 (0%)

Salisbury NHS Foundation Trust 16 16 (100%) 16 (100%) 14 10 (83%)


25 18 (72%) 18 (100%) 20 ≤5 (-%)

Sussex Community NHS Trust 7 7 (100%) 7 (100%) ≤5 ≤5 (-%)

Taunton and Somerset NHS Trust 39 39 (100%) 39 (100%) 29 12 (41%)


22 19 (86%) 19 (100%) 8 ≤5 (-%)


11 9 (82%) ≤5 (-%) ≤5 0 (0%)


22 21 (96%) 11 (52%) 12 9 (75%)









Weston Area Health NHS Trust 25 23 (92%) 17 (74%) 19 13 (81%)


11 11 (100%) 9 (82%) 8 ≤5 (-%)







National 3,185 2,831 (89%) 2,614 (92%) 2,162 840 (52%)

Wales 233 213 (91%) 186 (87%) 172 81 (57%)


35 29 (83%) 22 (76%) 33 16 (76%)

Aneurin Bevan University Health Board 16 11 (69%) 9 (82%) 7 ≤5 (-%)

Betsi Cadwaladr University Health Board 83 78 (94%) 78 (100%) 57 15 (28%)

Cardiff and Vale University Health Board 13 13 (100%) 12 (92%) 6 ≤5 (-%)

Cwm Taf University Health Board 62 58 (94%) 49 (85%) 54 37 (77%)

Hywel Dda University Health Board 24 24 (100%) 16 (67%) 15 8 (62%)


NICE Quality Standard 6 states that people with rheumatoid arthritis and disease flares or possible drug related side effects should receive advice within 1 working day of contacting the rheumatology service.

Table 7.59 provider compliance with NICE Quality Standard 6 within the London region

Provider name Number of patients N (%) of patients with access to urgent advice

National 5,002 4,597 (92%)

London region 587 526 (90%)

Barking, Havering and Redbridge University Hospitals NHS Trust 28 28 (100%)

Chelsea and Westminster Hospital NHS Foundation Trust 24 23 (96%)

Croydon Health Services NHS Trust 81 66 (82%)

Ealing Hospital NHS Trust 27 27 (100%)

Epsom & St Helier University Hospitals NHS Trust 25 24 (96%)

Guy's and St Thomas' NHS Foundation Trust 42 39 (93%)

Homerton University Hospital NHS Foundation Trust 35 35 (100%)



Imperial College Healthcare NHS Trust 14 14 (100%)

King’s College Hospital NHS Foundation Trust 103 86 (84%)

Kingston Hospital NHS Foundation Trust 54 51 (94%)

Lewisham and Greenwich NHS Trust 28 18 (64%)

North West London Hospitals NHS Trust 52 44 (85%)

Royal Free London NHS Foundation Trust 20 20 (100%)

St George's Healthcare NHS Trust, London 13 13 (100%)

University College London Hospitals NHS Foundation Trust 33 32 (97%)

Table 7.60 provider compliance with NICE Quality Standard 6 within the Midlands and East of England region


National 5,002 4,597 (92%)

Midlands & East of England region 1,391 1,305 (94%)

Basildon & Thurrock University Hospitals NHS Foundation Trust 28 27 (96%)

Burton Hospitals NHS Foundation Trust 29 29 (100%)

Cambridge University Hospitals NHS Foundation Trust 57 52 (91%)

Chesterfield Royal Hospital NHS Foundation Trust 6 6 (100%)

Derby Hospitals NHS Foundation Trust 83 76 (92%)

Dudley Group NHS Foundation Trust 64 64 (100%)

East and North Hertfordshire NHS Trust 115 115 (100%)

George Eliot Hospital NHS Trust 9 9 (100%)

Gloucestershire Hospitals NHS Foundation Trust 15 14 (93%)

Heart of England NHS Foundation Trust 43 43 (100%)

Hinchingbrooke Health Care NHS Trust 24 24 (100%)

Ipswich Hospitals NHS Trust 59 38 (64%)

James Paget University Hospital Foundation NHS Trust 29 29 (100%)

Luton and Dunstable University Hospital NHS Foundation Trust 28 28 (100%)

Norfolk and Norwich University Hospital NHS Foundation Trust 57 55 (97%)

Northampton General Hospital NHS Trust 41 41 (100%)

Nottingham NHS Treatment Centre 122 104 (85%)


59 45 (76%)





Royal Wolverhampton Hospitals NHS Trust 70 69 (99%)

Sandwell and West Birmingham Hospital NHS Trust 39 39 (100%)

Sherwood Forest Hospitals NHS Foundation Trust 25 25 (100%)

South Warwickshire NHS Foundation Trust 34 33 (97%)

Southend University Hospital NHS Foundation Trust 57 56 (98%)

Staffordshire and Stoke on Trent Partnership NHS Trust 30 28 (93%)

University Hospitals Birmingham NHS Foundation Trust 72 64 (89%)

University Hospitals Coventry and Warwickshire NHS Trust 14 13 (93%)

University Hospitals of Leicester NHS Trust 47 46 (98%)

Walsall Healthcare NHS Trust 12 12 (100%)

West Hertfordshire Hospitals NHS Trust 17 17 (100%)

West Suffolk NHS Foundation Trust 18 16 (89%)

Worcestershire Acute Hospitals NHS Trust 45 45 (100%)

Wye Valley NHS Trust 30 30 (100%)

Table 7.61 provider compliance with NICE Quality Standard 6 within the North of England region


National 5,002 4,597 (92%)

North of England region 1,576 1,421 (90%)

Aintree University Hospital NHS Foundation Trust 63 63 (100%)

Airedale Hospital NHS Foundation Trust 22 22 (100%)

Barnsley Hospital NHS Foundation Trust 48 39 (81%)

Blackpool Teaching Hospitals NHS Foundation Trust 22 22 (100%)

Bolton NHS Foundation Trust 62 62 (100%)

Bradford Teaching Hospitals NHS Foundation Trust 18 18 (100%)

Central Manchester University Hospitals NHS Foundation Trust 26 26 (100%)

City Hospitals Sunderland NHS Foundation Trust 59 59 (100%)

Countess of Chester Hospital NHS Foundation Trust 36 32 (89%)

County Durham and Darlington NHS Foundation Trust 18 14 (78%)

Doncaster and Bassetlaw Hospitals NHS Foundation Trust 44 33 (75%)

East Cheshire NHS Trust 25 25 (100%)

East Lancashire Healthcare Trust 50 39 (78%)





Harrogate and District NHS Foundation Trust 7 7 (100%)

Hull and East Yorkshire Hospitals NHS Trust 31 28 (90%)

Lancashire Care NHS Foundation Trust 51 51 (100%)

Leeds Teaching Hospitals NHS Trust 46 32 (70%)

Mid Cheshire Hospitals NHS Foundation Trust 27 27 (100%)

Mid Yorkshire Hospitals NHS Trust 31 28 (90%)

Newcastle upon Tyne Hospitals Foundation Trust 75 75 (100%)

North Cumbria University Hospitals NHS Trust 11 11 (100%)

Northern Lincolnshire and Goole NHS Foundation Trust 13 13 (100%)

Northumbria Healthcare NHS Foundation Trust 42 40 (95%)

Pennine Acute Hospitals NHS Trust 46 45 (98%)

Pennine Musculoskeletal Partnership 96 74 (77%)

Rotherham NHS Foundation Trust 24 24 (100%)

Royal Liverpool & Broadgreen University Hospitals NHS Trust 21 21 (100%)

Salford Royal NHS Foundation Trust 40 33 (83%)

Sheffield Teaching Hospitals NHS Foundation Trust 47 46 (98%)

South Tees Hospitals NHS Foundation Trust 95 91 (96%)

Southport & Formby District General Hospital 28 28 (100%)

St Helens and Knowsley Teaching Hospitals NHS Trust 42 42 (100%)

Stockport NHS Foundation Trust 10 7 (70%)

Tameside Hospital NHS Foundation Trust 44 ≤5 (-%)

University Hospital of South Manchester NHS Foundation Trust 40 36 (90%)

University Hospitals of Morecambe Bay NHS Foundation Trust 91 80 (88%)

Warrington and Halton Hospital NHS Trust 20 20 (100%)

Wirral University Teaching Hospital NHS Foundation Trust 47 47 (100%)

Wrightington, Wigan and Leigh NHS Foundation Trust 28 27 (96%)

York Teaching Hospitals NHS Foundation Trust 14 13 (93%)



Table 7.62 provider compliance with NICE Quality Standard 6 within the South of England region


National 5,002 4,597 (92%)

South of England region 1,105 1,027 (93%)

Ashford & St Peter's Hospitals NHS Foundation Trust 32 32 (100%)

Buckinghamshire Healthcare NHS Trust 51 45 (88%)

East Kent Hospitals University NHS Foundation Trust 23 22 (96%)

Frimley Park Hospital NHS Foundation Trust 19 19 (100%)

Great Western Hospital NHS Foundation Trust 17 17 (100%)

Hampshire Hospitals NHS Foundation Trust 35 35 (100%)

Heatherwood and Wexham Park Hospitals NHS Foundation Trust 8 8 (100%)

Isle of Wight NHS Trust 28 27 (96%)

Maidstone and Tunbridge Wells NHS Trust 37 28 (76%)

Medway NHS Foundation Trust 44 44 (100%)

North Bristol NHS Trust 49 48 (98%)

Northern Devon Healthcare NHS Trust 32 32 (100%)

Oxford University Hospitals NHS Trust 79 77 (98%)

Plymouth Hospitals NHS Trust 59 59 (100%)

Portsmouth Hospitals NHS Trust 110 102 (93%)

Royal Berkshire NHS Foundation Trust 14 14 (100%)


71 71 (100%)


30 29 (97%)

Salisbury NHS Foundation Trust 36 19 (53%)

Surrey and Sussex Healthcare NHS Trust 57 52 (91%)

Sussex Community NHS Trust 20 13 (65%)

Taunton and Somerset NHS Trust 45 45 (100%)

University Hospital Southampton NHS Foundation Trust 77 70 (91%)

University Hospitals Bristol NHS Foundation Trust 18 18 (100%)

Western Sussex Hospitals NHS Foundation Trust 33 27 (82%)

Weston Area Health NHS Trust 48 46 (96%)

Yeovil District Hospital NHS Foundation Trust 21 17 (81%)

Table 7.63 provider compliance with NICE Quality Standard 6 within Wales


National 5,002 4,597 (92%)

Wales 343 318 (93%)

Abertawe Bro Morgannwg University Health Board 51 45 (88%)

Aneurin Bevan University Health Board 30 24 (80%)

Betsi Cadwaladr University Health Board 131 119 (91%)

Cardiff and Vale University Health Board 24 23 (96%)

Cwm Taf University Health Board 71 71 (100%)

Hywel Dda University Health Board 36 36 (100%)


NICE Quality Standard 7 recommends that people with rheumatoid arthritis should have a comprehensive annual review that is coordinated by the rheumatology service.


Provider name Annual review in place?

Barking, Havering and Redbridge University Hospitals NHS Trust Yes

Chelsea and Westminster Hospital NHS Foundation Trust Yes

Croydon Health Services NHS Trust Yes

Ealing Hospital NHS Trust Yes

Epsom & St Helier University Hospitals NHS Trust Yes

Guy's and St Thomas' NHS Foundation Trust Yes

Homerton University Hospital NHS Foundation Trust Yes

Imperial College Healthcare NHS Trust Yes

King's College Hospital NHS Foundation Trust Yes

Kingston Hospital NHS Foundation Trust Yes

Lewisham and Greenwich NHS Trust No

North West London Hospitals NHS Trust Yes

Royal Free London NHS Foundation Trust Yes

St George's Healthcare NHS Trust, London Yes

University College London Hospitals NHS Foundation Trust Yes

West Middlesex University Hospital NHS Trust Yes





Basildon & Thurrock University Hospitals NHS Foundation Trust Yes

Burton Hospitals NHS Foundation Trust Yes

Cambridge University Hospitals NHS Foundation Trust Yes

Chesterfield Royal Hospital NHS Foundation Trust Yes

Derby Hospitals NHS Foundation Trust Yes

Dudley Group NHS Foundation Trust Yes

East and North Herts NHS Trust Yes

Gloucestershire Hospitals NHS Foundation Trust Yes

Heart of England NHS Foundation Trust Yes

Hinchingbrooke Health Care NHS Trust Yes

Ipswich Hospitals NHS Trust Yes

James Paget University Hospital Foundation NHS Trust Yes

Luton and Dunstable University Hospital NHS Foundation Trust No

Norfolk and Norwich University Hospital NHS Foundation Trust No

Northampton General Hospital NHS Trust Yes

Nottingham NHS Treatment Centre Yes

Peterborough and Stamford Hospitals NHS Foundation Trust Yes

Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust Yes

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust No

Royal Wolverhampton Hospitals NHS Trust Yes

Sandwell and West Birmingham Hospital NHS Trust Yes

Sherwood Forest Hospitals NHS Foundation Trust Yes

South Warwickshire NHS Foundation Trust Yes

Southend University Hospital NHS Foundation Trust Yes

Staffordshire and Stoke on Trent Partnership NHS Trust Yes

University Hospitals Birmingham NHS Foundation Trust Yes

University Hospitals Coventry and Warwickshire NHS Trust Yes

University Hospitals of Leicester NHS Trust No

Walsall Healthcare NHS Trust No

West Hertfordshire Hospitals NHS Trust Yes

West Suffolk NHS Foundation Trust Yes

Worcestershire Acute Hospitals NHS Trust Yes

Wye Valley NHS Trust Yes

Table 7.66 - provider compliance with NICE Quality Standard 7 within the North of England region


Aintree University Hospital NHS Foundation Trust Yes

Airedale Hospital NHS Foundation Trust Yes

Barnsley Hospital NHS Foundation Trust Yes

Blackpool Teaching Hospitals NHS Foundation Trust Yes

Bolton NHS Foundation Trust Yes

Bradford Teaching Hospitals NHS Foundation Trust Yes

Central Manchester University Hospitals NHS Foundation Trust Yes

City Hospitals Sunderland NHS Foundation Trust Yes

Countess of Chester Hospital NHS Foundation Trust Yes

County Durham and Darlington NHS Foundation Trust Yes

Doncaster and Bassetlaw Hospitals NHS Foundation Trust Yes

East Cheshire NHS Trust Yes

East Lancashire Healthcare Trust Yes

Gateshead Health NHS Foundation Trust Yes

Harrogate and District NHS Foundation Trust Yes

Hull and East Yorkshire Hospitals NHS Trust Yes

Lancashire Care NHS Foundation Trust Yes

Leeds Teaching Hospitals NHS Trust Yes

Mid Cheshire Hospitals NHS Foundation Trust No

Mid Yorkshire Hospitals NHS Trust No

Newcastle upon Tyne Hospitals Foundation Trust Yes

North Cumbria University Hospitals NHS Trust No

Northern Lincolnshire and Goole NHS Foundation Trust No

Northumbria Healthcare NHS Foundation Trust No

Pennine Acute Hospitals NHS Trust Yes

Pennine Musculoskeletal Partnership Yes

Rotherham NHS Foundation Trust Yes

Royal Liverpool & Broadgreen University Hospitals NHS Trust Yes

Salford Royal NHS Foundation Trust Yes

Sheffield Teaching Hospitals NHS Foundation Trust Yes

South Tees Hospitals NHS Foundation Trust No

Southport & Formby District General Hospital Yes

St Helens and Knowsley Teaching Hospitals NHS Trust Yes

Stockport NHS Foundation Trust Yes

Tameside Hospital NHS Foundation Trust No

University Hospitals of Morecambe Bay NHS Foundation Trust No





University Hospital of South Manchester NHS Foundation Trust Yes

Warrington and Halton Hospital NHS Trust Yes

Wirral University Teaching Hospital NHS Foundation Trust Yes

Wrightington, Wigan and Leigh NHS Foundation Trust Yes

York Teaching Hospitals NHS Foundation Trust Yes



Ashford & St Peter's Hospitals NHS Foundation Trust Yes

Buckinghamshire Healthcare NHS Trust Yes

East Kent Hospitals University NHS Foundation Trust No

Frimley Park Hospital NHS Foundation Trust No

Great Western Hospital NHS Foundation Trust No

Hampshire Hospitals NHS Foundation Trust Yes

Heatherwood and Wexham Park Hospitals NHS Foundation Trust Yes

Isle of Wight NHS Trust Yes

Medway NHS Foundation Trust Yes

North Bristol NHS Trust Yes

Northern Devon Healthcare NHS Trust Yes

Oxford University Hospitals NHS Trust Yes

Plymouth Hospitals NHS Trust No

Portsmouth Hospitals NHS Trust Yes

Royal Berkshire NHS Foundation Trust Yes

Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust Yes

Royal National Hospital for Rheumatic Disease NHS Foundation Trust No

Salisbury NHS Foundation Trust Yes

Surrey and Sussex Healthcare NHS Trust Yes

Sussex Community NHS Trust Yes

Taunton and Somerset NHS Trust Yes

University Hospitals Bristol NHS Foundation Trust No

University Hospital Southampton NHS Foundation Trust Yes

Western Sussex Hospitals NHS Foundation Trust Yes

Weston Area Health NHS Trust Yes

Yeovil District Hospital NHS Foundation Trust Yes



Abertawe Bro Morgannwg University Health Board No

Aneurin Bevan University Health Board Yes

Betsi Cadwaladr University Health Board Yes

Cardiff and Vale University Health Board No

Cwm Taf University Health Board Yes

Hywel Dda University Health Board Yes

Rheumatoid Arthritis Impact of Disease (RAID) score

The Rheumatoid Arthritis Impact of Disease (RAID) score is the primary patient reported outcome measure for patients with a diagnosis of RA in this audit. Mean RAID scores with their standard deviation are reported at national and regional level for all patients at baseline. For patients with a diagnosis of rheumatoid arthritis, we report the proportion of RA patients for whom baseline and follow up RAID scores were available, mean RAID scores at follow-up, the mean reduction in RAID from baseline and the proportion of patients achieving a Minimum Clinically Important Difference (MCID) for RAID, which has been defined as a reduction of 3 or more points, or a percentage reduction of 50% from the baseline score.



Tabl

e 7.

69

Rhe

umat

oid

Art

hrit

is I

mpa

ct o

f D

isea

se (

RA

ID)

scor

es a

nd c

hang

es in

the

Lon

don

regi

on

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nat

iona

l5

,00

24

,32

4

(86

%)

5.8

(2

.3)

3,1

85

2,7

67

(8

7%

)6

.1 (

2.2

)2

,16

21

,00

1 (

46

%)

4.0

(2

.5)

93

3-2

.2 (

2.5

)4

06

(4

4%

)

Lond

on r

egio

n5

87

474

(8

1%

)5

.5 (

2.4

)3

20

26

4 (

83

%)

6.0

(2

.3)

20

98

8 (

42

%)

3.6

(2

.4)

84

-2.3

(2

.4)

33

(3

9%

)

Bar

king

, H

aver

ing

and

Red

brid

ge

Uni

vers

ity

Hos

pita

ls N

HS

Tr

ust

28

23

(8

2%

)6

.1 (

3.0

)1

81

4 (

78

%)

7.5

(2

.3)

12

≤5

(-%

)-

≤5

-≤

5 (10

0%

)

Che

lsea

and

W

estm

inst

er

Hos

pita

l NH

S

Foun

dati

on

Trus

t

24

16

(6

7%

)5

.7 (

3.1

)7

6 (

86

%)

5.4

(3

.0)

6≤

5 (

-%)

-≤

5-

0 (

0%

)

Cro

ydon

Hea

lth

Ser

vice

s N

HS

Tr

ust

81

64

(79

%)

5.4

(2

.1)

31

22

(71

%)

6.2

(2

.0)

≤5

≤5

(-%

)-

≤5

-≤

5 (

-%)

Eal

ing

Hos

pita

l N

HS

Tru

st27

25

(9

3%

)6

.5 (

2.3

)24

22

(9

2%

)6

.8 (

2.0

)2

21

5 (

68

%)

3.7

(2

.7)

14

-3.2

(2

.7)

7 (

50

%)

Epso

m &

St

Hel

ier

Uni

vers

ity

Hos

pita

ls N

HS

Tr

ust

25

22

(8

8%

)5

.7 (

2.3

)1

91

8 (

95

%)

5.7

(2

.4)

171

1 (

65

%)

4.0

(2

.5)

11

-2.1

(2

.1)

≤5

(-%

)

Hom

erto

n U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

35

≤5

(-%

)-

15

0 (

0%

)1

40

(0

%)

-0

--

Tabl

e 7.

69

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Impe

rial

Col

lege

H

ealt

hcar

e N

HS

Tr

ust

14

11

(79

%)

6.1

(1

.7)

99

(10

0%

)6

.3 (1

.7)

≤5

0 (

0%

)-

0-

-

Kin

g's

Col

lege

H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

10

38

8 (

85

%)

5.9

(2

.5)

80

71 (

89

%)

5.7

(2

.5)

713

3 (47

%)

3.4

(2

.4)

30

-1.8

(2

.0)

11

(37

%)

Kin

gsto

n H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

54

52

(9

6%

)3

.7 (1

.7)

14

14

(10

0%

)4

.4 (1

.7)

≤5

0 (

0%

)-

0-

-

Lew

isha

m a

nd

Gre

enw

ich

NH

S

Trus

t

28

27

(9

6%

)5

.9 (

2.6

)1

21

1 (

92

%)

6.4

(2

.3)

90

(0

%)

-0

--

Nor

th W

est

Lond

on

Hos

pita

ls N

HS

Tr

ust

52

38

(73

%)

5.3

(2

.5)

30

22

(73

%)

5.6

(2

.6)

10

6 (

60

%)

2.4

(1

.9)

6-3

.4 (

2.7

)≤

5 (

-%)

Roy

al F

ree

Lond

on N

HS

Fo

unda

tion

Tr

ust

20

20

(10

0%

)6

.4 (

2.1

)17

17 (10

0%

)6

.9 (1

.5)

15

9 (

60

%)

4.1

(2

.8)

9-2

.7 (

3.6

)≤

5 (

-%)

St

Geo

rge'

s H

ealt

hcar

e N

HS

Tr

ust,

Lon

don

13

13

(10

0%

)5

.5 (

2.7

)9

9 (10

0%

)6

.6 (

2.3

)≤

50

(0

%)

-0

--



Tabl

e 7.

69

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Uni

vers

ity

Col

lege

Lon

don

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

33

32

(97

%)

6.1

(2

.5)

19

19

(10

0%

)6

.1 (

2.6

)1

87

(3

9%

)3

.9 (1

.7)

7-0

.6 (1

.7)

≤5

(-%

)

Tabl

e 7.

70

Rhe

umat

oid

Art

hrit

is I

mpa

ct o

f D

isea

se (

RA

ID)

scor

es a

nd c

hang

es in

the

Mid

land

s an

d E

ast

of E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nat

iona

l5

,00

24

,32

4

(86

%)

5.8

(2

.3)

3,1

85

2,7

67

(8

7%

)6

.1 (

2.2

)2

,16

21

,00

1 (

46

%)

4.0

(2

.5)

93

3-2

.2 (

2.5

)4

06

(4

4%

)

Mid

land

s &

E

ast

of E

ngla

nd

regi

on

13

91

12

54

(9

0%

)5

.8 (

2.3

)9

58

874

(9

1%

)6

.0 (

2.2

)6

45

27

8 (

43

%)

4.1

(2

.5)

26

8-2

.0 (

2.4

)1

10

(4

1%

)

Bas

ildon

&

Thu

rroc

k U

nive

rsit

y H

ospi

tals

NH

S

Foun

dati

on

Trus

t

28

27

(97

%)

7.0

(1

.6)

23

22

(9

6%

)7.

1 (1

.4)

20

≤5

(-%

)-

≤5

-≤

5 (

-%)

Tabl

e 7.

70

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Bur

ton

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

29

28

(97

%)

5.1

(2

.4)

24

23

(9

6%

)5

.2 (

2.4

)2

39

(3

9%

)2

.8 (1

.6)

9-1

.7 (1

.3)

≤5

(-%

)

Cam

brid

ge

Uni

vers

ity

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

57

57

(10

0%

)5

.0 (

2.4

)1

81

8 (10

0%

)5

.9 (

2.4

)1

81

1 (

61

%)

4.7

(2

.5)

11

-0.8

(2

.4)

≤5

(-%

)

Che

ster

field

R

oyal

Hos

pita

l N

HS

Fou

ndat

ion

Trus

t

66

(10

0%

)6

.2 (

2.6

)6

6 (10

0%

)6

.2 (

2.6

)6

≤5

(-%

)-

≤5

-≤

5 (10

0%

)

Der

by H

ospi

tals

N

HS

Fou

ndat

ion

Trus

t

83

67

(8

1%

)5

.5 (

2.1

)6

25

3 (

86

%)

5.4

(2

.1)

12

≤5

(-%

)-

≤5

-0

(0

%)

Dud

ley

Gro

up

NH

S F

ound

atio

n Tr

ust

64

58

(9

1%

)6

.2 (

2.1

)4

54

2 (

93

%)

6.5

(2

.0)

31

17 (

55

%)

4.9

(2

.7)

17-1

.9 (2

.6)

7 (41

%)

Eas

t an

d N

orth

H

ertf

ords

hire

N

HS

Tru

st

11

51

13

(9

8%

)5

.0 (

2.5

)3

331

(9

4%

)4

.4 (

2.4

)≤

5≤

5 (10

0%

)-

≤5

-≤

5 (

-%)

Geo

rge

Elio

t H

ospi

tal

NH

S T

rust

99

(10

0%

)6

.8 (

2.6

)8

8 (10

0%

)6

.8 (

2.8

)6

6 (10

0%

)7.

8 (1

.5)

60

(1

.7)

0 (

0%

)



Tabl

e 7.

70

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Glo

uces

ters

hire

H

ospi

tals

NH

S

Foun

dati

on

Trus

t

15

14

(9

3%

)5

.6 (

2.4

)1

21

1 (

92

%)

6.3

(2

.0)

10

6 (

60

%)

5.4

(2

.6)

≤5

-≤

5 (

-%)

Hea

rt o

f Eng

land

NH

S

Foun

dati

on

Trus

t

43

39

(9

1%

)6

.3 (

2.3

)3

83

4 (

90

%)

6.4

(2

.3)

22

14

(6

4%

)4

.1 (

2.6

)1

2-2

.5 (

2.4

)7

(5

8%

)

Hin

chin

gbro

oke

Hea

lth

Car

e N

HS

Tru

st

24

24

(10

0%

)6

.3 (1

.8)

16

16

(10

0%

)6

.2 (1

.9)

15

10

(6

7%

)2

.7 (

2.3

)10

-3.6

(2

.1)

6 (

60

%)

Ipsw

ich

Hos

pita

ls

NH

S T

rust

59

37

(6

3%

)5

.4 (

2.4

)1

91

5 (

79

%)

6.4

(2

.4)

80

%-

0-

-

Jam

es P

aget

U

nive

rsit

y H

ospi

tal

Foun

dati

on N

HS

Tr

ust

29

28

(97

%)

6.6

(1

.5)

29

28

(97

%)

6.6

(1

.5)

26

21

(8

1%

)3

.6 (

2.1

)2

0-3

.1 (1

.8)

12

(6

0%

)

Luto

n an

d D

unst

able

U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

28

28

(10

0%

)4

.6 (

2.2

)2

62

6 (10

0%

)4

.5 (2

.3)

23

0 (

0%

)-

0-

-

Tabl

e 7.

70

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nor

folk

and

N

orw

ich

Uni

vers

ity

Hos

pita

l NH

S

Foun

dati

on

Trus

t

57

56

(9

8%

)6

.8 (

2.1

)4

34

2 (

98

%)

7.2

(1

.9)

19

13

(6

9%

)4

.5 (2

.3)

13

-3.1

(2

.0)

7 (

54

%)

Nor

tham

pton

G

ener

al

Hos

pita

l N

HS

Tru

st

41

39

(9

5%

)5

.6 (

2.0

)3

937

(9

5%

)5

.7 (

2.0

)3

93

2 (

82

%)

3.6

(2

.1)

31

-1.8

(2

.4)

12

(3

9%

)

Not

ting

ham

N

HS

Tre

atm

ent

Cen

tre

12

210

6 (

87

%)

6.0

(2

.3)

80

70

(8

8%

)6

.4 (

2.0

)71

28

(3

9%

)4

.0 (

2.6

)2

6-2

.3 (

2.8

)1

4 (

54

%)

Rob

ert

Jone

s an

d A

gnes

Hun

t O

rtho

paed

ic

Hos

pita

l NH

S

Foun

dati

on

Trus

t

59

59

(10

0%

)5

.8 (

2.0

)5

05

0 (10

0%

)6

.0 (1

.9)

39

37

(9

5%

)4

.9 (

2.4

)37

-1.1

(2

.5)

7 (1

9%

)

Roy

al

Wol

verh

ampt

on

Hos

pita

ls

NH

S T

rust

70

50

(71

%)

6.6

(1

.4)

40

28

(70

%)

7.0

(1

.0)

9≤

5 (

-%)

-≤

5-

≤5

(-%

)

San

dwel

l an

d W

est

Bir

min

gham

H

ospi

tal

NH

S T

rust

39

39

(10

0%

)5

.8 (

2.3

)3

33

3 (10

0%

)6

.0 (

2.3

)2

68

(31

%)

3.9

(2

.9)

8-0

.9 (1

.3)

≤5

(-%

)



Tabl

e 7.

70

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

She

rwoo

d Fo

rest

Hos

pita

ls

NH

S F

ound

atio

n Tr

ust

25

21

(8

4%

)6

.5 (1

.6)

24

20

(8

3%

)6

.5 (1

.6)

170

(0

%)

-0

--

Sou

th

War

wic

kshi

re

NH

S F

ound

atio

n Tr

ust

34

23

(6

8%

)6

.2 (1

.7)

28

23

(8

2%

)6

.2 (1

.7)

27

14

(5

2%

)3

.8 (

2.8

)1

3-2

.0 (

2.2

)≤

5 (

-%)

Sou

then

d U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

57

49

(8

6%

)5

.2 (

2.6

)4

23

5 (

83

%)

5.2

(2

.6)

12

≤5

(-%

)-

≤5

-0

(0

%)

Sta

ffor

dshi

re

and

Sto

ke

on T

rent

Par

tner

ship

N

HS

Tru

st

30

28

(9

3%

)5

.6 (1

.9)

18

17 (

94

%)

5.8

(2

.0)

90

(0

%)

-0

--

Uni

vers

ity

Hos

pita

ls

Bir

min

gham

N

HS

Fou

ndat

ion

Trus

t

72

72

(10

0%

)5

.3 (

2.6

)4

24

2 (10

0%

)5

.8 (

2.6

)4

08

(2

0%

)3

.9 (

2.0

)8

-1.5

(2

.2)

≤5

(-%

)

Uni

vers

ity

Hos

pita

ls

Cov

entr

y an

d W

arw

icks

hire

N

HS

Tru

st

14

14

(10

0%

)6

.9 (1

.5)

11

11

(10

0%

)7.

2 (1

.4)

11

≤5

(-%

)-

≤5

-≤

5 (10

0%

)

Tabl

e 7.

70

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Wal

sall

Hea

lthc

are

N

HS

Tru

st

12

11

(9

2%

)7.

0 (

2.6

)1

21

1 (

92

%)

7.0

(2

.6)

7≤

5 (

-%)

-≤

5-

≤5

(-%

)

Wes

t H

ertf

ords

hire

H

ospi

tals

N

HS

Tru

st

1717

(10

0%

)5

.7 (

2.7

)1

51

5 (10

0%

)6

.1 (

2.4

)7

≤5

(-%

)-

≤5

-≤

5 (

-%)

Wes

t S

uffo

lk

NH

S F

ound

atio

n Tr

ust

18

17 (

94

%)

5.6

(2

.1)

66

(10

0%

)6

.0 (

2.2

)≤

5≤

5 (10

0%

)-

≤5

-0

(0

%)

Wor

cest

ersh

ire

Acu

te H

ospi

tals

N

HS

Tru

st

45

45

(10

0%

)5

.3 (

2.4

)3

83

8 (10

0%

)5

.6 (

2.4

)2

88

(2

9%

)4

.2 (

3.6

)8

-1.0

(2

.1)

≤5

(-%

)

Wye

Val

ley

N

HS

Tru

st3

02

8 (

93

%)

5.5

(2

.4)

27

25

(9

3%

)5

.7 (

2.3

)2

51

1 (4

4%

)3

.0 (

2.4

)1

1-2

.3 (

2.6

)7

(6

4%

)

Tabl

e 7.

71

Rhe

umat

oid

Art

hrit

is I

mpa

ct o

f D

isea

se (

RA

ID)

scor

es a

nd c

hang

es in

the

Nor

th o

f E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nat

iona

l5

,00

24

,32

4

(86

%)

5.8

(2

.3)

3,1

85

2,7

67

(8

7%

)6

.1 (

2.2

)2

,16

21

,00

1 (

46

%)

4.0

(2

.5)

93

3-2

.2 (

2.5

)4

06

(4

4%

)



Tabl

e 7.

71

Rhe

umat

oid

Art

hrit

is I

mpa

ct o

f D

isea

se (

RA

ID)

scor

es a

nd c

hang

es in

the

Nor

th o

f E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nor

th o

f E

ngla

nd r

egio

n1

,57

61

,33

4

(85

%)

5.9

(2

.3)

99

28

37

(8

4%

)6

.2 (

2.2

)6

97

357

(5

1%

)4

.1 (

2.6

)3

28

-2.2

(2

.6)

14

3 (

44

%)

Ain

tree

U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

63

32

(51

%)

6.7

(2

.1)

57

26

(4

6%

)6

.9 (

2.0

)5

20

(0

%)

-0

--

Air

edal

e H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

22

21

(9

6%

)5

.4 (1

.9)

11

10

(9

1%

)5

.9 (1

.4)

10

9 (

90

%)

3.9

(2

.8)

9-1

.9 (2

.5)

≤5

(-%

)

Bar

nsle

y H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

48

47 (

98

%)

5.3

(2

.3)

25

25

(10

0%

)5

.8 (1

.9)

20

7 (

35

%)

5.2

(2

.3)

7-0

.1 (1

.2)

≤5

(-%

)

Bla

ckpo

ol

Teac

hing

H

ospi

tals

NH

S

Foun

dati

on

Trus

t

22

17 (

77

%)

5.0

(2

.5)

18

14

(78

%)

5.0

(2

.7)

15

7 (47

%)

2.3

(1

.6)

7-2

.8 (

2.3

)≤

5 (

-%)

Bol

ton

NH

S

Foun

dati

on

Trus

t

62

59

(9

5%

)5

.7 (

2.4

)3

431

(9

1%

)6

.1 (

2.5

)24

17 (

71%

)3

.8 (1

.7)

16

-2.4

(2

.4)

7 (4

4%

)

Bra

dfor

d Te

achi

ng

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

18

16

(8

9%

)6

.5 (

2.5

)1

41

2 (

86

%)

6.4

(2

.0)

14

≤5

(-%

)-

≤5

-≤

5 (

-%)

Tabl

e 7.

71

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Cen

tral

M

anch

este

r U

nive

rsit

y H

ospi

tals

NH

S

Foun

dati

on

Trus

t

26

12

(4

6%

)5

.5 (

2.4

)1

2≤

5 (

-%)

-≤

5≤

5 (

-%)

-0

--

Cit

y H

ospi

tals

S

unde

rlan

d N

HS

Fou

ndat

ion

Trus

t

59

58

(9

8%

)6

.6 (

2.4

)4

44

3 (

98

%)

6.6

(2

.6)

44

38

(8

6%

)3

.8 (

2.4

)37

-2.9

(3

.1)

20

(5

4%

)

Cou

ntes

s of

Che

ster

H

ospi

tal N

HS

Fo

unda

tion

Tr

ust

36

28

(78

%)

6.5

(2

.4)

31

24

(7

7%

)6

.7 (

2.4

)2

1≤

5 (

-%)

-≤

5-

≤5

(-%

)

Cou

nty

Dur

ham

an

d D

arlin

gton

N

HS

Fou

ndat

ion

Trus

t

18

13

(72

%)

6.6

(2

.7)

171

2 (

71%

)6

.9 (

2.6

)≤

5≤

5 (

-%)

-0

--

Don

cast

er a

nd

Bas

setl

aw

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

44

43

(9

8%

)6

.1 (1

.8)

27

26

(9

6%

)6

.1 (1

.4)

13

13

(10

0%

)4

.5 (2

.9)

13

-1.5

(2

.8)

≤5

(-%

)

Eas

t C

hesh

ire

NH

S T

rust

25

23

(9

2%

)4

.9 (2

.1)

18

16

(8

9%

)5

.1 (

2.1

)16

6 (

37.

5%

)3

.2 (2

.3)

≤5

-≤

5 (

-%)

Eas

t La

ncas

hire

H

ealt

hcar

e Tr

ust

50

47 (

94

%)

6.0

(2

.2)

37

34

(9

2%

)6

.1 (

2.3

)37

14

(3

8%

)4

.8 (2

.5)

14

-1.2

(2

.5)

≤5

(-%

)



Tabl

e 7.

71

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Gat

eshe

ad

Hea

lth

NH

S

Foun

dati

on

TRU

ST

16

15

(9

4%

)5

.9 (

2.2

)16

15

(9

4%

)5

.9 (

2.2

)10

≤5

(-%

)-

≤5

-≤

5 (

-%)

Har

roga

te a

nd

Dis

tric

t N

HS

Fo

unda

tion

Tr

ust

77

(10

0%

)3

.8 (2

.0)

≤5

≤5

(10

0%

)-

≤5

0 (

0%

)-

0-

-

Hul

l and

Eas

t Yo

rksh

ire

Hos

pita

ls

NH

S T

rust

31

26

(8

4%

)6

.3 (1

.9)

19

17 (

90

%)

6.7

(1

.5)

76

(8

6%

)5

.4 (

2.0

)6

-1.3

(1

.5)

≤5

(-%

)

Lanc

ashi

re C

are

NH

S F

ound

atio

n Tr

ust

51

45

(8

8%

)5

.8 (

2.3

)4

64

0 (

87

%)

5.9

(2

.3)

24

15

(6

3%

)2

.8 (

2.8

)1

3-2

.4 (1

.7)

8 (

62

%)

Leed

s Te

achi

ng

Hos

pita

ls

NH

S T

rust

46

38

(8

3%

)5

.3 (

2.5

)7

≤5

(-%

)-

0-

-0

--

Mid

Che

shir

e H

ospi

tals

NH

S

Foun

dati

on

Trus

t

27

27

(10

0%

)5

.9 (1

.9)

19

19

(10

0%

)6

.2 (

2.0

)0

--

0-

-

Mid

Yor

kshi

re

Hos

pita

ls

NH

S T

rust

31

26

(8

4%

)6

.1 (

2.0

)1

51

2 (

80

%)

7.1

(1

.5)

11

≤5

(-%

)-

≤5

-0

(0

%)

Tabl

e 7.

71

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

New

cast

le u

pon

Tyne

Hos

pita

ls

Foun

dati

on

Trus

t

75

73

(97

%)

6.1

(2

.0)

56

54

(9

6%

)6

.1 (

2.1

)47

22

(47

%)

4.6

(2

.6)

22

-2.0

(2

.7)

7 (

32

%)

Nor

th C

umbr

ia

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

11

11

(10

0%

)5

.3 (1

.5)

10

10

(10

0%

)5

.1 (1

.4)

60

(0

%)

-0

--

Nor

ther

n Li

ncol

nshi

re

and

Goo

le N

HS

Fo

unda

tion

Tr

ust

13

13

(10

0%

)6

.6 (

3.1

)1

21

2 (10

0%

)7.

1 (

2.5

)1

21

2 (10

0%

)3

.6 (1

.9)

12

-3.6

(1

.9)

7 (

58

%)

Nor

thum

bria

H

ealt

hcar

e N

HS

Fo

unda

tion

Tr

ust

42

35

(8

3%

)5

.7 (

2.3

)2

52

0 (

80

%)

5.8

(2

.5)

≤5

≤5

(-%

)-

0-

-

Penn

ine

Acu

te

Hos

pita

ls

NH

S T

rust

46

31

(6

7%

)6

.7 (

2.0

)31

23

(74

%)

6.2

(2

.0)

16

8 (

50

%)

4.4

(3

.2)

8-2

.6 (

3.6

)≤

5 (

-%)

Penn

ine

Mus

culo

skel

etal

Par

tner

ship

96

84

(8

8%

)6

.4 (

2.1

)6

457

(8

9%

)6

.7 (1

.9)

56

35

(6

3%

)3

.8 (

2.8

)3

3-2

.5 (

2.2

)17

(5

2%

)

Rot

herh

am N

HS

Fo

unda

tion

Tr

ust

24

19

(79

%)

5.3

(2

.6)

20

15

(75

%)

5.8

(2

.5)

20

10

(5

0%

)4

.8 (

2.7

)6

0.1

(1

.9)

0 (

0%

)



Tabl

e 7.

71

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Roy

al L

iver

pool

&

Bro

adgr

een

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

21

19

(9

1%

)6

.4 (

2.4

)10

9 (

90

%)

6.8

(2

.9)

77

(10

0%

)3

.9 (

2.7

)6

-2.8

(2

.6)

≤5

(-%

)

Sal

ford

Roy

al

NH

S F

ound

atio

n Tr

ust

40

27

(6

8%

)6

.3 (

2.3

)1

41

3 (

92

.9%

)6

.7 (

2.1

)8

≤5

(-%

)-

≤5

-≤

5 (

-%)

She

ffiel

d Te

achi

ng

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

473

9 (

83

%)

6.9

(2

.1)

37

31

(8

4%

)6

.7 (

2.2

)3

22

0 (

63

%)

2.0

(1

.7)

19

-4.5

(2

.3)

16

(8

4%

)

Sou

th T

ees

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

95

83

(8

7%

)5

.5 (

2.3

)6

05

2 (

87

%)

6.0

(2

.2)

53

33

(6

2%

)4

.6 (

2.4

)3

0-1

.3 (

2.2

)7

(2

3%

)

Sou

thpo

rt

& F

orm

by

Dis

tric

t G

ener

al

Hos

pita

l

28

27

(9

6%

)5

.9 (

2.0

)1

41

4 (10

0%

)6

.4 (

2.1

)1

18

(73

%)

5.8

(2

.4)

8-0

.8 (2

.0)

≤5

(-%

)

St

Hel

ens

and

Kno

wsl

ey

Teac

hing

H

ospi

tals

N

HS

Tru

st

42

39

(9

3%

)6

.3 (

2.3

)24

21

(8

8%

)6

.4 (

2.6

)2

316

(70

%)

4.1

(2

.9)

14

-2.7

(2

.6)

9 (

64

%)

Sto

ckpo

rt N

HS

Fo

unda

tion

Tr

ust

10

10

(10

0%

)5

.6 (

2.5

)≤

5≤

5 (10

0%

)-

0-

-0

--

Tabl

e 7.

71

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Tam

esid

e H

ospi

tal N

HS

Fo

unda

tion

Tru

st

44

31

(71

%)

5.8

(2

.3)

18

15

(8

3%

)5

.7 (

2.2

)1

2≤

5 (

-%)

-≤

5-

≤5

(-%

)

Uni

vers

ity

Hos

pita

l of

Sou

th

Man

ches

ter

NH

S

Foun

datio

n Tr

ust

40

32

(8

0%

)6

.1 (

2.1

)2

31

9 (

83

%)

6.7

(1

.7)

7≤

5 (

-%)

-≤

5-

0 (

0%

)

Uni

vers

ity

Hos

pita

ls o

f M

orec

ambe

Bay

N

HS

Fou

ndat

ion

Trus

t

91

77

(8

5%

)4

.9 (2

.3)

31

26

(8

4%

)5

.9 (

2.3

)1

28

(6

7%

)4

.0 (

3.2

)7

-2.0

(3

.9)

≤5

(-%

)

War

ring

ton

and

Hal

ton

Hos

pita

l N

HS

Tru

st

20

17 (

85

%)

6.5

(1

.6)

12

10

(8

3%

)6

.1 (1

.5)

≤5

0 (

0%

)-

0-

-

Wirra

l Uni

vers

ity

Teac

hing

H

ospi

tal N

HS

Fo

unda

tion

Tru

st

473

5 (

75

%)

5.1

(2

.2)

28

22

(79

%)

5.6

(1

.9)

28

13

(4

6%

)6

.1 (

2.5

)9

0.0

(2

.6)

≤5

(-%

)

Wri

ghti

ngto

n,

Wig

an a

nd L

eigh

N

HS

Fou

ndat

ion

Trus

t

28

23

(8

2%

)6

.3 (

2.1

)2

016

(8

0%

)6

.1 (

2.2

)10

≤5

(-%

)-

≤5

-≤

5 (

-%)

York

Tea

chin

g H

ospi

tals

NH

S

Foun

dati

on

Trus

t

14

9 (

64

%)

3.8

(2

.5)

96

(6

7%

)4

.8 (2

.3)

60

(0

%)

-0

--



Tabl

e 7.

72

Rhe

umat

oid

Art

hrit

is I

mpa

ct o

f D

isea

se (

RA

ID)

scor

es a

nd c

hang

es in

the

Sou

th o

f E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nat

iona

l5

,00

24

,32

4

(86

%)

5.8

(2

.3)

3,1

85

2,7

67

(8

7%

)6

.1 (

2.2

)2

,16

21

,00

1 (

46

%)

4.0

(2

.5)

93

3-2

.2 (

2.5

)4

06

(4

4%

)

Sou

th o

f E

ngla

nd r

egio

n1

,10

59

49

(8

6%

)5

.5 (

2.3

)6

82

579

(8

5%

)5

.7 (

2.3

)4

39

19

0 (

43

%)

3.6

(2

.4)

170

-2.4

(2

.2)

78

(4

6%

)

Ashf

ord

&

St

Pete

r's

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

32

32

(10

0%

)5

.5 (

2.9

)1

51

5 (10

0%

)5

.6 (

3.0

)0

--

0-

-

Buc

king

ham

shire

H

ealth

care

N

HS

Tru

st

51

42

(8

2%

)5

.6 (

2.6

)41

37

(9

0%

)5

.9 (

2.5

)3

80

(0

%)

-0

--

Eas

t K

ent

Hos

pita

ls

Uni

vers

ity

NH

S

Foun

dati

on

Trus

t

23

19

(8

3%

)5

.0 (

2.0

)1

31

1 (

85

%)

5.6

(2

.1)

80

(0

%)

-0

--

Frim

ley

Park

H

ospi

tal N

HS

Fo

unda

tion

Tru

st

19

18

(9

5%

)5

.8 (

2.3

)9

9 (10

0%

)7.

0 (1

.8)

≤5

0 (

0%

)-

0-

-

Gre

at W

este

rn

Hos

pita

l NH

S

Foun

dation

Tru

st

1716

(9

4%

)6

.2 (1

.5)

13

12

(9

2%

)6

.3 (1

.6)

12

7 (

58

%)

4.7

(2

.1)

6-2

.5 (

2.7

)≤

5 (

-%)

Ham

pshi

re

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

35

29

(8

3%

)5

.8 (1

.7)

28

22

(79

%)

5.6

(1

.9)

18

7 (

39

%)

3.2

(2

.6)

6-1

.8 (1

.4)

≤5

(-%

)

Tabl

e 7.

72

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Hea

ther

woo

d an

d W

exha

m

Par

k H

ospi

tals

N

HS

Fou

ndat

ion

Trus

t

88

(10

0%

)5

.6 (

2.7

)6

6 (10

0%

)5

.1 (

3.0

)≤

50

(0

%)

-0

--

Isle

of

Wig

ht

NH

S T

rust

28

20

(71

%)

5.0

(2

.7)

18

13

(72

%)

5.0

(2

.8)

14

0 (

0%

)-

0-

-

Mai

dsto

ne a

nd

Tunb

ridg

e W

ells

N

HS

Tru

st

37

34

(9

2%

)5

.0 (1

.9)

14

13

(9

3%

)4

.8 (1

.8)

13

6 (4

6%

)2

.9 (

0.9

)6

-1.4

(1

.5)

≤5

(-%

)

Med

way

NH

S

Foun

dati

on

Trus

t

44

41

(9

3%

)6

.0 (

2.2

)31

30

(97

%)

6.1

(2

.4)

12

≤5

(-%

)-

≤5

-≤

5 (

-%)

Nor

th B

rist

ol

NH

S T

rust

49

47 (

96

%)

5.7

(2

.2)

33

31

(9

4%

)5

.7 (

2.2

)1

98

(4

2%

)1

.9 (1

.6)

7-2

.8 (

3.1

)≤

5 (

-%)

Nor

ther

n D

evon

H

ealt

hcar

e

NH

S T

rust

32

30

(9

4%

)5

.2 (

2.3

)27

25

(9

3%

)4

.9 (

2.4

)2

52

2 (

88

%)

3.5

(2

.3)

21

-1.9

(2

.2)

8 (

38

%)

Oxf

ord

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

79

75

(9

5%

)6

.2 (

2.0

)3

837

(97

%)

6.3

(2

.3)

70

(0

%)

-0

--

Plym

outh

H

ospi

tals

N

HS

Tru

st

59

36

(6

1%

)5

.1 (

2.3

)4

83

4 (

71%

)5

.1 (

2.2

)10

0 (

0%

)-

0-

-



Tabl

e 7.

72

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Port

smou

th

Hos

pita

ls

NH

S T

rust

110

96

(8

7%

)5

.9 (

2.1

)8

06

8 (

85

%)

6.4

(2

.0)

716

2 (

87

%)

3.9

(2

.2)

54

-2.6

(2

.1)

27

(5

0%

)

Roy

al B

erks

hire

N

HS

Fou

ndat

ion

Trus

t

14

14

(10

0%

)7.

8 (1

.6)

≤5

≤5

(10

0%

)-

≤5

0 (

0%

)-

0-

-

Roy

al

Bou

rnem

outh

an

d C

hris

tchu

rch

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

715

5 (

78

%)

5.6

(2

.3)

66

52

(79

%)

5.7

(2

.2)

63

20

(3

2%

)2

.7 (1

.9)

19

-3.0

(1

.8)

13

(6

9%

)

Roy

al N

atio

nal

Hos

pita

l for

R

heum

atic

D

isea

se N

HS

Fo

unda

tion

Tr

ust

30

22

(73

%)

3.8

(2

.4)

15

11

(73

%)

3.8

(2

.1)

≤5

≤5

(-%

)-

≤5

-≤

5 (

-%)

Sal

isbu

ry N

HS

Fo

unda

tion

Tr

ust

36

32

(8

9%

)5

.3 (

2.4

)16

13

(8

1%

)6

.8 (1

.8)

14

10

(71

%)

4.6

(2

.2)

8-2

.2 (

2.6

)≤

5 (

-%)

Sur

rey

and

Sus

sex

Hea

lthc

are

NH

S

Trus

t

57

54

(9

5%

)5

.1 (

2.3

)2

524

(9

6%

)5

.1 (

2.6

)2

00

(0

%)

-0

--

Sus

sex

Com

mun

ity

N

HS

Tru

st

20

18

(9

0%

)5

.6 (1

.9)

76

(8

6%

)6

.3 (

2.1

)≤

5≤

5 (10

0%

)-

≤5

-≤

5 (

-%)

Tabl

e 7.

72

con

tinu

ed

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Taun

ton

and

Som

erse

t

NH

S T

rust

45

39

(8

7%

)5

.9 (

2.3

)3

93

3 (

85

%)

5.8

(2

.3)

29

10

(3

5%

)5

.5 (

2.6

)9

-0.5

(1

.5)

≤5

(-%

)

Uni

vers

ity

Hos

pita

l S

outh

ampt

on

NH

S F

ound

atio

n Tr

ust

77

63

(8

2%

)5

.1 (

2.5

)2

21

3 (

59

%)

6.4

(2

.5)

88

(10

0%

)3

.2 (

3.2

)6

-2.8

(3

.6)

≤5

(-%

)

Uni

vers

ity

Hos

pita

ls B

rist

ol

NH

S F

ound

atio

n Tr

ust

18

16

(8

9%

)6

.6 (1

.7)

11

9 (

82

%)

6.5

(1

.7)

≤5

≤5

(-%

)-

≤5

-≤

5 (

-%)

Wes

tern

Sus

sex

Hos

pita

ls N

HS

Fo

unda

tion

Tr

ust

33

32

(97

%)

4.9

(2

.3)

22

22

(10

0%

)4

.8 (2

.6)

12

6 (

50

%)

1.0

(0

.4)

6-4

.3 (1

.5)

6 (10

0%

)

Wes

ton

Are

a H

ealt

h N

HS

Tr

ust

48

31

(6

5%

)5

.1 (

2.5

)2

51

3 (

52

%)

6.3

(2

.2)

19

≤5

(-%

)-

≤5

-≤

5 (

-%)

Yeov

il D

istr

ict

Hos

pita

l NH

S

Foun

dati

on

Trus

t

21

20

(9

5%

)4

.8 (2

.3)

11

11

(10

0%

)5

.1 (

2.0

)8

≤5

(-%

)-

≤5

-≤

5 (

-%)



Tabl

e 7.

73

Rhe

umat

oid

Art

hrit

is I

mpa

ct o

f D

isea

se (

RA

ID)

scor

es a

nd c

hang

es in

Wal

es

Pro

vide

r na

me

Num

ber

of

pati

ents

at

base

line

N (

%)

of

pati

ents

w

ith

RA

ID

at b

asel

ine

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

sN

(%

) of

R

A p

atie

nts

wit

h R

AID

at

bas

elin

e

Mea

n (S

D)

RA

ID a

t ba

selin

e

Num

ber

of

RA

pat

ient

s at

fol

low

-up

N (

%)

of

RA

pat

ient

s w

ith

RA

ID

at f

ollo

w-u

p

Mea

n (S

D)

RA

ID a

t fo

llow

-up

in

RA

pat

ient

s

Num

ber

of

RA

pat

ient

s w

ith

ba

selin

e

& f

ollo

w-u

p R

AID

Mea

n (S

D)

chan

ge in

RA

ID in

RA

pa

tien

ts

N (

%)

RA

pa

tien

ts

wit

h M

CID

Nat

iona

l5

,00

24

,32

4

(86

%)

5.8

(2

.3)

3,1

85

2,7

67

(8

7%

)6

.1 (

2.2

)2

,16

21

,00

1 (

46

%)

4.0

(2

.5)

93

3-2

.2 (

2.5

)4

06

(4

4%

)

Wal

es3

43

31

3 (

91

%)

6.2

(2

.3)

23

32

13

(9

1%

)6

.5 (

2.3

)17

28

8 (

51

%)

3.9

(2

.2)

83

-2.8

(2

.6)

42

(5

1%

)

Abe

rtaw

e B

ro

Mor

gann

wg

Uni

vers

ity

Hea

lth

Boa

rd

51

46

(9

0%

)6

.4 (1

.8)

35

32

(9

1%

)6

.8 (1

.4)

33

17 (

52

%)

4.0

(2

.7)

17-3

.0 (

2.7

)9

(5

3%

)

Ane

urin

Bev

an

Uni

vers

ity

Hea

lth

Boa

rd

30

26

(8

7%

)5

.7 (

2.9

)16

15

(9

4%

)5

.6 (

3.4

)7

≤5

(-%

)-

≤5

-0

(0

%)

Bet

si C

adw

alad

r U

nive

rsit

y H

ealt

h B

oard

131

12

1 (

92

%)

5.7

(2

.4)

83

74 (

89

%)

6.1

(2

.5)

57

23

(4

0%

)4

.1 (

2.0

)1

9-2

.2 (

2.4

)8

(4

2%

)

Car

diff

and

Va

le U

nive

rsit

y H

ealt

h B

oard

24

21

(8

8%

)6

.1 (

2.2

)1

31

1 (

85

%)

5.6

(2

.1)

6≤

5 (

-%)

-≤

5-

≤5

(10

0%

)

Cw

m T

af

Uni

vers

ity

Hea

lth

Boa

rd

716

4 (

90

%)

7.5

(1

.9)

62

58

(9

4%

)7.

6 (1

.9)

54

31

(57

%)

3.9

(2

.3)

31

-3.5

(2

.6)

20

(6

5%

)

Hyw

el D

da

Uni

vers

ity

Hea

lth

Boa

rd

36

35

(97

%)

6.0

(2

.0)

24

23

(9

6%

)5

.9 (1

.9)

15

13

(8

7%

)3

.5 (1

.7)

12

-1.5

(1

.7)

≤5

(-%

)

Disease Activity Score (DAS)

DAS-28 is the second validated outcome measure reported in this audit that has a component of patient reporting within it. DAS-28 provides an assessment of disease activity in rheumatoid arthritis using a composite of clinician and patient-derived measures. The DAS-28 can range from 0-9.55. A DAS-28 > 5.1 defines high disease activity with scores of 3.2-5.1 reflecting intermediate disease activity and scores < 3.2 reflecting low disease activity. A DAS-28 <2.6 is considered to indicate remission. A reduction in DAS-28 of >1.2 is considered to be a clinically meaningful response. Baseline DAS-28 are presented for the first table of providers in individual NHS regions and from follow up visits in the second table.

Table 7.74 Disease activity score at presentation in the London region



Mean (SD) DAS score

Remission Low disease activity



National 3,185 2,557 (80%) 5.0 (1.4) 114 (5%) 135 (5%) 1080 (42%) 1,228 (48%)

London region 320 255 (80%) 5.0 (1.4) 12 (5%) 18 (7%) 101 (40%) 124 (49%)


18 9 (50%) 5.0 (2.4) ≤5 (-%) ≤5 (-%) ≤5 (-%) ≤5 (-%)


7 6 (86%) 5.9 (1.6) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


31 29 (94%) 4.7 (1.2) ≤5 (-%) 0 (0%) 14 (48%) 13 (45%)

Ealing Hospital NHS Trust

24 24 (100%) 5.3 (1.0) 0 (0%) 0 (0%) 10 (42%) 14 (58%)


19 11 (58%) 5.2 (1.9) ≤5 (-%) ≤5 (-%) ≤5 (-%) 7 (64%)


10 8 (80%) 5.0 (1.1) 0 (0%) ≤5 (-%) ≤5 (-%) ≤5 (-%)


15 15 (100%) 4.8 (0.8) 0 (0%) ≤5 (-%) 11 (73%) ≤5 (-%)


9 9 (100%) 5.1 (1.6) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)

King’s College Hospital NHS Foundation Trust

80 69 (86%) 5.0 (1.4) ≤5 (-%) ≤5 (-%) 25 (36%) 36 (52%)


14 13 (93%) 4.1 (1.6) ≤5 (-%) ≤5 (-%) ≤5 (-%) ≤5 (-%)






Mean (SD) DAS score





12 7 (58%) 5.6 (1.2) 0 (0%) ≤5 (-%) 0 (0%) 6 (86%)


30 12 (40%) 3.8 (1.4) ≤5 (-%) ≤5 (-%) 6 (50%) ≤5 (-%)


17 15 (88%) 5.4 (1.1) 0 (0%) 0 (0%) 6 (40%) 9 (60%)


9 8 (89%) 5.4 (1.1) 0 (0%) 0 (0%) ≤5 (-%) 6 (75%)


19 16 (84%) 4.9 (1.7) 0 (0%) ≤5 (-%) 9 (56%) 6 (38%)

Tabl

e 7.

75

Dis

ease

Act

ivit

y S

core

at

follo

w u

p an

d ch

ange

s in

sco

re in

the

Lon

don

regi

on

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nat

iona

l2

,16

21

,73

6 (

80

%)

3.5

(1

.5)

53

1 (

31

%)

25

4 (

15

%)

70

3 (

41

%)

24

8 (

14

%)

-1.7

(1

.6)

84

9 (

60

%)

Lond

on2

09

175

(8

4%

)3

.3 (

1.5

)6

0 (

34

%)

31

(1

8%

)6

5 (

37

%)

19

(1

1%

)-1

.8 (

1.7

)9

4 (

64

%)

Bar

king

, H

aver

ing

and

Red

brid

ge

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

12

8 (

67

%)

4.8

(0

.7)

0 (

0%

)0

(0

%)

6 (

75

%)

≤5

(-%

)-1

.1 (

3.4

)≤

5 (

-%)

Che

lsea

and

W

estm

inst

er

Hos

pita

l NH

S

Foun

dati

on T

rust

66

(10

0%

)3

.4 (1

.1)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-2.2

(1

.4)

≤5

(-%

)

Eal

ing

Hos

pita

l N

HS

Tru

st2

22

1 (

96

%)

3.0

(1

.1)

10

(4

8%

)≤

5 (

-%)

7 (

33

%)

≤5

(-%

)-2

.2 (1

.3)

18

(8

6%

)

Epso

m &

St

Hel

ier

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

171

1 (

65

%)

3.2

(1

.3)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-2.4

(1

.2)

6 (

86

%)

Hom

erto

n U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tru

st

14

12

(8

6%

)2

.9 (1

.2)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.8

(1

.4)

8 (

67

%)

Kin

g’s

Col

lege

H

ospi

tal N

HS

Fo

unda

tion

Tru

st

715

9 (

83

%)

3.4

(1

.5)

19

(3

2%

)1

1 (1

9%

)2

1 (

36

%)

8 (1

4%

)-1

.3 (1

.6)

29

(57

%)

Lew

isha

m a

nd

Gre

enw

ich

N

HS

Tru

st

99

(10

0%

)3

.9 (1

.5)

≤5

(-%

)0

(0

%)

6 (

67

%)

≤5

(-%

)-2

.0 (

2.4

)≤

5 (

-%)



Tabl

e 7.

75

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nor

th W

est

Lond

on

Hos

pita

ls

NH

S T

rust

10

7 (

70

%)

3.7

(0

.9)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

0.7

(0

.9)

0 (

0%

)

Roy

al F

ree

Lond

on N

HS

Fo

unda

tion

Tru

st

15

14

(9

3%

)2

.9 (1

.5)

6 (4

3%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-2.5

(1

.9)

9 (

69

%)

Uni

vers

ity

Col

lege

Lon

don

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

18

13

(72

%)

3.0

(2

.0)

7 (

54

%)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)-1

.7 (1

.4)

≤5

(-%

)

Table 7.76 Disease activity score at presentation in the Midlands and East of England region



Mean (SD) DAS score




National 3,185 2,557 (80%) 5.0 (1.4) 114 (5%) 135 (5%) 1,080 (42%) 1,228 (48%)


958 821 (86%) 5.0 (1.3) 40 (5%) 35 (4%) 369 (45%) 377 (46%)


23 21 (91%) 5.3 (1.0) 0 (0%) 0 (0%) 9 (43%) 12 (57%)


24 23 (96%) 5.0 (1.2) ≤5 (-%) 0 (0%) 13 (57%) 9 (39%)


18 16 (89%) 4.5 (1.3) ≤5 (-%) 0 (0%) 9 (56%) ≤5 (-%)


6 6 (100%) 5.3 (1.7) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


62 59 (95%) 4.6 (1.6) 7 (12%) ≤5 (-%) 25 (42%) 24 (41%)


45 29 (64%) 5.8 (1.1) 0 (0%) ≤5 (-%) 8 (28%) 20 (69%)


33 31 (94%) 4.0 (1.2) 6 (19%) ≤5 (-%) 17 (55%) 6 (19%)


8 8 (100%) 4.5 (1.0) 0 (0%) ≤5 (-%) ≤5 (-%) ≤5 (-%)


12 8 (67%) 4.7 (1.1) ≤5 (-%) 0 (0%) ≤5 (-%) ≤5 (-%)


38 37 (97%) 5.4 (1.1) 0 (0%) 0 (0%) 18 (49%) 19 (51%)


16 16 (100%) 5.6 (1.3) 0 (0%) 0 (0%) 6 (38%) 10 (63%)

Ipswich Hospitals NHS Trust

19 19 (100%) 4.3 (1.5) ≤5 (-%) ≤5 (-%) 8 (42%) 7 (37%)


29 29 (100%) 5.9 (1.3) 0 (0%) ≤5 (-%) 7 (24%) 21 (72%)






Mean (SD) DAS score





26 25 (96%) 3.7 (1.0) ≤5 (-%) ≤5 (-%) 16 (64%) ≤5 (-%)


43 38 (88%) 5.2 (1.2) ≤5 (-%) 0 (0%) 17 (45%) 20 (53%)


39 35 (90%) 5.5 (1.4) ≤5 (-%) 0 (0%) 13 (37%) 20 (57%)


80 46 (58%) 4.9 (1.2) ≤5 (-%) ≤5 (-%) 26 (57%) 18 (39%)


50 41 (82%) 4.8 (1.4) ≤5 (-%) ≤5 (-%) 24 (59%) 14 (34%)


40 37 (93%) 5.4 (1.1) 0 (0%) ≤5 (-%) 16 (43%) 20 (54%)


33 33 (100%) 5.3 (1.0) 0 (0%) 0 (0%) 17 (52%) 16 (49%)


24 23 (96%) 4.7 (1.3) 0 (0%) ≤5 (-%) 13 (57%) 7 (30%)


28 8 (29%) 5.2 (1.1) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


42 39 (93%) 4.6 (1.3) ≤5 (-%) ≤5 (-%) 17 (44%) 15 (39%)


18 18 (100%) 5.9 (1.3) 0 (0%) 0 (0%) ≤5 (-%) 13 (72%)


42 29 (69%) 5.2 (1.3) ≤5 (-%) ≤5 (-%) 11 (38%) 16 (55%)


11 11 (100%) 5.4 (0.9) 0 (0%) 0 (0%) ≤5 (-%) 7 (64%)




Mean (SD) DAS score





41 34 (83%) 4.6 (1.2) ≤5 (-%) ≤5 (-%) 22 (65%) 9 (27%)

Walsall Healthcare NHS Trust

12 12 (100%) 6.5 (1.3) 0 (0%) 0 (0%) ≤5 (-%) 11 (92%)


15 14 (93%) 4.6 (1.5) 0 (0%) ≤5 (-%) 8 (57%) ≤5 (-%)


6 6 (100%) 4.7 (0.7) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


38 34 (90%) 4.7 (1.3) ≤5 (-%) ≤5 (-%) 10 (29%) 18 (53%)

Wye Valley NHS Trust

27 26 (96%) 5.2 (1.4) 0 (0%) ≤5 (-%) 8 (31%) 14 (54%)



Tabl

e 7.

77

Dis

ease

Act

ivit

y S

core

at

follo

w u

p an

d ch

ange

s in

sco

re in

the

Mid

land

s an

d E

ast

of E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nat

iona

l2

16

217

36

(8

0.3

%)

3.5

(1

.5)

53

1 (

30

.6%

)2

54

(1

4.6

%)

70

3 (

40

.5%

)2

48

(1

4.3

%)

-1.7

(1

.6)

84

9 (

60

.3%

)

Mid

land

s &

E

ast

of E

ngla

nd6

45

50

0 (

77.

5%

)3

.7 (

1.4

)1

29

(2

5.8

%)

70

(1

4.0

%)

22

2 (

44

.4%

)7

9 (

15

.8%

)-1

.6 (

1.5

)2

49

(5

9.3

%)

Bas

ildon

&

Thu

rroc

k U

nive

rsit

y H

ospi

tals

NH

S

Foun

dati

on T

rust

20

18

(9

0.0

%)

3.5

(1

.5)

6 (

33

.3%

)≤

5 (

-%)

7 (

38

.9%

)≤

5 (

-%)

-1.9

(1

.5)

10

(6

2.5

%)

Bur

ton

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

23

23

(10

0%

)3

.5 (1

.6)

6 (

26

.1%

)≤

5 (

-%)

8 (

34

.8%

)≤

5 (

-%)

-1.6

(1

.3)

15

(6

8.2

%)

Cam

brid

ge

Uni

vers

ity

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

18

≤5

(-%

)4

.2 (1

.4)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.2

(1

.0)

≤5

(-%

)

Che

ster

field

R

oyal

Hos

pita

l N

HS

Fou

ndat

ion

Trus

t

66

(10

0%

)2

.5 (

2.0

)≤

5 (

-%)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)-2

.8 (1

.2)

6 (10

0%

)

Der

by H

ospi

tals

N

HS

Fou

ndat

ion

Trus

t

12

≤5

(-%

)4

.8 (2

.0)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

0.8

(1

.3)

0 (

0%

)

Dud

ley

Gro

up

NH

S F

ound

atio

n Tr

ust

31

30

(9

6.8

%)

4.1

(1

.8)

7 (2

3.3

%)

≤5

(-%

)10

(3

3.3

%)

10

(3

3.3

%)

-1.9

(1

.8)

11

(57.

9%

)

Eas

t an

d N

orth

H

erts

NH

S T

rust

≤5

≤5

(10

0%

)2

.5 (

0.9

)≤

5 (

-%)

0 (

0%

)≤

5 (

-%)

0 (

0%

)-0

.7 (

2.5

)≤

5 (

-%)

Geo

rge

Elio

t H

ospi

tal

NH

S T

rust

66

(10

0%

)5

.0 (1

.3)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-0.1

(1

.5)

≤5

(-%

)

Tabl

e 7.

77

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Glo

uces

ters

hire

H

ospi

tals

NH

S

Foun

dati

on T

rust

10

6 (

60

.0%

)3

.6 (1

.3)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-0.7

(0

.4)

0 (

0%

)

Hea

rt o

f Eng

land

N

HS

Fou

ndat

ion

Trus

t

22

21

(9

5.5

%)

3.9

(1

.3)

≤5

(-%

)≤

5 (

-%)

10

(47

.6%

)≤

5 (

-%)

-1.8

(1

.5)

14

(70

.0%

)

Hin

chin

gbro

oke

Hea

lth

Car

e N

HS

Tru

st

15

13

(8

6.7

%)

3.1

(1

.9)

8 (

61

.5%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-2.6

(1

.6)

10

(76

.9%

)

Ipsw

ich

Hos

pita

ls

NH

S T

rust

8≤

5 (

-%)

4.7

(2

.5)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

-0.4

(1

.2)

≤5

(-%

)

Jam

es P

aget

U

nive

rsit

y H

ospi

tal

Foun

dati

on

NH

S T

rust

26

20

(76

.9%

)3

.6 (1

.4)

≤5

(-%

)≤

5 (

-%)

9 (4

5.0

%)

≤5

(-%

)-2

.3 (1

.4)

16

(8

0.0

%)

Luto

n an

d D

unst

able

U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tru

st

23

≤5

(-%

)2

.9 (

0.4

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

0 (

0%

)-1

.5 (

0.7

)≤

5 (

-%)

Nor

folk

and

N

orw

ich

Uni

vers

ity

Hos

pita

l NH

S

Foun

dati

on T

rust

19

17 (

89.5

%)

3.5

(1

.4)

6 (

35

.3%

)≤

5 (

-%)

7 (41

.2%

)≤

5 (

-%)

-1.5

(1

.6)

9 (

56

.3%

)

Nor

tham

pton

G

ener

al H

ospi

tal

NH

S T

rust

39

38

(97.

4%

)3

.2 (1

.3)

13

(3

4.2

%)

≤5

(-%

)1

5 (

39.5

%)

≤5

(-%

)-2

.3 (1

.4)

26

(76

.5%

)



Tabl

e 7.

77

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Not

ting

ham

N

HS

Tre

atm

ent

Cen

tre

715

5 (

77.

5%

)3

.6 (1

.2)

10

(1

8.2

%)

11

(2

0.0

%)

28

(5

0.9

%)

6 (10

.9%

)-1

.6 (1

.7)

14

(51

.9%

)

Pete

rbor

ough

an

d S

tam

ford

H

ospi

tals

NH

S

Foun

dati

on T

rust

≤5

≤5

(10

0%

)3

.5 (1

.1)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-2.0

(1

.4)

≤5

(-%

)

Rob

ert

Jone

s an

d A

gnes

Hun

t O

rtho

paed

ic

Hos

pita

l NH

S

Foun

dati

on T

rust

39

33

(8

4.6

%)

3.8

(1

.4)

9 (

27.

3%

)≤

5 (

-%)

16

(4

8.5

%)

6 (1

8.2

%)

-1.1

(1

.5)

14

(4

8.3

%)

Roy

al

Wol

verh

ampt

on

Hos

pita

ls

NH

S T

rust

99

(10

0%

)3

.7 (1

.3)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

.-2.0

(1

.2)

6 (

75

.0%

)

San

dwel

l an

d W

est

Bir

min

gham

H

ospi

tal

NH

S T

rust

26

17 (

65

.4%

)4

.2 (1

.4)

≤5

(-%

)≤

5 (

-%)

10

(5

8.8

%)

≤5

(-%

)-1

.3 (1

.5)

9 (

52

.9%

)

She

rwoo

d Fo

rest

Hos

pita

ls

NH

S F

ound

atio

n Tr

ust

179

(5

2.9

%)

3.0

(1

.0)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-2.0

(1

.8)

≤5

(-%

)

Sou

th

War

wic

kshi

re

NH

S F

ound

atio

n Tr

ust

27

12

(4

4.4

%)

3.7

(1

.0)

≤5

(-%

)≤

5 (

-%)

8 (

66

.7%

)≤

5 (

-%)

-2.0

(1

.8)

≤5

(-%

)

Tabl

e 7.

77

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Sou

then

d U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tru

st

12

10

(8

3.3

%)

4.4

(1

.2)

≤5

(-%

)0

(0

%)

7 (

70

.0%

)≤

5 (

-%)

-1.1

(0

.8)

≤5

(-%

)

Sta

ffor

dshi

re

and

Sto

ke

on T

rent

Par

tner

ship

N

HS

Tru

st

99

(10

0%

)2

.9 (

0.8

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

0 (

0%

)-2

.7 (1

.7)

7 (

77.

8%

)

Uni

vers

ity

Hos

pita

ls

Bir

min

gham

N

HS

Fou

ndat

ion

Trus

t

40

30

(75

.0%

)3

.8 (1

.5)

7 (2

3.3

%)

≤5

(-%

)1

5 (

50

.0%

)≤

5 (

-%)

-1.5

(1

.1)

13

(5

9.1

%)

Uni

vers

ity

Hos

pita

ls

Cov

entr

y an

d W

arw

icks

hire

N

HS

Tru

st

11

11

(10

0%

)4

.1 (

0.9

)≤

5 (

-%)

0 (

0%

)9

(8

1.8

%)

≤5

(-%

)-1

.3 (1

.0)

6 (

54

.5%

)

Uni

vers

ity

Hos

pita

ls o

f Le

ices

ter

N

HS

Tru

st

31

24

(7

7.4

%)

3.3

(1

.6)

9 (

37.

5%

)≤

5 (

-%)

7 (

29.2

%)

≤5

(-%

)-1

.3 (1

.6)

12

(57.

1%

)

Wal

sall

Hea

lthc

are

N

HS

Tru

st

77

(10

0%

)4

.5 (1

.7)

0 (

0%

)≤

5 (

-%)

5 (

71.4

%)

≤5

(-%

)-1

.7 (1

.3)

≤5

(-%

)

Wes

t H

ertf

ords

hire

H

ospi

tals

N

HS

Tru

st

7≤

5 (

-%)

3.4

(2

.2)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.6

(0

.7)

≤5

(-%

)



Tabl

e 7.

77

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Wes

t S

uffo

lk

NH

S F

ound

atio

n Tr

ust

≤5

≤5

(10

0%

)4

.6 (.)

0 (

0%

)0

(0

%)

≤5

(10

0%

)0

(0

%)

0.2

(.)

0 (

0%

)

Wor

cest

ersh

ire

Acu

te H

ospi

tals

N

HS

Tru

st

28

23

(8

2.1

%)

3.7

(1

.5)

6 (

26

.1%

)≤

5 (

-%)

9 (

39.1

%)

≤5

(-%

)-1

.1 (1

.8)

10

(4

3.5

%)

Wye

Val

ley

N

HS

Tru

st2

524

(9

6.0

%)

3.6

(1

.5)

6 (

25

.0%

)≤

5 (

-%)

13

(5

4.2

%)

≤5

(-%

)-1

.5 (1

.6)

14

(6

0.9

%)

Table 7.78 Disease activity score at presentation in the North of England region



Mean (SD) DAS score




National 3,185 2,557 (80%) 5.0 (1.4) 114 (5%) 135 (5%) 1,080 (42%) 1,228 (48%)

North of England region

992 748 (75%) 5.1 (1.4) 27 (4%) 41 (6%) 295 (39%) 385 (52%)


57 9 (16%) 5.8 (1.3) 0 (0%) 0 (0%) ≤5 (-%) 6 (67%)


11 11 (100%) 5.3 (1.1) 0 (0%) 0 (0%) 6 (55%) ≤5 (-%)


25 21 (84%) 4.6 (1.2) ≤5 (-%) ≤5 (-%) 11 (52%) 7 (33%)


18 14 (78%) 4.9 (0.9) 0 (0%) ≤5 (-%) 6 (43%) 7 (50%)

Bolton NHS Foundation Trust

34 32 (94%) 4.9 (1.4) ≤5 (-%) ≤5 (-%) 14 (44%) 12 (38%)


14 9 (64%) 6.4 (0.8) 0 (0%) 0 (0%) ≤5 (-%) 8 (89%)


12 11 (92%) 5.4 (1.0) 0 (0%) 0 (0%) ≤5 (-%) 7 (64%)


44 43 (98%) 4.9 (1.4) ≤5 (-%) ≤5 (-%) 22 (51%) 16 (37%)


31 23 (74%) 6.3 (1.4) 0 (0%) ≤5 (-%) ≤5 (-%) 18 (78%)


17 12 (71%) 4.6 (1.0) 0 (0%) ≤5 (-%) 6 (50%) ≤5 (-%)


27 22 (82%) 4.9 (1.6) ≤5 (-%) ≤5 (-%) 8 (36%) 11 (50%)

East Cheshire NHS Trust

18 16 (89%) 3.9 (1.4) ≤5 (-%) ≤5 (-%) 6 (38%) ≤5 (-%)


37 29 (79%) 4.8 (1.4) ≤5 (-%) ≤5 (-%) 11 (38%) 13 (45%)






Mean (SD) DAS score





16 ≤5 (-%) 4.6 (0.9) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


19 12 (63%) 5.3 (0.7) 0 (0%) 0 (0%) ≤5 (-%) 9 (75%)


46 34 (74%) 5.2 (1.6) ≤5 (-%) ≤5 (-%) 11 (32%) 19 (56%)


7 ≤5 (-%) 5.7 (1.8) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


19 17 (90%) 5.3 (1.0) 0 (0%) ≤5 (-%) ≤5 (-%) 12 (71%)


15 13 (87%) 5.4 (1.0) 0 (0%) 0 (0%) 6 (46%) 7 (54%)


56 51 (91%) 4.3 (1.4) ≤5 (-%) 9 (18%) 24 (47%) 14 (28%)


10 10 (100%) 5.1 (1.1) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


12 12 (100%) 6.0 (1.2) 0 (0%) 0 (0%) ≤5 (-%) 8 (67%)


25 22 (88%) 5.3 (1.4) ≤5 (-%) 0 (0%) 7 (32%) 14 (64%)


31 30 (97%) 5.5 (1.3) 0 (0%) ≤5 (-%) 10 (33%) 19 (63%)


64 45 (70%) 5.3 (1.1) ≤5 (-%) ≤5 (-%) 15 (33%) 28 (62%)


20 18 (90%) 4.9 (1.3) ≤5 (-%) 0 (0%) 9 (50%) 8 (44%)


10 6 (60%) 5.2 (2.2) ≤5 (-%) 0 (0%) ≤5 (-%) ≤5 (-%)




Mean (SD) DAS score





14 6 (43%) 4.5 (0.8) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


37 33 (89%) 5.1 (1.2) ≤5 (-%) 0 (0%) 14 (42%) 18 (55%)


60 47 (78%) 5.1 (1.3) ≤5 (-.%) ≤5 (-%) 17 (36%) 27 (57%)


14 12 (86%) 5.0 (1.0) 0 (0%) 0 (0%) 7 (58%) ≤5 (-%)


24 24 (100%) 5.3 (1.5) ≤5 (-%) 0 (0%) 6 (25%) 16 (67%)


18 16 (89%) 5.2 (1.3) 0 (0%) ≤5 (-%) 6 (38%) 9 (56%)


23 20 (87%) 4.8 (1.2) 0 (0%) ≤5 (-%) 13 (65%) 6 (30%)


31 28 (90%) 5.6 (1.4) 0 (0%) ≤5 (-%) 7 (25%) 19 (68%)


12 11 (92%) 5.0 (1.0) 0 (0%) 0 (0%) 7 (64%) ≤5 (-%)


28 ≤5 (-%) 6.4 (0.2) 0 (0%) 0 (0%) 0 (0%) ≤5 (100%)


20 6 (30%) 5.9 (1.9) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


9 7 (78%) 4.8 (1.6) ≤5 (-%) 0 (0%) ≤5 (-%) ≤5 (-%)



Tabl

e 7.

79

Dis

ease

Act

ivit

y S

core

at

follo

w u

p an

d ch

ange

s in

sco

re in

the

Nor

th o

f E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nat

iona

l2

,16

21

,73

6 (

80

%)

3.5

(1

.5)

53

1 (

31

%)

25

4 (

15

%)

70

3 (

41

%)

24

8 (

14

%)

-1.7

(1

.6)

84

9 (

60

%)

Nor

th o

f E

ngla

nd r

egio

n6

97

54

1 (

78

%)

3.5

(1

.5)

16

9 (

31

%)

79

(1

5%

)2

19

(4

1%

)74

(1

4%

)-1

.7 (

1.7

)2

51

(6

2%

)

Ain

tree

U

nive

rsit

y H

ospi

tal N

HS

Fo

unda

tion

Tru

st

52

51

(9

8%

)3

.5 (1

.3)

12

(24

%)

10

(2

0%

)2

2 (4

3%

)7

(1

4%

)-2

.2 (

0.7

)≤

5 (10

0%

)

Air

edal

e H

ospi

tal N

HS

Fo

unda

tion

Tru

st

10

10

(10

0%

)3

.5 (1

.6)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

-1.9

(1

.4)

7 (

70

%)

Bar

nsle

y H

ospi

tal N

HS

Fo

unda

tion

Tru

st

20

10

(5

0%

)4

.6 (

0.9

)0

(0

%)

≤5

(-%

)7

(70

%)

≤5

(-%

)-0

.3 (

0.8

)≤

5 (

-%)

Bla

ckpo

ol

Teac

hing

H

ospi

tals

NH

S

Foun

dati

on T

rust

15

14

(9

3%

)2

.8 (

0.9

)6

(4

3%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-2.4

(1

.4)

10

(9

1%

)

Bol

ton

NH

S

Foun

dati

on T

rust

24

19

(79

%)

3.2

(1

.1)

7 (

37

%)

0 (

0%

)1

1 (

58

%)

≤5

(-%

)-1

.7 (1

.7)

12

(6

7%

)

Bra

dfor

d Te

achi

ng

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

14

9 (

64

%)

4.1

(1

.2)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.8

(1

.3)

≤5

(-%

)

Cit

y H

ospi

tals

S

unde

rlan

d N

HS

Fo

unda

tion

Tru

st

44

41

(9

3%

)3

.4 (1

.2)

12

(2

9%

)6

(1

5%

)2

2 (

54

%)

≤5

(-%

)-1

.5 (1

.3)

25

(6

3%

)

Cou

ntes

s of

C

hest

er H

ospi

tal

NH

S F

ound

atio

n Tr

ust

21

18

(8

6%

)4

.1 (1

.2)

≤5

(-%

)≤

5 (

-%)

9 (

50

%)

≤5

(-%

)-1

.8 (1

.9)

8 (

62

%)

Tabl

e 7.

79

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Don

cast

er a

nd

Bas

setl

aw

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

13

13

(10

0%

)3

.0 (1

.7)

7 (

54

%)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)-1

.6 (

2.4

)6

(6

0%

)

Eas

t C

hesh

ire

NH

S T

rust

16

≤5

(-%

)3

.2 (1

.6)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.5

(3

.0)

≤5

(-%

)

Eas

t La

ncas

hire

H

ealt

hcar

e Tr

ust

37

22

(6

0%

)3

.4 (1

.4)

6 (27

%)

≤5

(-%

)1

1 (

50

%)

≤5

(-%

)-1

.6 (1

.4)

12

(6

7%

)

Gat

eshe

ad

Hea

lth

NH

S

Foun

dati

on T

rust

10

≤5

(-%

)4

.4 (1

.7)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

-2.6

(.)

≤5

(10

0%

)

Hul

l and

Eas

t Yo

rksh

ire

Hos

pita

ls

NH

S T

rust

70

(0

%)

--

--

--

-

Lanc

ashi

re C

are

NH

S F

ound

atio

n Tr

ust

24

20

(8

3%

)2

.7 (1

.3)

12

(6

0.0

%)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)-1

.9 (1

.9)

11

(6

5%

)

Mid

Yor

kshi

re

Hos

pita

ls

NH

S T

rust

11

9 (

82

%)

3.7

(1

.1)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.6

(1

.6)

≤5

(-%

)

New

cast

le u

pon

Tyne

Hos

pita

ls

Foun

dati

on T

rust

4741

(8

7%

)3

.3 (1

.6)

18

(4

4%

)6

(1

5%

)10

(24

%)

7 (17

%)

-0.9

(1

.7)

20

(5

3%

)

Nor

th C

umbr

ia

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

66

(10

0%

)3

.3 (1

.4)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-1.7

(2

.0)

≤5

(-%

)



Tabl

e 7.

79

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nor

ther

n Li

ncol

nshi

re

and

Goo

le N

HS

Fo

unda

tion

Tru

st

12

12

(10

0%

)3

.8 (1

.4)

≤5

(-%

)≤

5 (

-%)

7 (

58

%)

≤5

(-%

)-2

.2 (1

.1)

10

(8

3%

)

Penn

ine

Acu

te

Hos

pita

ls

NH

S T

rust

16

8 (

50

%)

3.7

(1

.4)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.7

(2

.1)

≤5

(-%

)

Penn

ine

Mus

culo

skel

etal

Par

tner

ship

56

38

(6

8%

)3

.8 (1

.7)

12

(3

2%

)≤

5 (

-%)

13

(3

4%

)9

(24

%)

-1.9

(1

.7)

17 (

71%

)

Rot

herh

am N

HS

Fo

unda

tion

Tru

st2

01

3 (

65

%)

3.5

(1

.5)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.7

(1

.2)

7 (

58

%)

Roy

al L

iver

pool

&

Bro

adgr

een

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

77

(10

0%

)3

.1 (1

.4)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-1.7

(1

.2)

≤5

(-%

)

Sal

ford

Roy

al

NH

S F

ound

atio

n Tr

ust

87

(8

8%

)3

.0 (1

.2)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)0

(0

%)

-1.6

(2

.0)

≤5

(-%

)

She

ffiel

d Te

achi

ng

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

32

31

(97

%)

2.2

(1

.4)

22

(71

%)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)-2

.8 (1

.5)

22

(8

2%

)

Sou

th T

ees

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

53

47 (

89

%)

3.4

(1

.5)

16

(3

4%

)7

(1

5%

)17

(3

6%

)7

(1

5%

)-1

.6 (1

.9)

22

(5

4%

)

Sou

thpo

rt &

Fo

rmby

Dis

tric

t G

ener

al H

ospi

tal

11

8 (

73

%)

3.8

(1

.2)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.3

(1

.6)

≤5

(-%

)

Tabl

e 7.

79

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

St

Hel

ens

and

Kno

wsl

ey

Teac

hing

H

ospi

tals

N

HS

Tru

st

23

21

(9

1%

)3

.0 (1

.6)

9 (4

3%

)≤

5 (

-%)

8 (

38

%)

≤5

(-%

)-2

.3 (1

.7)

15

(71

%)

Tam

esid

e H

ospi

tal N

HS

Fo

unda

tion

Tru

st

12

6 (

50

%)

4.0

(1

.5)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.4

(2

.4)

≤5

(-%

)

Uni

vers

ity

Hos

pita

l of

Sou

th

Man

ches

ter

NH

S F

ound

atio

n Tr

ust

77

(10

0%

)3

.8 (

0.7

)0

(0

%)

≤5

(-%

)6

(8

6%

)0

(0

%)

-1.5

(1

.4)

≤5

(-%

)

Uni

vers

ity

Hos

pita

ls o

f M

orec

ambe

Bay

N

HS

Fou

ndat

ion

Trus

t

12

11

(9

2%

)4

.4 (1

.7)

≤5

(-%

)≤

5 (

-%)

6 (

55

%)

≤5

(-%

)-1

.0 (1

.3)

≤5

(-%

)

Wir

ral U

nive

rsit

y Te

achi

ng

Hos

pita

l NH

S

Foun

dati

on T

rust

28

12

(4

3%

)4

.5 (1

.4)

≤5

(-%

)0

(0

%)

7 (

58

%)

≤5

(-%

)-2

.1 (.)

≤5

(10

0%

)

Wri

ghti

ngto

n,

Wig

an a

nd L

eigh

N

HS

Fou

ndat

ion

Trus

t

10

7 (

70

%)

3.7

(1

.8)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

-1.8

(0

.5)

≤5

(10

0%

)

York

Tea

chin

g H

ospi

tals

NH

S

Foun

dati

on T

rust

6≤

5 (

-%)

6.0

(0

.7)

0 (

0%

)0

(0

%)

0 (

0%

)≤

5 (10

0%

)0

.4 (.)

0 (

0%

)



Table 7.80 Disease activity score at presentation in the South of England region



Mean (SD) DAS score




National 3,185 2,557 (80%) 5.0 (1.4) 114 (5%) 135 (5%) 1,080 (42%) 1,228 (48%)

South of England region

682 517 (76%) 5.0 (1.4) 24 (5%) 30 (6%) 227 (44%) 236 (46%)


15 14 (93%) 4.9 (1.9) ≤5 (-%) 0 (0%) 7 (50%) 6 (43%)


41 19 (46%) 4.6 (1.4) ≤5 (-%) ≤5 (-%) 12 (63%) ≤5 (-%)


13 11 (85%) 4.7 (1.2) 0 (0%) 0 (0%) 7 (64%) ≤5 (-%)


9 9 (100%) 4.2 (1.5) ≤5 (-%) ≤5 (-%) ≤5 (-%) ≤5 (-%)


13 8 (62%) 4.9 (1.5) ≤5 (-%) 0 (0%) ≤5 (-%) ≤5 (-%)


28 20 (71%) 5.3 (1.2) 0 (0%) ≤5 (-%) 10 (50.0%) 9 (45%)


6 ≤5 (-%) 4.5 (1.7) ≤5 (-%) 0 (0%) ≤5 (-%) ≤5 (-%)

Isle of Wight NHS Trust

18 13 (72%) 5.5 (1.5) ≤5 (-%) 0 (0%) ≤5 (-%) 9 (69%)


14 13 (93%) 3.8 (1.0) ≤5 (-%) ≤5 (-%) 10 (77%) 0 (0%)

Medway NHS Foundation Trust

31 29 (94%) 5.1 (1.2) ≤5 (-%) ≤5 (-%) 13 (45%) 14 (48%)

North Bristol NHS Trust

33 19 (58%) 5.0 (1.2) 0 (0%) ≤5 (-%) 10 (53%) 8 (42%)


27 22 (82%) 4.5 (1.1) 0 (0%) ≤5 (-%) 13 (59%) ≤5 (-%)


38 6 (16%) 5.4 (1.3) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)

Plymouth Hospitals NHS Trust

48 47 (98%) 4.8 (1.2) ≤5 (-%) ≤5 (-%) 24 (51%) 20 (43%)


National 3,185 2,557 (80%) 5.0 (1.4) 114 (5%) 135 (5%) 1,080 (42%) 1,228 (48%)


80 52 (65%) 5.5 (1.3) ≤5 (-%) ≤5 (-%) 17 (33%) 32 (62%)

Royal Berkshire NHS Foundation Trust

≤5 ≤5 (100%) 5.8 (0.8) 0 (0%) 0 (0%) ≤5 (-%) ≤5 (-%)


66 57 (86%) 4.9 (1.4) ≤5 (-%) 6 (11%) 23 (40%) 26 (46%)


15 14 (93%) 3.8 (1.2) ≤5 (-%) ≤5 (-%) 7 (50%) ≤5 (-%)


16 14 (88%) 5.7 (1.2) 0 (0%) 0 (0%) ≤5 (-%) 10 (71%)


25 25 (100%) 4.6 (1.3) ≤5 (-%) ≤5 (-%) 12 (48%) 10 (40%)

Sussex Community NHS Trust

7 7 (100%) 4.8 (1.2) ≤5 (-%) 0 (0%) ≤5 (-%) ≤5 (-%)


39 37 (95%) 5.2 (1.6) ≤5 (-%) ≤5 (-%) 11 (30%) 22 (60%)


22 9 (41%) 5.5 (1.8) ≤5 (-%) 0 (0%) ≤5 (-%) 6 (67%)


11 8 (73%) 5.0 (1.1) 0 (0%) 0 (0%) 6 (75%) ≤5 (-%)


22 22 (100%) 5.2 (1.5) ≤5 (-%) ≤5 (-%) 6 (27%) 13 (59%)

Weston Area Health NHS Trust

25 20 (80%) 5.0 (1.0) 0 (0%) ≤5 (-%) 8 (40%) 11 (55%)


11 8 (73%) 5.0 (1.7) 0 (0%) ≤5 (-%) ≤5 (-%) ≤5 (-%)



Tabl

e 7.

81

Dis

ease

Act

ivit

y S

core

at

follo

w u

p an

d ch

ange

s in

sco

re in

the

Sou

th o

f E

ngla

nd r

egio

n

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nat

iona

l2

,16

21

,73

6 (

80

%)

3.5

(1

.5)

53

1 (

31

%)

25

4 (

15

%)

70

3 (

41

%)

24

8 (

14

%)

-1.7

(1

.6)

84

9 (

60

%)

Sou

th o

f E

ngla

nd4

39

37

1 (

85

%)

3.5

(1

.5)

11

2 (

30

%)

55

(1

5%

)1

43

(3

9%

)6

1 (

16

%)

-1.5

(1

.7)

15

8 (

54

%)

Buc

king

ham

shire

H

ealth

care

N

HS

Tru

st

38

23

(6

1%

)2

.9 (1

.4)

9 (

39

%)

≤5

(-%

)9

(3

9%

)≤

5 (

-%)

-2.0

(1

.8)

7 (

58

%)

Eas

t K

ent

Hos

pita

ls

Uni

vers

ity

NH

S

Foun

dati

on T

rust

87

(8

8%

)3

.2 (1

.5)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.3

(2

.4)

≤5

(-%

)

Gre

at W

este

rn

Hos

pita

l NH

S

Foun

dati

on T

rust

12

8 (

67

%)

4.5

(1

.7)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-0.6

(2

.6)

≤5

(-%

)

Ham

pshi

re

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

18

16

(8

9%

)3

.4 (1

.3)

≤5

(-%

)≤

5 (

-%)

8 (

50

%)

≤5

(-%

)-1

.8 (1

.5)

7 (

54

%)

Isle

of

Wig

ht

NH

S T

rust

14

14

(10

0%

)3

.5 (1

.2)

≤5

(-%

)0

(0

%)

9 (

64

%)

≤5

(-%

)-2

.8 (1

.6)

9 (

90

%)

Mai

dsto

ne a

nd

Tunb

ridg

e W

ells

N

HS

Tru

st

13

11

(8

5%

)2

.8 (1

.0)

6 (

55

%)

≤5

(-%

)≤

5 (

-%)

0 (

0%

)-1

.3 (

0.8

)6

(5

5%

)

Med

way

NH

S

Foun

dati

on T

rust

12

12

(10

0%

)3

.1 (1

.4)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-2.0

(1

.9)

8 (

67

%)

Nor

th B

rist

ol

NH

S T

rust

19

14

(74

%)

3.4

(1

.4)

≤5

(-%

)≤

5 (

-%)

7 (

50

%)

≤5

(-%

)-1

.3 (1

.9)

≤5

(-%

)

Nor

ther

n D

evon

H

ealt

hcar

e

NH

S T

rust

25

20

(8

0%

)3

.3 (1

.3)

6 (

30

%)

7 (

35

%)

6 (

30

%)

≤5

(-%

)-0

.9 (1

.2)

≤5

(-%

)

Tabl

e 7.

81

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Oxf

ord

Uni

vers

ity

Hos

pita

ls

NH

S T

rust

7≤

5 (

-%)

3.5

(1

.6)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

0.2

(.)

0 (

0%

)

Plym

outh

H

ospi

tals

N

HS

Tru

st

10

8 (

80

%)

3.6

(0

.9)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.4

(1

.1)

≤5

(-%

)

Port

smou

th

Hos

pita

ls

NH

S T

rust

715

8 (

82

%)

3.2

(1

.5)

22

(3

8%

)9

(16

%)

23

(4

0%

)≤

5 (

-%)

-2.2

(1

.8)

28

(72

%)

Roy

al

Bou

rnem

outh

an

d C

hris

tchu

rch

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

63

59

(9

4%

)3

.5 (1

.2)

16

(27

%)

12

(2

0%

)24

(41

%)

7 (1

2%

)-1

.5 (1

.6)

31

(6

0%

)

Sal

isbu

ry N

HS

Fo

unda

tion

Tru

st1

41

3 (

93

%)

3.8

(1

.6)

≤5

(-%

)0

(0

%)

7 (

54

%)

≤5

(-%

)-1

.7 (

2.2

)6

(5

5%

)

Sur

rey

and

Sus

sex

Hea

lthc

are

N

HS

Tru

st

20

18

(9

0%

)3

.4 (1

.7)

≤5

(-%

)≤

5 (

-%)

8 (4

4%

)≤

5 (

-%)

-1.3

(1

.3)

8 (4

4%

)

Taun

ton

and

Som

erse

t N

HS

Tru

st

29

26

(9

0%

)4

.6 (1

.7)

≤5

(-%

)≤

5 (

-%)

7 (27

%)

12

(4

6%

)-0

.8 (1

.5)

10

(4

0%

)

Uni

vers

ity

Hos

pita

l S

outh

ampt

on

NH

S F

ound

atio

n Tr

ust

86

(75

%)

3.5

(1

.8)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

-2.2

(2

.6)

≤5

(-%

)



Tabl

e 7.

81

con

tinu

ed

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Wes

tern

Sus

sex

Hos

pita

ls N

HS

Fo

unda

tion

Tru

st

12

12

(10

0%

)2

.7 (1

.4)

8 (

67

%)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)-2

.4 (1

.8)

9 (

75

%)

Wes

ton

Are

a H

ealt

h N

HS

Tr

ust

19

18

(9

5%

)4

.5 (1

.5)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)9

(5

0%

)-0

.7 (1

.5)

≤5

(-%

)

Yeov

il D

istr

ict

Hos

pita

l NH

S

Foun

dati

on T

rust

87

(8

8%

)3

.9 (1

.4)

≤5

(-%

)0

(0

%)

≤5

(-%

)≤

5 (

-%)

-1.6

(1

.4)

≤5

(-%

)

Table 7.82 Disease activity score at presentation in Wales



Mean (SD) DAS score




National 3,185 2,557 (80%) 5.0 (1.4) 114 (5%) 135 (5%) 1,080 (42%) 1,228 (48%)

Wales 233 216 (93%) 5.0 (1.3) 11 (5%) 11 (5%) 88 (41%) 106 (49%)


35 30 (86%) 5.2 (1.2) ≤5 (-%) 0 (0%) 13 (43%) 16 (53%)


16 15 (94%) 4.9 (1.8) ≤5 (-%) ≤5 (-%) ≤5 (-%) 8 (53%)


83 75 (90%) 4.7 (1.4) 6 (8%) 6 (8%) 33 (44%) 30 (40%)


13 13 (100%) 4.5 (1.3) ≤5 (-%) ≤5 (-%) 6 (46%) ≤5 (-%)


62 60 (97%) 5.3 (1.1) ≤5 (-%) ≤5 (-%) 22 (37%) 35 (58%)


24 23 (96%) 5.3 (1.2) 0 (0%) ≤5 (-%) 10 (44%) 12 (52%)



Tabl

e 7.

83

Dis

ease

Act

ivit

y S

core

at

follo

w u

p an

d ch

ange

s in

sco

re in

Wal

es

Pro

vide

r na

me

Num

ber

of R

A

pati

ents

at

follo

w-u

p

N (

%)

RA

pat

ient

s w

ith

follo

w-u

p D

AS

Mea

n (S

D)

D

AS

sco

reR

emis

sion

Low

dis

ease

ac

tivi

tyIn

term

edia

te

dise

ase

acti

vity

Hig

h di

seas

e ac

tivi

tyM

ean

(SD

) ch

ange

in

D

AS

sco

re

N (

%)

wit

h re

duct

ion

in D

AS

scor

e of

>1

.2

Nat

iona

l2

,16

21

,73

6 (

80

%)

3.5

(1

.5)

53

1 (

31

%)

25

4 (

15

%)

70

3 (

41

%)

24

8 (

14

%)

-1.7

(1

.6)

84

9 (

60

%)

Wal

es17

21

49

(8

7%

)3

.3 (

1.4

)6

1 (

41

%)

19

(1

3%

)5

4 (

36

%)

15

(1

0%

)-1

.9 (

1.7

)9

7 (

68

%)

Abe

rtaw

e B

ro

Mor

gann

wg

Uni

vers

ity

Hea

lth

Boa

rd

33

24

(73

%)

2.9

(1

.4)

12

(5

0%

)≤

5 (

-%)

9 (

38

%)

≤5

(-%

)-2

.5 (1

.6)

17 (

81

%)

Ane

urin

Bev

an

Uni

vers

ity

Hea

lth

Boa

rd

76

(8

6%

)4

.4 (1

.5)

0 (

0%

)≤

5 (

-%)

≤5

(-%

)≤

5 (

-%)

-1.4

(1

.8)

≤5

(-%

)

Bet

si C

adw

alad

r U

nive

rsit

y H

ealt

h B

oard

57

49

(8

6%

)3

.5 (1

.4)

16

(3

3%

)8

(16

%)

19

(3

9%

)6

(1

2%

)-1

.2 (1

.6)

26

(5

5%

)

Car

diff

and

Va

le U

nive

rsit

y H

ealt

h B

oard

6≤

5 (

-%)

3.4

(3

.4)

≤5

(-%

)0

(0

%)

0 (

0%

)≤

5 (

-%)

-0.9

(3

.9)

≤5

(-%

)

Cw

m T

af

Uni

vers

ity

Hea

lth

Boa

rd

54

54

(10

0%

)3

.1 (1

.4)

24

(4

4%

)7

(1

3%

)1

9 (

35

%)

≤5

(-%

)-2

.3 (1

.5)

40

(74

%)

Hyw

el D

da

Uni

vers

ity

Hea

lth

Boa

rd

15

13

(8

7%

)3

.1 (1

.3)

7 (

54

%)

≤5

(-%

)≤

5 (

-%)

≤5

(-%

)-2

.1 (1

.7)

8 (

62

%)

Consultant and nurse staffing levels

This section provides a breakdown of consultant and nurse staffing levels at a provider level by NHS region and Wales.

Table 7.84 number of consultants and nurses per 100,000 population in the London region

Provider name Catchment population

Total number consultants


Total number specialist nurses


National 52,389,759 498.3 0.95 381.2 0.73

London 7,735,017 74.7 0.97 41.3 0.53


700,000 5.0 0.71 2.0 0.29


170,000 2.2 1.29 3.0 1.76


380,000 3.2 0.84 1.0 0.26

Ealing Hospital NHS Trust 250,000 1.4 0.56 1.0 0.40


250,000 3.1 1.24 2.0 0.80


600,000 5.3 0.89 2.0 0.33


350,000 3.0 0.86 2.5 0.71


586,621 6.0 1.02 4.0 0.68


920,000 8.6 0.93 5.8 0.63


350,000 2.7 0.77 1.0 0.29


291,004 3.0 1.03 1.0 0.34


375,000 4.1 1.09 2.5 0.67


1,000,000 10.4 1.04 7.6 0.76


253,350 4.0 1.58 0.6 0.24


500,000 9.1 1.83 3.0 0.60

West Middlesex University Hospital NHS Trust

259,042 1.7 0.66 1.8 0.69



Table 7.85 number of consultants and nurses per 100,000 population in the Midlands and East of England region






National 52,389,759 498.3 0.95 381.2 0.73

Midlands & East of England 14,194,150 137.5 0.97 107.1 0.75


428,630 4.6 1.07 1.2 0.28


250,000 2 0.80 2.5 1.00


350,000 5 1.43 2 0.57


270,000 2 0.74 3 1.11


750,000 6.3 0.84 6.5 0.87


450,000 6.3 1.40 5 1.11


500,000 4 0.80 3 0.60


550,000 4.6 0.84 3.2 0.58


1,000,000 7.2 0.72 5.1 0.51


160,000 2.2 1.38 3.7 2.31

Ipswich Hospitals NHS Trust 350,000 4.7 1.34 2.8 0.80


250,000 1.5 0.60 1.4 0.56


350,000 3 0.86 3 0.86


600,000 5.35 0.89 7.85 1.31


390,000 3 0.77 2 0.51


650,000 5 0.77 3.8 0.58

Peterborough and Stamford Hospitals NHS Foundation Trust

300,000 2.3 0.77 1.4 0.47

Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

161,941 2 1.24 2 1.24








300,000 4 1.33 2 0.67


380,000 4 1.05 5 1.32


400,000 6 1.50 5 1.25


400,000 3 0.75 3 0.75


270,000 2.6 0.96 2 0.74


256,946 4 1.56 3.26 1.27


500,000 7 1.40 4.5 0.90


400,000 5.5 1.38 3.5 0.88


500,000 7.7 1.54 3.5 0.70


1,000,000 6 0.60 4 0.40

Walsall Healthcare NHS Trust 174,633 2 1.15 2 1.15


500,000 2.5 0.50 1 0.20


240,000 2.5 1.04 2.6 1.08


550,000 3.8 0.69 3.5 0.64

Wye Valley NHS Trust 240,000 2.8 1.17 1.8 0.75



Table 7.86 number of consultants and nurses per 100,000 population in the North of England region






National 52,389,759 498.3 0.95 381.2 0.73

North of England 15,795,092 152.4 0.97 131.4 0.83


330,000 4.5 1.36 4 1.21


220,000 2 0.91 2 0.91


250,000 2 0.80 2 0.80


330,000 3 0.91 5 1.52

Bolton NHS Foundation Trust 270,000 3 1.11 3.2 1.19


501,000 3.8 0.76 4.2 0.84


487,000 4.8 0.99 6 1.23


450,000 5 1.11 2 0.44


270,000 2.6 0.96 2 0.74


300,000 3.1 1.03 1.4 0.47


420,000 3.6 0.86 3 0.71

East Cheshire NHS Trust 200,000 1.75 0.88 1.3 0.65


525,300 3.3 0.63 5 0.95


300,000 3.5 1.17 4 1.33


240,000 2.2 0.92 2 0.83


1,200,000 4 0.33 3 0.25


330,000 3 0.91 3 0.91


400,000 5.5 1.38 2.88 0.72


280,000 2 0.71 1 0.36


500,000 7 1.40 5 1.00








500,000 9 1.80 2.5 0.50


325,000 2.4 0.74 3.4 1.05


370,000 4 1.08 2.8 0.76


550,000 5.275 0.96 8 1.45


600,000 4.55 0.76 7.2 1.20


241,430 1.96 0.81 3 1.24


250,000 2.6 1.04 1.4 0.56


380,000 3.5 0.92 3.6 0.95


230,000 6 2.61 4 1.74


550,000 8 1.45 4.5 0.82


428,362 4.7 1.10 2.2 0.51


250,000 1.5 0.60 2 0.80


300,000 2.6 0.87 3.6 1.20

Stockport NHS Foundation Trust

300,000 2 0.67 2 0.67


250,000 2.4 0.96 1 0.40


570,000 3.5 0.61 1.7 0.30


327,000 3.6 1.10 4 1.22


270,000 1.7 0.63 3 1.11


300,000 2 0.67 1 0.33


450,000 3.5 0.78 4.5 1.00


550,000 8 1.45 4 0.73



Table 7.87 number of consultants and nurses per 100,000 population in the South of England region






National 52,389,759 498.3 0.95 381.2 0.73

South of England 11,695,500 101.7 0.87 75.7 0.65


450,000 3 0.67 3 0.67


550,000 3.5 0.64 1.2 0.22


730,000 5 0.68 0 0.00


350,000 2 0.57 1 0.29


350,000 2.6 0.74 2.49 0.71


570,000 5 0.88 5.4 0.95


400,000 5 1.25 3 0.75

Isle of Wight NHS Trust 150,000 3.1 2.07 2 1.33

Medway NHS Foundation Trust 660,000 5 0.76 2 0.30

North Bristol NHS Trust 500,000 5.05 1.01 3.11 0.62


170,000 2 1.18 2.6 1.53


650,000 2.25 0.35 4 0.62

Plymouth Hospitals NHS Trust 500,000 5.5 1.10 5.5 1.10


600,000 6.6 1.10 5.26 0.88


600,000 3.4 0.57 5 0.83


300,000 3 1.00 4 1.33


121,500 3 2.47 1 0.82


250,000 3 1.20 3 1.20


535,000 2.2 0.41 2 0.37

Sussex Community NHS Trust 120,000 1.25 1.04 1.64 1.37








350,000 3 0.86 3 0.86


450,000 6 1.33 4 0.89


400,000 5 1.25 2.6 0.65


280,000 4.7 1.68 1.2 0.43

Weston Area Health NHS Trust 170,000 1.6 0.94 1.5 0.88


185,000 1.6 0.86 0.8 0.43

Table 7.88 number of consultants and nurses per 100,000 population in Wales






National 52,389,759 498.3 0.95 381.2 0.73

Wales 2,970,000 32.1 1.08 25.7 0.87


500,000 6.2 1.24 2 0.40


600,000 6.7 1.12 6 1.00


770,000 7.8 1.01 5.8 0.75


500,000 4.5 0.90 2.8 0.56


290,000 3.5 1.21 5.5 1.90


310,000 3.4 1.10 3.6 1.16

139 8 Outlier providers – NICE Quality Standard 2


138 7 Analyses and interpretation


8. Outlier providers – NICE Quality Standard 2

The proportion of patients seen within 3 weeks from referral for each provider was compared to the overall national mean proportion of patients seen within the NICE recommended 3 weeks of referral (37%).

Data from providers which did not achieve a case ascertainment level sufficient to underpin robust data benchmarking were removed from the analysis to identify outliers.

A total of 31 providers (24%) which provided data had a much lower than expected proportion of patients seen within the NICE recommended 3 weeks of referral. These providers are listed in table 8.1.

Of these providers, 15 (48%) had a proportion of patients seen within 3 weeks of referral outside the 95% confidence limit (2 standard deviations) for the mean national result. This reflects a 5% chance, or 25 chances in 500, that this result occurred by chance alone. These providers are marked as a group for whom there is an ‘alert.’

A total of 16 providers (52%) had a proportion of patients seen within 3 weeks of referral that was outside the 99.8% confidence limit (3 standard deviations) for the national mean. This reflects a 0.2% chance, or one chance in 500, that this result occurred by chance alone. These providers have been classified as an ‘alarm.’

Providers that fell into these three groups were notified of their outlier status and asked to verify the accuracy of their submitted data prior to publication of this annual report. The results presented reflect this verified data and rely on the accurate upload of information to the IT platform. Many indicated that they were aware that they were unable to meet this key quality standard and their feedback indicated that this was primarily due to staffing issues.

It is important to note that these results are based on data submitted up to 29 January 2016 and may not reflect current performance against this NICE Quality Standard. Some trusts listed in table 8.1 may have changed their practice since.

Table 8.1 outlier providers by NHS region and Wales

Alert status Alarm status

London London Barking, Havering and Redbridge University Hospitals NHS Trust Imperial College Healthcare NHS Trust

Midlands and East of England Basildon & Thurrock University Hospitals NHS Foundation Trust Cambridge University Hospitals NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust Sandwell and West Birmingham Hospital NHS Trust Sherwood Forest Hospitals NHS Foundation Trust Walsall Healthcare NHS Trust West Hertfordshire Hospitals NHS Trust Worcestershire Acute Hospitals NHS Trust

Midlands and East of England Heart of England NHS Foundation Trust Norfolk and Norwich University Hospital NHS Foundation Trust Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust

North of England Gateshead Health NHS Foundation Trust Royal Liverpool & Broadgreen University Hospitals NHS Trust Tameside Hospital NHS Foundation Trust

North of England Bolton NHS Foundation Trust East Lancashire Healthcare Trust Leeds Teaching Hospitals NHS Trust Pennine Acute Hospitals NHS Trust Southport & Formby District General Hospital Warrington and Halton Hospital NHS Trust

Table 8.1 continued

Alert status Alarm status

South of England Buckinghamshire Healthcare NHS Trust University Hospitals Bristol NHS Foundation Trust Weston Area Health NHS Trust

South of England Surrey and Sussex Healthcare NHS Trust Western Sussex Hospitals NHS Foundation Trust

Wales Cardiff and Vale University Health Board

Wales Aneurin Bevan University Health Board Hywel Dda University Health Board

Use of data in research

As the largest contemporary survey of clinical activity surrounding the diagnosis and management of early arthritis, the audit presents an unparalleled opportunity for health services research. Since the audit’s inception, the BSR has encouraged researchers to access the dataset through a formal application and approval process. Projects are evaluated by the BSR Research Committee which provides a recommendation to the HQIP data access group. This formal review process is applied equally to projects initiated internally by the BSR. The broad aim of the evaluation process is to check the feasibility and scientific rigour of research proposals, and to help achieve coherence between research proposals with overlapping aims. The committee also monitors the progress of research and reviews research outputs. The BSR and HQIP have approved 7 requests for access to the audit data for related research projects:

In 2015-2016, the committee approved seven research proposals.

The multidisciplinary team in the management of rheumatoid arthritis (leads Dr Alan Roach, BSR; Dr Lindsay Bearne, King’s College London)

The BSR has published data indicating significant variation in the composition of the multidisciplinary teams across the UK. This project will investigate this further in the data by identifying regional level variation. The analysis will be used to inform research into the optimal composition of the MDT, their clinical impact and cost effectiveness.

Work participation in early rheumatoid arthritis (lead: Dr Karen Walker-Bone, Southampton)

Past long term data has suggested that as many as 50% of those receiving a diagnosis of rheumatoid arthritis leave their employment within 5 years. This project will compare employment outcomes among patients treated according to current ‘best practice’ guidelines with historical controls from the BSR Biologics Register and the Norfolk Arthritis Register; and will compare employment outcomes in the audit data between those that achieve and fail to achieve a good response.

Initial treatment strategy and early clinical outcomes (lead: Dr James Galloway, King’s College London)

The project aims to examine if there is a relationship between initial treatment strategy and early clinical outcomes assessed at three months; and if patient factors influence initial treatment strategy.

140 141 9 Use of data in research9 Use of data in research


Relationship between departmental staffing structure and early clinical outcomes (lead: Dr James Galloway, King’s College London)

The project will examine the data to assess if there is a relationship between rheumatology departmental staffing structures and the duration and severity of disease both at presentation and at three months.

SiM-SK: Simulation of musculoskeletal healthcare services in England and Wales (leads: Dr Alan Roach, BSR; Prof. Alex MacGregor, University of East Anglia)

The project is developing an agent based simulation model of the rheumatology healthcare systems populated by real word data from different sources including data from the audit. The analysis will address the long term consequences of adhering to NICE guidelines on the outcome of early arthritis. Collaborators in this project include BSR and the Nuffield Trust.

The burden of disease in psoriatic arthritis (lead: Prof. Neil McHugh, Bath)

This project will examine the data to compare patients with a diagnosis of psoriatic arthritis and rheumatoid arthritis for diagnostic delay, disease activity, physical function, quality of life and work participation. The analysis will provide some of the first evidence of the importance of establishing a diagnosis early in psoriatic arthritis.

The relationship between antibody status and treatment delay (lead: Dr Arthur Pratt, Newcastle University)

Data from the Northeast Early Arthritis Cohort has suggested that antibody status is a predictor of treatment delay. The project will attempt to see if this observation is replicated in data from the audit.

Publications to date

1. Determinants of waiting time for patients with early onset inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Ledingham J, Snowden N, Rivett A, Galloway J, Firth J, MacPhie E, Ide Z, Rowe I, Kandala N, Dennison E, Rheumatology 2016, vol 55, suppl 1.

2. National variation in the composition of Rheumatology multidisciplinary teams; Rachel Ferguson, Michael Backhouse, Lindsay Bearne, Mwidimi Ndosi, Elaine Dennison, Phillip Ainsworth, Alan Roach and Lindsey Cherry, Rheumatology 2016, vol 55, suppl 1.

3. Regional variation in delays from initial presentation to primary care and referral for specialist assessment for patients with new presentation of inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Galloway J, Ledingham J, Snowden N, Rivett A, MacPhie E, Firth J, Ide Z, Rowe I, Kandala N, Dennison E, Rheumatology 2016, vol 55, suppl 1.

4. Use of disease modifying therapies and glucocorticoids in the early treatment of rheumatoid arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Snowden N, Ledingham J, Rivett A, Galloway J, MacPhie E, Firth J, Ide Z, Rowe I, Kandala N, Dennison E; Rheumatology 2016, vol 55, suppl 1.

5. Clinical and patient reported outcomes from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Ledingham J, Snowden N, Rivett A, Galloway J, Dennison E, MacPhie E, Firth J, Ide Z, Rowe I, Kandala N; Rheumatology 2016, vol 55, suppl 1.

6. Impact of new arthritis on ability to work: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Dennison E, Snowden N, Rivett A, Galloway J, Firth J, MacPhie E, Rowe I, Ide Z, Kandala N, Ledingham J; Rheumatology 2016, vol 55, suppl 1.

7. Importance of early detection and referral of rheumatoid arthritis; Ledingham J; BMJ 2016;353:i2172.

8. Patient and clinician reported outcomes for patients with new presentation of inflammatory arthritis: observations from the UK national clinical audit; Ledingham J, Galloway J, Snowden N, Rivett A, Firth J, Macphie E, Kandala N, Rowe I, Ide Z, Dennison E, Ann Rheum Dis 2016. vol 75 (suppl2), 657.

9. Achievement of NICE quality standards for patients with new presentation of inflammatory arthritis: Results from the UK national clinical audit for rheumatoid and early inflammatory arthritis; Ledingham J, Snowden N, Galloway J, Rivett A, Ide Z, Firth J, Macphie E; Kandala N, Dennison E; Rowe I; Ann Rheum Dis 2016, vol 75 (suppl2), 1247.

10. The first national clinical audit for rheumatoid arthritis; Firth J, Ledingham J, Snowden N, Rivett, A, Galloway J, Dennison EM, MacPhie E, Ide Z, Rowe I, Kandala N, Jameson K; British Journal of Nursing 2016, vol 25 issue 11.

Submitted papers for publication

11. Components of treatment delay in rheumatoid arthritis differ according to autoantibody status: validation of a single-centre observation using national audit data; Pratt A, Lendrem D, Hargreaves B, Aslam O, Galloway J, Isaacs J; Rheumatology 2016 (in press).

12. Regional variation in delays from initial presentation to primary care and referral for specialist assessment for patients with new presentation of inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Ledingham J, Snowden N, Galloway J, Rivett A; RCGP Annual Conference 2016 (in press).

13. Achievement of NICE quality standards for patients with new presentation of inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Ledingham, J, Snowden, N, Rivett, A, Galloway, J, Ide, Z, Firth, J, Macphie, E; Kandala, N, Dennison, E; Rowe, I; Rheumatology 2016 (in press).

14. Patient and clinician reported outcomes for patients with new presentation of inflammatory arthritis: observations from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis; Ledingham, J, Snowden, N; Rivett, A, Galloway, J, Ide, Z, Firth, J, Macphie, E; Kandala, N; Dennison, E; Rowe, I; Rheumatology 2016 (in press).

143 10 Appendices


142 9 Use of data in research


Appendices

Appendix 1 – Report on data quality

Introduction

This appendix relates to the assessment and reporting of the quality of data submitted to HQIP and the CQC by the British Society for Rheumatology (BSR) audit working group. This is the first report on the quality of nationally submitted early inflammatory arthritis (EIA) data for England and Wales.

It is important to highlight that good quality data are essential to allow meaningful interpretation and inform subsequent operational and strategic use. The development of the False or Misleading Information (FOMI) offence, enacted in the Care Act 2014, and the United Kingdom Statistics Authority (UKSA) exposure draft report on Quality Assurance and Audit Arrangements for Administrative Data highlight the importance of data quality.

Objectives

This appendix aims to describe the quality of data submitted to and presented by the audit in year 2. For the context of the reader, it should be understood that the quality of the data do not imply clinical quality, but are simply a measure of how much we trust the information presented.

Three key domains are considered for data quality evaluation:

1. Participation What proportion of providers participated in the audit?

2. Case ascertainment What proportion of eligible cases in each provider were included in the audit?

3. Data completeness What is the extent and impact of missing information?

Each of these aspects are considered in detail, although it is first appropriate to review how data were collected during the audit.

Data capture processes

The audit collected core data for all patients presenting with suspected EIA and extended data were collected on rheumatoid arthritis patients up to and at three months after first presentation. Data were collected both from patients and clinicians. These processes are relevant to understanding data quality and are recapped here:

Clinician data

• At the first outpatient appointment

• At each subsequent follow up appointment up to and including 3 months

These data included information on patient demographics, patient history, diagnosis, treatment, disease activity, treatment targets and the support available to the patient. Clinician data were captured electronically via a secure online portal.

Patient data

• At the first outpatient appointment

• At the nearest appointment to 3 months

These data provided information on the impact of the disease on patients’ everyday lives and on ability to work, along with patient outcome and experience measures based on the treatment that they have received. Clinicians were asked to ensure that patients were able to complete the experience measures in private and return their follow up audit forms in such a way that the anonymity and confidentiality of data was preserved. Completed forms were forwarded to someone independent of the rheumatology team for uploading onto the online tool, e.g. by a member of the provider’s audit department.

In addition, organisational data were captured annually, which provided details on service configuration, catchment population and staffing numbers for each provider. These were uploaded to the online tool by the provider lead for the audit. It is relevant to highlight that hospital catchment populations were based upon estimates provided by the individual participating providers.

Participation

It is specified in the NHS Standard Contract 2014/2015,section 26.1.2, that providers must participate in national clinical audits within the National Clinical Audit and Patient Outcomes Programme (NCAPOP) relevant to the Service. The EIA programme is an NCAPOP project, and as such NHS services providing care for patients with suspected inflammatory arthritis are contractually obliged to participate.

In England and Wales there were 146 providers that could potentially have participated in the audit. Five providers did not participate at all:

1. Dorset Healthcare University NHS Foundation Trust

2. Hillingdon Hospitals NHS Trust

3. Poole Hospital NHS Foundation Trust

4. Princess Alexandra Hospital NHS Trust

5. United Lincolnshire Hospitals NHS Trust

Each of these providers was contacted to identify reasons for non-participation. Dorset Healthcare University NHS Foundation Trust represented a very small unit, with very few referrals for early inflammatory arthritis, and therefore decided that participation would not be worthwhile. The four other providers that did not participated cited a lack of resources to conduct the audit.

The remaining 141 providers registered for participation in the audit. Of these, 129 recruited at least one patient to the audit (see Table 1).

144 145 10 Appendices10 Appendices


Table 1 – national and regional recruitment to audit

Region Number of eligible and registered providers

N (%) of eligible and registered providers submitting data

National 141 129 (91%)

London 19 17 (89%)




Wales 6 6 (100%)

Regionally there was similarly high uptake for the audit, demonstrating robust engagement with the rheumatology community. The following providers did not recruit any patients to the audit in year 2:

1. Barts Health NHS Trust

2. Bedford Hospital NHS Trust

3. Calderdale and Huddersfield NHS Foundation Trust

4. Kettering NHS Foundation Trust

5. Mid Essex Hospital Services NHS Trust

6. North Middlesex University Hospital Trust

7. North Tees and Hartlepool NHS Trust

8. Queen Victoria Hospital NHS Foundation Trust

9. Royal Cornwall Hospitals NHS Trust

10. Royal Devon & Exeter Foundation Trust

11. Royal Surrey County Hospital NHS Foundation Trust

12. South Devon Healthcare Foundation Trust

These providers were contacted individually to ascertain reasons for failure to recruit any patients. The most frequent reported barrier was administrative support to run the audit.

Case ascertainment

In order to evaluate the quality of service at any given unit, the audit needs to be considered in the light of case ascertainment. If a centre captured all EIA patients within their data collection, this would provide the most robust resource to measure performance. However, in reality, acknowledging the resource implications of the audit as well as the requirement for patient consent, it is realistic to expect less than 100% ascertainment. Whilst 100% ascertainment may not be feasible, especially in the initial years of the audit, it is relevant to consider actual and expected ascertainment as this may provide information that contextualises performance statistics as well as flag up concerns regarding ‘cherry-picking’ of cases. A provider’s performance should therefore be considered alongside its level of case ascertainment.

In order to estimate the level of case ascertainment, it is important to consider what might represent an expected numbers of cases. At national level this is achieved using existing observational studies that provide incidence data. However, at local levels it is much more challenging to estimate an anticipated recruitment rate.

National anticipated recruitment rate

The incidence of rheumatoid arthritis in England and Wales has been estimated at 15/100,000 population using published data from the Clinical Practice Research. The population studied comprised 1.2 million adults aged 20-79 under follow-up within a primary care. The estimate reflects patients diagnosed with rheumatoid arthritis over a 2-year period between 1996 and 1997.

In order to provide a pragmatic target, the more conservative estimate (15/100,000) was used as a benchmark against which to estimate expected rates of rheumatoid arthritis.

Recruitment rates at national level in the audit

Nationally, the estimated incidence of early inflammatory arthritis was 14/100,000, and when limited to those with a confirmed diagnosis of rheumatoid, 9/100,000 (Table 2). Assuming the 15/100,000 incidence to be accurate for inflammatory arthritis, then these incidence rates would suggest that the audit has captured a large proportion of cases.

Table 2 recruitment rates at national and regional level

Region Adult population (≥16 yrs)

Number of patients recruited over 9 months (all cases)

Annual incidence / 100,000 persons all cases (95% CI)

Number of RA patients recruited over 9 months

Annual incidence / 100,000 RA only (95% CI)

National 46,550,257 5,002 14.33 (13.99, 14.68)

3,185 9.12 (8.85, 9.4)

London 6,806,412 587 11.5 (10.71, 12.34)

320 6.27 (5.69, 6.9)


13,256,698 1,391 13.99 (13.36, 14.64)

958 9.64 (9.12, 10.18)

North of England 12,292,531 1,576 17.09 (16.37, 17.84)

992 10.76 (10.19, 11.36)

South of England 11,657,421 1,105 12.64 (12.0, 13.3)

682 7.8 (7.3, 8.32)

Wales 2,537,195 343 18.03 (16.4, 19.74)

233 12.24 (10.93, 13.7)

Calculate estimated incidence at local level by annualising rate and multiplying supplied catchment population by 0.8 to provide estimate for adult only population.



Recruitment rates at local level

As already suggested, the estimation of local incidence rates is fraught with challenges, including imprecise estimation of hospital catchment areas, overlapping hospital catchment regions (especially in inner cities), and lack of hospital catchment level data specifically providing adult only data (between 15-25% of local population residents are <16 years old). Variations in recruitment by centre may also be explained by other factors including: (1) local engagement with the audit; (2) regional variation in disease incidence; (3) variation in referral pathways.

The following providers recruited fewer than 5 patients to the audit in year 2:

1. West Middlesex University Hospital NHS Trust

2. Whittington Hospital NHS Trust

3. Colchester Hospital University NHS Foundation Trust

4. Peterborough and Stamford Hospitals NHS Foundation Trust

5. Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust

6. East Sussex Healthcare NHS

7. Milton Keynes Foundation Trust

Substantial variation in recruitment rates was observed across providers that recruited more than 5 patients. Acknowledging that expected recruitment rates need to take into account the catchment population size, a funnel plot (figure 3) is presented showing how many trusts fell outside 2 or 3 standard deviations from the national mean recruitment rate. This is explained in more detail below.

Figure 3

recr

uitm

ent

rate

/ 1

00,0

00

pop

ulat

ion

60

80

40

20

200,0000 400,000 600,000 800,0000

Reported catchment population

Funnel plot assumes binomial distribution, with dotted lines showing 5% (2 standard deviations) and 0.2% (3 standard deviation) boundaries.

Interpreting this funnel plot relies upon understanding of some important concepts. First, it would be inappropriate to assume a trust has failed to recruit adequately based upon the absolute number of patients enrolled into the audit.

EIA is a rare event, and natural variation will inevitably lead to fluctuations across regions. Therefore it is appropriate to consider a confidence interval, between which the true case presentation rate for any given trust could reasonably be expected to lie. The confidence interval will be dependent upon the catchment population for the particular trust, with smaller catchments resulting in wider confidence intervals. Consider the funnel plot, the dotted lines refer to 2 and 3 standard deviations from the national average recruitment rate, reflecting 95% and 99% confidence intervals respectively. It can be inferred from the graph that the majority of providers attained recruitment rates within 3 standard deviations.

In total, 23/120 providers had their upper bound of their 99% confidence interval for recruitment falling below the national average of 14/100,000. The individual provider data are available in full in the appendix.

Data completeness

NICE Quality Standards 1 and 2

There was substantial variation in the amount of missing information by quality standard as well as by provider. Near complete data were available for clinician baseline items, with inadequate information to assess quality standard 1 (time from GP assessment to referral) in only 13/5002 (<1%) patients. Similarly, NICE Quality Standard 2 (time from GP referral to rheumatology clinic) was able to be assessed in all but 4/5002 patients.

Clinical outcomes for RA patients required information captured at a subsequent time point in order to calculate responses. Figure 4 shows the availability of follow up data. Out of 3185 patients with RA identified in the audit, follow up information on at least from time point was available for 2162 (68%) people.



Figure 4 Number of forms provided at each stage by patient diagnosis


NICE Quality Standard 3 recommends that people with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral. Table 5 presents the breakdown for the levels of missing data for commencing DMARDs, combination DMARDs and steroids. Missing information was higher for steroids, although data were available for 90% or more for all aspects of the quality standard evaluation.

Data from both the clinician baseline and clinician follow up form could be used to assess NICE Quality Standard 3. If a patient did not commence therapy at their baseline visit, and no follow up visit record was returned, it was assumed that the standard had not been achieved. Follow up forms were not available for 32% of RA cases, and assuming that in some of these cases DMARDs were commenced within the appropriate timescale at follow up, it is likely that performance for this quality standard may have been underestimated.

Table 5 missing data for NICE Quality Standard 3

Region Number of RA patients

Missing for commence DMARDs ≤6wks

Missing for combination DMARDs at any time

Missing steroids at any time

National 3,185 14 (<1%) 135 (4%) 286 (9%)

London 320 2 (1%) 12 (4%) 32 (10%)


958 5 (1%) 43 (5%) 97 (10%)

North of England 992 2 (<1%) 45 (5%) 75 (8%)

South of England 682 4 (1%) 29 (4%) 61 (9%)

Wales 233 1 (<1%) 6 (3%) 21 (9%)


NICE Quality Standard 4 recommends that patients with rheumatoid arthritis are offered educational and self-management activities within 1 month of diagnosis. This quality standard could only be assessed on the follow up form supplied by clinicians. Data were available for all but 13/2,162 returned follow up forms (table 6). Where forms were returned, data quality was excellent. Quality standard 4 could only calculated from the clinician follow up form and so, in contrast to quality standard 3, it is not possible to speculate about the impact of missing follow up forms.



N (%) missing data

National 2,162 13 (1%)

London 209 2 (1%)



South of England 439 1 (<1%)

Wales 172 0 (0%)


NICE Quality Standard 5 recommends that people who have active rheumatoid arthritis should be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target. The extent of missing data for quality standard 5 is shown in table 7. Levels of missing data were higher for this quality standard than other standards, reflecting the more complex data required to calculate performance. In order to achieve this standard, a treatment target needed to be set and also met, requiring complete data on the target agreed (captured in the clinician baseline form) and the treatment response in terms of disease activity score (DAS) captured on the clinician follow up form.

5,002 patients recruited at

baseline

257 patients without baseline diagnosis and at least 1 follow up

record

2,162 RA patients with at least one follow

up record

1,244 RA patients with >1 follow up visit record

1,118 patients with non-RA diagnosis

699 patients without diagnosis

at baseline

3,185 RA patients

at baseline





Number of patients with missing data preventing target ascertainment to be judged

National 2,162 544 (25%)

London 209 60 (29%)




Wales 172 29 (17%)

Clinical outcomes

Table 8 provides information regarding the completeness of data amongst patients who had at least one follow up. Clinician reported disease response information was available for 80% of patients at national level. Patient returned follow up was lower, with over half of patient follow up forms not available.

Table 8 missing data for clinical outcomes


N (%) RA patients with follow-up DAS

N (%) of patient follow up forms not returned

National 2,162 1,736 (80%) 1,222 (57%)

London 209 175 (84%) 127 (61%)

Midlands & East of England 645 500 (78%) 370 (57%)

North of England 697 541 (78%) 371 (53%)

South of England 439 371 (85%) 262 (60%)

Wales 172 149 (87%) 92 (54%)

Provider level information regarding missing data are presenting in the main audit report alongside each quality standard.

Summary

In conclusion, the data quality for the second year of the audit was high and provides a robust resource for evaluation of rheumatology services in the English NHS regions and Wales. Participation levels were very high, with nearly all eligible trusts engaging. Recruitment of patients to the audit was successful, with case ascertainment at expected levels, although a significant minority of trusts failed to recruit patients at all, or had recruitment rates well below what might reasonably be expected.

Data quality within the audit was excellent for NICE Quality Standards 1 and 2, which relied upon baseline information solely. There was a predictable drop off in the return of follow up forms, which should be borne in mind when assessing quality standards reliant upon data from follow up. Missing follow up was particularly high for the patient reported experience measures that relied upon patients returning a questionnaire.

Recruitment rates by individual providers

Trust Name Patients recruited (over 9 months)

Catchment population

Adult population estimate (assumed 80%)

Recruitment to audit / 100,000

Lower 99% CI

Upper 99% CI

National 5,002 52,389,759 46,550,256 14.3 13.8 14.9

London region 587 7,735,017 6,806,412 11.5 10.3 12.8


28 700000 560000 6.6 3.8 10.7


24 170000 136000 23.5 12.7 39.4


81 380000 304000 35.5 25.9 47.4


27 250000 200000 18.0 10.1 29.3


25 250000 200000 16.5 9.0 27.4


42 600000 480000 11.7 7.4 17.3


35 350000 280000 16.4 9.9 25.4


14 586621 469296 3.8 1.6 7.5


103 920000 736000 18.6 14.1 24.1


54 350000 280000 25.7 17.4 36.5


28 291004 232803 15.9 9.0 25.7


52 375000 300000 23.0 15.4 32.9



Recruitment rates by individual providers continued





Lower 99% CI

Upper 99% CI


20 1000000 800000 3.3 1.6 5.7


13 253350 202680 8.4 3.5 16.8


33 500000 400000 11.0 6.6 17.2


1391 14194150 13256698 14.0 13.0 15.0


28 428630 342904 10.8 6.1 17.5


29 250000 200000 19.0 10.9 30.6


57 350000 280000 27.1 18.5 38.2


6 270000 216000 3.7 0.9 9.8


83 750000 600000 18.3 13.4 24.4


64 450000 360000 23.6 16.5 32.6


115 500000 400000 38.3 29.4 48.8


15 550000 440000 4.5 2.0 8.6


43 1000000 800000 7.1 4.6 10.6


24 160000 128000 25.0 13.5 41.9


59 350000 280000 27.9 19.1 39.0


29 250000 200000 19.0 10.9 30.6


28 350000 280000 13.2 7.5 21.4


57 600000 480000 15.8 10.8 22.3






Lower 99% CI

Upper 99% CI


41 390000 312000 17.3 10.9 25.9


122 650000 520000 31.2 24.1 39.5


59 300000 240000 32.5 22.3 45.6


70 380000 304000 30.6 21.7 41.7


39 400000 320000 16.3 10.2 24.5


25 400000 320000 10.3 5.6 17.2


34 270000 216000 20.8 12.5 32.3


57 256946 205556 37.0 25.2 52.0


30 500000 400000 10.0 5.8 15.9


72 400000 320000 30.0 21.4 40.7


14 500000 400000 4.5 1.9 8.8

University Hospitals of Leicester NHS trust

47 1000000 800000 7.8 5.1 11.3


12 174633 139706 11.5 4.6 23.4


17 500000 400000 5.5 2.6 10.2


18 240000 192000 12.5 6.1 22.6


45 550000 440000 13.6 8.8 20.0

Wye Valley NHS Trust 30 240000 192000 20.8 12.1 33.2








Lower 99% CI

Upper 99% CI

North of England region

1576 15795092 12292531 17.1 16.0 18.3


63 330000 264000 31.8 22.2 44.1


22 220000 176000 16.5 8.6 28.3


48 250000 200000 32.0 21.0 46.4


22 330000 264000 11.0 5.7 18.9


62 270000 216000 38.0 26.3 52.8


18 501000 400800 6.0 2.9 10.8


26 487000 389600 8.7 4.8 14.4


59 450000 360000 21.7 14.9 30.4


36 270000 216000 22.2 13.6 34.0


18 300000 240000 10.0 4.9 18.1


44 420000 336000 17.3 11.1 25.5


25 200000 160000 20.6 11.3 34.3


50 525300 420240 15.7 10.4 22.6


16 300000 240000 8.8 4.0 16.4


7 240000 192000 4.7 1.3 11.8


31 1200000 960000 4.3 2.5 6.8


51 330000 264000 25.8 17.2 36.9






Lower 99% CI

Upper 99% CI


46 400000 320000 19.1 12.4 27.9


27 280000 224000 16.1 9.0 26.2


31 500000 400000 10.3 6.0 16.2


75 500000 400000 25.0 18.0 33.7


11 325000 260000 5.4 2.0 11.5


13 370000 296000 5.7 2.4 11.5


42 550000 440000 12.7 8.1 18.9


46 600000 480000 12.7 8.3 18.6


96 241430 193144 66.3 49.6 86.4


24 250000 200000 16.0 8.7 26.8


21 380000 304000 9.2 4.8 16.0


40 230000 184000 28.8 18.1 43.2


47 550000 440000 14.1 9.2 20.5


95 428362 342689 36.8 27.5 48.1


28 250000 200000 18.5 10.5 30.0


42 300000 240000 23.3 14.9 34.7


10 300000 240000 5.4 1.9 11.9


44 250000 200000 29.0 18.6 42.8








Lower 99% CI

Upper 99% CI


40 570000 456000 11.6 7.3 17.5


91 327000 261600 46.3 34.3 60.8


20 270000 216000 12.0 6.0 21.3


47 300000 240000 25.8 16.9 37.7


28 450000 360000 10.3 5.8 16.6


14 550000 440000 4.1 1.7 8.0

South of England region

1105 11695500 11657421 12.6 11.6 13.7


32 450000 360000 11.7 6.9 18.4

Brighton & Sussex University Hospitals NHS Trust

7 500000 400000 2.3 0.6 5.7


51 550000 440000 15.5 10.3 22.2


23 730000 584000 5.1 2.7 8.7


19 350000 280000 8.9 4.4 15.9


17 350000 280000 7.9 3.7 14.5


35 570000 456000 10.1 6.1 15.6


8 400000 320000 3.1 0.9 7.5

Isle of Wight NHS Trust 28 150000 120000 30.8 17.5 49.9


44 660000 528000 11.0 7.1 16.2

North Bristol NHS Trust 49 500000 400000 16.3 10.7 23.5


32 170000 136000 30.9 18.2 48.6






Lower 99% CI

Upper 99% CI


79 650000 520000 20.2 14.6 27.1


59 500000 400000 19.5 13.4 27.3


110 600000 480000 30.4 23.2 39.0


14 600000 480000 3.8 1.6 7.4


71 300000 240000 39.2 27.9 53.3

Royal National Hospital for Rheumatic Disease NHS FT

30 121500 97200 41.2 23.9 65.5


36 250000 200000 24.0 14.7 36.8


57 535000 428000 17.8 12.1 25.0


20 120000 96000 27.1 13.6 47.8


45 350000 280000 21.4 13.9 31.4


77 450000 360000 28.3 20.4 38.1


18 400000 320000 7.5 3.6 13.5


33 280000 224000 19.6 11.7 30.6


48 170000 136000 47.1 31.0 68.2


21 185000 148000 18.9 9.8 32.8








Lower 99% CI

Upper 99% CI

Wales 343 2970000 2537195 18.0 15.5 20.8


51 500000 400000 17.0 11.3 24.4


30 600000 480000 8.3 4.8 13.3


131 770000 616000 28.2 22.1 35.5


24 500000 400000 8.0 4.3 13.4


71 290000 232000 40.5 28.8 55.2


36 310000 248000 19.4 11.9 29.6

Appendix 2 – Providers in England and Wales (as of 29 January 2016)








Barts Health NHS Trust


Bedford Hospital NHS Trust








Calderdale and Huddersfield NHS Foundation Trust







Colchester Hospital University NHS Foundation Trust













East Sussex Healthcare NHS


















Isle of Wight NHS Trust




Kettering NHS Foundation Trust










Mid Essex Hospital Services NHS Trust


Milton Keynes Foundation Trust



North Bristol NHS Trust


North Middlesex University Hospital Trust

North Tees and Hartlepool NHS Trust






Nottingham University Hospitals NHS Trust




Peterborough and Stamford Hospitals NHS Foundation Trust



Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

Queen Victoria Hospital NHS Foundation Trust





Royal Cornwall Hospitals NHS Trust

Royal Devon & Exeter Foundation Trust




Royal Surrey County Hospital NHS Foundation Trust







South Devon Healthcare Foundation Trust
























West Middlesex University Hospital NHS Trust






Whittington Hospital NHS Trust




Wye Valley NHS Trust



Providers whose case ascertainment was not sufficient to provide robust benchmarking at trust level

Barts Health NHS Trust

Bedford Hospital NHS Trust


Calderdale and Huddersfield NHS Foundation Trust

Colchester Hospital University NHS Foundation Trust)

East Sussex Healthcare NHS Trust

Kettering NHS Foundation Trust

Mid Essex Hospital Services NHS Trust

Milton Keynes Foundation Trust

North Middlesex University Hospital Trust

North Tees and Hartlepool NHS Trust

Queen Victoria Hospital NHS Foundation Trust

Royal Cornwall Hospitals NHS Trust

Royal Devon & Exeter Foundation Trust

Royal Surrey County Hospital NHS Foundation Trust

South Devon Healthcare Foundation Trust

Whittington Hospital NHS Trust

Providers not participating in the audit

Dorset Healthcare University NHS Foundation Trust

Hillingdon Hospitals NHS Trust

Poole Hospital NHS Foundation Trust

Princess Alexandra Hospital NHS Trust

United Lincolnshire Hospitals NHS Trust

Appendix 3 - Committee structure and membership

Project Working Group

Alex MacGregor Ali Rivett Derek McShane Elaine Dennison

Elizabeth Macphie Helen Linklater Ian Rowe Ian Mulcahy

James Galloway James Thomas Jill Firth Jo Ledingham

Karen Jameson Neil Snowden Rosemarie David Zoe Ide

Steering Group

Ailsa Bosworth Ali Rivett Anna Gillespie

Benjamin Ellis Carol Black Christian Mallen

Charlotte McClymont Christopher Gush David McKinlay

Derek McShane Elaine Dennison Federico Moscogiuri

John Isaacs James Thomas Jo Ledingham

Judi Rees Laura Guest Louise Warburton

Rhona Buckingham Rosemarie David Simon Bowman

Appendix 4 – List of tables and figures

Section 6. Methodology

Table 6.1 metrics used to address NICE Quality Standards

Figure 6.2 number of forms provided at each stage in year 2 by patient diagnosis

Section 7. Analyses and interpretation

Table 7.1 participation by NHS region and Wales

Table 7.2 Anticipated recruitment by NHS regions and Wales

Figure 7.3 cumulative number of patients recruited over the 2-year data collection period

Table 7.4 recruitment and annualised adult incidence by NHS regions and Wales

Table 7.5 numbers of consultants and specialist nurses per 100,000 by NHS region and Wales

Table 7.6 proportion of trusts within each NHS region and Wales that reported access to other allied health professionals

Table 7.7 number and proportion of trusts reporting availability of service provision models by NHS region and Wales

Table 7.8 number and proportion of age and gender of participants

Table 7.9 ethnicity of recruited patients by NHS region and Wales

Table 7.10 number and proportion of patient diagnosis at baseline

Table 7.11 number (%) of patients referred to rheumatology within 3 working days of presentation to their GP by NHS region and Wales



Figure 7.12 time to referral in days by NHS region and Wales

Table 7.13 number (%) of patients seen in a rheumatology service within 3 weeks of referral by NHS region and Wales

Figure 7.14 median time from referral to first specialist appointment nationally and for each NHS region and Wales, along with the interquartile ranges and outlying values for NICE Quality Standard 2

Table 7.15 number (%) of patients starting DMARDs within 6 weeks of referral by NHS region and Wales


Table 7.17 number (%) of RA patients offered education and self-management within 1 month of diagnosis by NHS region and Wales

Figure 7.18 number (%) of RA patients offered education and self-management within 1 month of diagnosis by NHS region and Wales

Table 7.19 number and proportion of patients for whom a treatment target was set by NHS region and Wales

Figure 7.20 number and proportion of patients for whom a treatment target was set by NHS region and Wales

Table 7.21 number and percentage of RA patients who achieved their treatment target at follow-up by NHS region and Wales

Figure 7.22 percentage of RA patients who achieved their treatment target at follow-up by NHS region and Wales


Table 7.24 number and proportion of patients with access to urgent advice by NHS region and Wales

Table 7.25 number and proportion of trusts with an annual review process by NHS region and Wales

Table 7.26 provides a breakdown of RAID scores for all patients at presentation by NHS region and Wales

Table 7.27 provides a breakdown of RAID scores for RA patients only at presentation by NHS region and Wales

Table 7.28 RAID scores at follow-up for RA patients by NHS region and Wales

Table 7.29 number and proportion of rheumatoid arthritis patients nationally and within NHS regions and Wales that had mild, moderate and severe disease activity at their first appointment

Table 7.30 number and proportion of rheumatoid arthritis patients nationally and within NHS regions and Wales that had mild, moderate and severe disease activity at their follow-up appointment

Table 7.31 number and proportion of rheumatoid arthritis patients providing responses to the question ‘overall in the past 3 months, I have had a good experience of care for my arthritis’ by NHS region and Wales

Table 7.32 number and proportion of RA patients <66 years returning a patient follow-up form and reporting impact of their arthritis on their ability to work by NHS region and Wales

Table 7.33 number and proportion of RA patients <66 years returning a patient follow-up form and responding to whether they were asked about work in the course of their consultation by NHS region and Wales






































Table 7.69 Rheumatoid Arthritis Impact of Disease (RAID) score and changes in the London region

Table 7.70 Rheumatoid Arthritis Impact of Disease (RAID) score and changes in the Midlands and East of England region

Table 7.71 Rheumatoid Arthritis Impact of Disease (RAID) score and changes in the North of England region

Table 7.72 Rheumatoid Arthritis Impact of Disease (RAID) score and changes in the South of England region

Table 7.73 Rheumatoid Arthritis Impact of Disease (RAID) score and changes in Wales

Table 7.74 Disease activity score at presentation in the London region

Table 7.75 Disease Activity Score at follow up and changes in score in the London region

Table 7.76 Disease activity score at presentation in the Midlands and East of England region

Table 7.77 Disease Activity Score at follow up and changes in score in the Midlands and East of England region

Table 7.78 Disease activity score at presentation in the North of England region

Table 7.79 Disease Activity Score at follow up and changes in score in the North of England region

Table 7.80 Disease activity score at presentation in the South of England region

Table 7.81 Disease Activity Score at follow up and changes in score in the South of England region

Table 7.82 Disease activity score at presentation in Wales

Table 7.83 Disease Activity Score at follow up and changes in score in Wales

Table 7.84 number of consultants and nurses per 100,000 population in the London region

Table 7.85 number of consultants and nurses per 100,000 population in the Midlands and East of England region

Table 7.86 number of consultants and nurses per 100,000 population in the North of England region

Table 7.87 number of consultants and nurses per 100,000 population in the South of England region

Table 7.88 number of consultants and nurses per 100,000 population in Wales

Section 8. Outlier providers – NICE Quality Standard 2

Table 8.1 outlier providers by NHS region and Wales

Appendix 5 – Glossary

Acronyms

BSR British Society for Rheumatology

CQRA Commissioning for Quality in Rheumatoid Arthritis

DAS Disease Activity Score

EIA Early Inflammatory Arthritis

HQIP Healthcare Quality Improvement Partnership

NICE National Institute for Health and Care Excellence

PREM Patient Reported Experience Measure

PROM Patient Reported Outcome Measure

QS Quality Standard

RA Rheumatoid Arthritis

RAID Rheumatoid Arthritis Impact of Disease

REMISSION A period in the course of a disease when symptoms become less severe

The British Society for Rheumatology Bride House, 18–20 Bride Lane London EC4Y 8EE

Tel: +44 (0)20 7842 0900 Fax: +44 (0)20 7842 0901

[email protected] www.rheumatology.org.uk

VAT No: 404 5637 66 Company Reg No: 3470316 Charity No: 1067124

BSR Audit 0716

Documents

National Clinical Audit for Rheumatoid and Early ...€¦ · National linical dit or heumatoid nd arly n˜ammatory thritis 2nd Annual Report 2016 2 National linical dit or heumatoid