The last 12 months have marked something of sea-change in RA policy and we are now daring to believe that the government might finally have grasped the nettle.
As the old saying goes, you wait for a bus and two come along at once – and this is exactly what has happened with RA policy. Having been unaccountably overlooked for decades, 2009 suddenly saw a splurge of activity with a King’s Fund report on the management of RA and a National Audit Office report on the same topic.
Separately, NICE also published a clinical guideline for RA to set out best practice for how to manage the disease. Following on from the NAO report, the House of Commons public accounts select committee then undertook an inquiry into the disease in 2010, making some strong recommendations for how things could be improved. Then, suddenly there was silence and little evidence of meaningful progress.
Improvements in 2012
Yet, fast forward to 2012 and things are starting to look a lot rosier, thanks to a flurry of announcements. First there was the announcement in October last year that the Healthcare Quality Improvement Partnership would be taking forward a national clinical audit on early RA during 2012/13 to collect data and ascertain what is really going on in hospitals.
Then in February this year NICE announced it would be developing a quality standard for RA (in effect a condensed clinical guideline) and in August NICE also recommended the inclusion of four new indicators on RA in the QOF, suggesting that GP practices should start producing a register of all patients aged 16 years and over with RA, and that patients with RA should be assessed for cardiovascular risk and fracture risk.
At the same time, NICE has also begun scoping for a new multi-technology review of RA drugs, which it hopes to complete by early 2014, and in September, the deputy NHS chief executive also announced that one of the new areas being considered for a best practice tariff in 2013/14 would be early inflammatory arthritis. But the job is not finished yet.
These developments can help to improve our baseline data about the disease, financially incentivise healthcare professionals to track and treat RA patients more effectively and potentially open up access to more treatments based on clinical need. However, progress will be seriously impeded if clinical commissioning groups (CCGs) are not also held to account for the overall quality of the services they commission.
COF will play key role
The Commissioning Outcomes Framework (COF) expected later this year is therefore going to be very important, because it will be the main mechanism the NHS Commissioning Board uses to do this. The theory goes that once you have a NICE quality standard, you are eligible to have indicators included in the COF (which the CCGs will be measured against). This is all very straightforward until you look at the small print.
A list of draft COF indicators was published earlier this year, which included a large number of proposed indicators that already have a quality standard, but the vast majority of quality standards have not been published yet. The message is clear: for the sake of expediency there is a basic risk of skewing CCGs to focus on a smaller group of conditions to the detriment of others.
To make my point, the current COF Indicator Programme on the NICE website sets out proposed categories, yet there is no category for musculoskeletal conditions (which includes RA), despite the fact these conditions were the fourth largest programme spend for the DH in 2008/9, worth £4.2bn. An appendix of draft COF indicators issued in an earlier consultation document provides a list of potential indicators for 'future development', which does not include any mention of RA or musculoskeletal conditions.
From what we have heard, the number of COF indicators is going to be limited. If this happens, then logically the government will have to refresh the list on a regular basis. The question is how often will it be refreshed, and what happens to the drive to improve services if a COF indicator falls off the list? It’s not clear, and this needs to be resolved quickly.
So we are clear about what needs to happen next for RA, even if some of the practical detail needs to be determined. If the government is serious about continuing to transform clinical outcomes for the estimated 580,000 people with RA in England, it must include a COF indicator to measure the number of people with the disease in remission. This would ensure commissioners and providers have to focus robustly on clinical outcomes for RA patients and take action to drive improvements where services are underperforming.