The role of the rheumatology nurse has developed from the collection of clinical measurements during drug trials in the 1970’s (Bird 1983), to encompass a much broader spectrum of activities. These activities include patient education and counselling, the monitoring of drug therapy, running specialist clinics, patient assessment and management and recommending treatment changes to the rheumatologist and general practitioner (Carr 2001).

Patients are often referred to a rheumatology nurse following diagnosis of an inflammatory rheumatological condition, most commonly rheumatoid arthritis (RA) to commence disease modifying drugs, begin the process of patient education, to obtain symptom control and receive emotional support. At the time of diagnosis the patient can experience a plethora of emotions including anger, shock, grief and denial.

Shaul (1995) demonstrated that in the early stages, women with rheumatoid arthritis needed to have their symptoms explained and managed before they could begin the process of learning coping strategies. The nurse consultation enables partnership, intimacy and reciprocity to evolve, and provides the forum to identify the patient’s priorities, providing care that has meaning and relevance to the patient. The key functions of nursing, as described by Wilson Barnett (1985) (Box 1.2.1) will be incorporated into the consultation to promote adaptation to the condition. Education and support will also be offered to family members, if the family does not appreciate the value of the management being advocated, for example exercise to assist with pain, stiffness and fatigue, then the individual may find it difficult to engage in this activity, without the endorsement of their family.

BOX 1.2.1 The key functions of nursing (Wilson Barnett 1985)

Understanding illness and treatment from the patient’s viewpoint

Providing continuous psychological care during illness and critical events

Helping patients cope with illness or potential health problems

Providing comfort

Co-ordinating treatment and other events affecting the patient.

Hill (1992) describes the characteristics of a nurse led clinic as

A survey of practice in nurse led clinics for patients with RA (Ryan & Hill 2004) demonstrated that nurses are engaged in

The model for clinics for patients with RA has been replicated to other conditions including connective tissue disorders, osteoporosis and chronic pain.

Nurse led clinics have been replicated in the community and GP practices to provide similar functions including:

Arthur and Clifford (2004) compared the satisfaction of patients attending drug monitoring within primary and secondary care locations. They found patients reported a higher level of satisfaction with secondary care based drug monitoring. Empathy, specialist knowledge, information provision, technical aspects, time and continuity of care were identified as important attributes contributing to the satisfaction experienced by patients attending secondary care drug monitoring.

Hill et al (1994) demonstrated the value of a clinic run on true nursing principles. This study was an evaluation of the effectiveness, safety and acceptability of a nurse practitioner in a rheumatology outpatient clinic. Seventy patients with RA were randomly allocated to either the nurse practitioner clinic or a consultant rheumatologist clinic and seen on six occasions over 12 months. On study entry the groups were well matched. At week 48 there was no significant difference between the two groups with both groups showing significant improvement in disease activity. However, the patients in the nurse practitioner cohort showed additional improvements not mirrored in the consultant group. The improvement was in levels of pain, morning stiffness, psychological status and satisfaction with care. One of the most noticeable aspects of the research was the marked difference in the referral patterns of the two practitioners, with the nurse practitioner making greater use of other members of the multi-disciplinary team, such as the physiotherapist. Hill’s work demonstrated that the nurse can add something extra to the management of patients with RA, and that extra is something that is valued by the patient.

A randomised controlled trial by Ryan et al (2006) examined the hypothesis that consultation with a consultant nurse specialist in a drug monitor clinic would have a measurable impact on the wellbeing of 71 patients with rheumatoid arthritis. Patients were randomised into two groups over a 3-year period. The intervention group was monitored by the consultant nurse specialist and an outpatient staff nurse reviewed the control group. Patients reviewed by the consultant nurse specialist reported a greater perception of being able to control their arthritis than those managed by the staff nurse. The role of the consultant nurse specialist in helping patients cope with their symptoms through goal setting, pacing, addressing low mood state and advocating exercise may be the nursing tools and expertise through which the ‘added value’ in influencing control perceptions was achieved. Ten patients from this study were interviewed by an independent researcher to explore ways of coping. The importance of nurse support in relation to enhancing positive control perceptions emerged as a clear theme in the intervention group (Hooper et al 2004).

Telephone advice lines have become an integral part of rheumatology care and are traditionally run by rheumatology nurses or other health professionals in extended roles (Thwaites 2004). The telephone advice line provides patients with the means of contacting the rheumatology nurse directly involved in their care and is accessed to provide advice of drug therapy and symptom management.

Almost all people in the UK are registered with a GP who typically provides treatment for both acute and chronic illnesses as well as providing preventive care and health education. Traditionally, GPs have also acted as gatekeepers to more specialist services, such as those provided in secondary care or by allied health professionals. Over the past few years, however, this model has started to change with the introduction of innovative services such as community matrons and primary care nurse practitioners. Despite significant reorganisation in the health service resulting in the provision of alternative providers of primary care such as NHS Direct and NHS walk-in centres, over 90% of primary care patient contacts still occur in general practice.

Rheumatological conditions are extremely common in general practice, where they account for an estimated one in five consultations (McCormick et al 1995). Consultation rates for musculoskeletal disorders rise with increasing age, with women of all ages consulting more frequently than men. Low back pain is the most frequent reason for consulting a GP in younger age groups and remains a leading cause of work absence, whereas osteoarthritis (particularly of the hip and knee) is the dominant condition managed in older adults (Jordan et al 2007, McCormick et al 1995) accounting for more than two million consultations per year. Referral to secondary care is relatively unusual occurring in approximately 5% of all consultations.

GPs are by name, and training, generalists making it impossible to have in-depth knowledge in all areas, yet given the large workload generated by rheumatological conditions in primary care, it is perhaps surprising that formal clinical training in rheumatology, rehabilitation or orthopaedics does not commonly feature as part of general practice training schemes (Hosie 2000). These unmet educational needs are currently being addressed with the introduction of the first formal curriculum for general practice in 2007. Core competencies for rheumatological disorders have been identified that should be met by all GPs in training (full details are available at www.rcgp.org.uk).

Two recent developments in primary care that have the potential to significantly impact on the delivery of musculoskeletal services in the community are the introduction of GPs with a special interest in rheumatology and practice-based commissioning. These will be discussed in more detail below.

One of the key components of the NHS Plan (2000) was the formal introduction of General Practitioners with a Special Interest (GPwSI). A GPwSI is defined as a general practitioner who supplements their core professional role and undertakes advanced procedures not normally undertaken by their peers (Hay et al 2007). In order to work as a GPwSI, GPs have to first demonstrate that they have the appropriate skills and competencies to deliver an enhanced rheumatological service within a defined quality framework. This enables them to accept direct referrals from other GPs, which has the potential to reduce demand for more specialised secondary care services. Services are provided at a local level, and may include areas such as more specialised joint injection and the management of patients with inflammatory arthropathies.

Another recent development in primary care has been the implementation of practice based commissioning. Practice based commissioning, which is currently only implemented in England, refers to the devolution of commissioning for health related services to GPs (or more usually groups of GPs within a defined geographical area such as a Primary Care Trust (PCT)). GPs, with the support of their local PCTs, have the potential to hold specific budgets and to be responsible for commissioning key services (a scheme not dissimilar to ‘fund holding’ which formed the cornerstone of NHS reform in the 1990s). It is envisaged that this will encourage a greater variety of services, from an increased number of providers, in settings that are both closer to home and more convenient for patients and their families. If successful, this scheme has the potential to reduce referrals to secondary care, improve co-ordination of patient services and improve collaboration between local GP practices (Greener et al 2006), however, uptake of practice based commissioning is currently low in many areas and its impact on the provision of services has yet to be evaluated.