Written evidence submitted by the British Society for Rheumatology (RTR0045)

Introduction

1. British Society for Rheumatology (BSR) is the UK’s leading specialist medical society for rheumatology and musculoskeletal professionals. We support our members to help deliver the best care for their patients, in order to improve the lives of children, young people and adults with rheumatic and musculoskeletal disease.

2. Our members represent the entire profession - from those at the beginning of their career to the most senior consultants, researchers, academics and health professionals in the multi-disciplinary team. Together, they form a powerful voice for paediatric, adolescent and adult rheumatology in the UK.

Reason for submission

3. There’s a crisis in rheumatology. Our workforce is understaffed and under resourced. Patients face debilitating consequences with longer waiting times and treatment delay. The Society is deeply concerned about how current plans for the recruitment, training and retention of the NHS workforce are impacting both the practice of rheumatology and the quality of patient care.

4. This evidence submission response is based on our members’ experiences and the Society’s substantial research and analysis. We have found that the rheumatology workforce in both adult and paediatric and adolescent services lacks sufficient staff to provide the level of care recommended by NICE guidance, and that regional and national variations in patient care persist due to workforce shortages.

What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

5. Understanding the scale of the problem: We cannot manage what we do not measure. British Society for Rheumatology’s census collection in 2020/1 was the first time the UK’s rheumatology workforce numbers were calculated and recorded[i]. Beyond our independent measures, there is no adequate regional or national system in place to record the number of rheumatology multidisciplinary team members working across the NHS.
1. The solution:  Maintaining these data would support the identification of workforce gaps and recruitment needs across the health sector and provide an evidence-based solution to long term workforce succession planning that the Hunt and Cumberlege workforce amendments call for.

6. Workforce numbers: There are not enough consultants or specialist nurses in rheumatology and access to certain members of the multidisciplinary team (MDT), including psychologists and pharmacists, is not sufficient.
1. The solution: Adult rheumatology consultant numbers must increase to secure the long-term sustainability of the workforce. This means 1 consultant per 60-80,000 population.

7. Workforce expansion: Workforce expansion must not stop at consultants – more rheumatology specialist nurses are needed across the UK to improve patient outcomes. Nurses care for people at every stage of life and across every rheumatology setting. The specialist nurse role is crucial to rheumatology services, and we have previously highlighted in our Specialist Nursing in Rheumatology report the need for an expansion of the workforce[ii]. In that report, 83% of specialist nurse survey respondents reported that there were aspects of care that their team was either unable to provide, or that were regularly delayed because of excessive workload.
1. The solution: Adult rheumatology specialist nurse numbers must increase to ensure departments are adequately staffed, with a specialist nurse to consultant ratio of at least 1:1.
8. Vacancy rates: We’re living through a rheumatology workforce crisis across the UK. Some MDT vacancies have gone unfilled for up to 2 years, stretching the entire rheumatology workforce.
1. The solution: We must ensure that enhanced roles for Allied Health Professionals (AHPs), pharmacists and nurses are developed in rheumatology settings to support a long term sustainable workforce plan.  
2. The solution: Roles should be recognised at appropriate Agenda for Change Bands 6, 7 and 8 to ensure the required level of skill is recognised and remunerated.

9. Meeting healthcare demand: Low levels of consultant provision lead to unacceptably high caseloads for the whole MDT and affect patient outcomes. Within England, consultant provision is unacceptably low, and far below our minimum recommendation of one consultant per 60-80,000. In England, there is one consultant per 99,423 population. Currently in England and Wales, 48% of patients referred for suspected early inflammatory arthritis are seen within three weeks, meeting the NICE target. However, substantial geographical variations persist.
1. The solution: Using National Early Inflammatory Arthritis Audit data, British Society for Rheumatology knows that to meet 100% of patient demand (compared to 48% of patients currently being seen within three weeks), rheumatology workforce numbers must expand to replicate one consultant per 60,000–80,000 of the population.

10. Trainee numbers: This variation in workforce provision is likely to persist due to the uneven distribution of trainees across the UK. The expansion of the consultant workforce must be targeted at the nations and regions that most need it.
1. The solution: Exposure to rheumatology must increase to undergraduate and postgraduate curricula through teaching modules and English clinic placement.
2. The solution: Rheumatology specialty training posts must increase in every home nation to address current workforce shortages and meet future demand on rheumatology services from increased waiting times.

What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:

1. To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?
2. Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

11. Exposure to specialties: Rheumatology exposure for medical students is limited. Anecdotally, medical students only attend a couple of clinics in rheumatology during their undergraduate training. Advances and changes in the practice of rheumatology has meant that much of the work is now outpatient based, which means the opportunity for trainee doctors to gain exposure to the specialty is also very limited.  
1. The solution: Rotations to include more exposure to rheumatology for Foundation Year and Core Medical Trainees. For example, taster days during medical rotations allow students to gain more insight into rheumatology. 
2. The solution: Greater involvement of rheumatology into General Internal Medicine. Examples of this would be physician of the week or attending system to see ward referrals & work as part of a team with juniors on the wards. 
3. The solution: More educational events for medical students at conference (ex. revision day to support students leading up to finals). 
4. The solution: Attracting trainees into the speciality needs to be a priority and this requires opportunities and investment.  Opportunities need to be created in the form of the above exposure, but also there is a need for an increased number of posts for various members of the MDT in rheumatology. 

12. Protected job titles: With the increase in tasks taken on by Allied Health Professionals there is a need for more structured educational courses to train AHPs in these skills. National recognition of these roles and standardised job descriptions will create consistency and ensure the value of these roles is recognised. Protected job titles ensure that those in position have the necessary training and skills required to meet the demands of these expanding roles. 
1. The solution: Creation of more structured educational opportunities coupled with protected job titles and standardised job descriptions to ensure that AHPs are appropriately upskilled and prepared for the demands of their growing roles. 

Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

13. Upskilling Allied Health Professionals: It is important we create opportunities to upskill Allied Health Professionals. This has a dual purpose of supplementing the shortage of consultants and improving retention of AHPs by creating opportunities for career advancement. The shortage of consultants and the move by many consultants to working less than full time has created a need for AHPs to take on more tasks.  

14. Solutions in action: One of our members working in a community setting reported that her service developed clear career progression for their specialist nurses working through from a Band 5 to Band 8a post, and have upskilled one of their physiotherapist to the role of Extended Scope Practitioner, undertaking triage and assessing new patients. The service has also recruited a pharmacist and pharmacy technician, both helping with providing drug education and the pharmacist has just started delivering an osteoporosis clinic.   

January 2022