British Journal of Rheumatology 1997;36:481–486
CLINICAL AUDIT
RHEUMATOLOGY OUT-PATIENT WORKLOAD INCREASES INEXORABLY
J. R. KIRWAN
For the former South West Regional Advisory Committee for Rheumatology*
Rheumatology Unit, University Division of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW
SUMMARY
Rheumatology out-patient consultations in the south-west of England from 1 to 30 November 1994 were recorded by standard
methods and compared to 1988, 1990, 1991 and 1992. Historical records at one centre provided additional detailed information.
There has been an overall increase of 31% in the number of patients seen (30% for follow-up cases, 36% for new referrals),
but the mean waiting time for new patient consultations increased from 65 to 108 days. The proportion of new patient
consultations with non-arthritic diseases increased by 8.2%, and those with rheumatoid arthritis and polyarthritis decreased by
9.0%. Variation in discharge rates and length of follow-up appointments occurred, but mostly in uncommon diagnostic
categories. Referral rates have been rising faster since the introduction of National Health Service reforms than can be
accommodated by the increased workload undertaken.
K : Audit, Region, Waiting time, Referrals, NHS reforms, Case mix.
P evaluation of the NHS reforms of 1991 [1]
was not undertaken either before or during their
introduction, but rheumatologists in the South West
Regional Health Authority (SWRHA) used the
opportunity provided by an earlier regional audit [2] to
monitor the effect on rheumatology out-patient
workloads. They had recorded all out-patient referrals
during the month of November 1988, together with the
diagnostic category and (for new patients) the time
waiting from referral to consultation. Similar surveys
were repeated in November 1990 (in anticipation of
organizational change), and in 1991 and 1992 (6 and 18
months after the initiation of change). These data
represent the NHS rheumatology service provision for
03.2 million people and the results of the surveys have
been published [3]. In essence, and contrary to fears
previously expressed [4], they showed that the
rheumatology workload had increased substantially
during the time of the surveys. Most of this increase
had occurred following the introduction of NHS
reforms in April 1991 and represented primarily an
increase in the workload of existing consultants rather
than the investment of new resources ‘following the
patient’ [1].
Informal discussions between the consultants involved in the surveys had suggested that they had
increased the interval between follow-up consultations
during this time period. There was, thus, an even
greater increase in the total number of patients under
continuing rheumatological care. In contrast, there was
a concomitant 22% increase in the time patients had to
wait from referral to first consultation. Presumably, the
rate of referral has increased, the opposite of what
might have been expected [5], and contrary to the
intentions of providing a more accessible service [1].
In order to monitor the continuing trend, to verify
the assumptions about changes in working practices
and to test the hypothesis that variations in clinical
practice might indicate opportunities for improving
patient throughput, a further survey was undertaken in
November 1994.
METHODS
A full account of the initial audit in November 1988
has been provided previously [2, 3]. Subsequent surveys
were conducted in the same way, but omitted private
practice (6% of the 1988 workload). Seven centres were
able to participate in each year of the survey (1988,
1990, 1991, 1992, 1994), an additional centre took part
in 1988, 1992 and 1994, and a newly formed centre in
1990, 1991, 1992 and 1994. In 1994, a new consultant
appointment was made at a new centre, but the practice
had not been fully opened by November and the few
patients seen were amalgamated with the centre
previously serving that geographical area.
All rheumatology out-patient consultations, including patients seen by trainee and other clinical staff,
during the period 1–30 November were included. At
each clinic, a standard form was used to record the
hospital, consultant, clinician and date. The principal
diagnosis of all patients attending the session was noted
and for new patients the date of the referral letter was
noted. Diagnostic categories were assigned as shown in
Table II. In 1994, a record was also made of the
outcome of the consultation. Outcomes recorded were:
time to next appointment; open appointment; admitted
to hospital; or discharged. Completed forms were
returned for analysis, and any apparent anomalies
promptly queried and ratified by telephone. Patients
failing to attend a consultation were not included.
Participating centres were arbitrarily coded A–I.
Analyses of new and follow-up consultations were
performed separately, according to centre and diagnosis. All 1988 figures were reduced by 6% to allow for
Submitted 3 June 1996; revised version accepted 11 October 1996.
*Former South West Regional Advisory Committee for Rheumatology: T. Palferman, P. Creamer, M. Davies, P. Dieppe, E. George,
P. Hickling, P. Hollingworth, C. Hutton, R. Jacoby, J. Kirwan,
V. Kyle, S. Rae, J. Woodland, A. Woolf, D. Yates.
= 1997 British Society for Rheumatology
481
512
564
564
1865
2099
2099
Follow-up
2377
2663
2663
Total
399
399
421
New
1973
1973
2122
Follow-up
1990
2372
2372
2543
Total
479
479
519
New
1867
1867
1974
Follow-up
1991
2346
2346
2493
Total
540
712
780
New
2228
2839
3024
Follow-up
1992
2768
3551
3804
Total
607
710
766
New
2157
2551
2719
Follow-up
1994
2764
3261
3485
Total
19
26
36
New
16
22
30
16
22
31
Follow-up Total
Increase (%) 1988–1994
The base hospitals of the participants were (in random order): Bristol Royal Infirmary, Bristol; Southmead Hospital, Bristol; Frenchay Hospital, Bristol; Princess Elizabeth Hospital, Exeter;
Standish Hospital, Gloucestershire; Royal Cornwall (City) Hospital, Truro; Mount Gould Hospital, Plymouth; Yeovil District Hospital, Yeovil; Musgrove Park Hospital, Taunton.
*Centre H did not participate in 1990 and 1991.
†Centre I was formed in 1990 and is omitted from 1988.
Centres A–G
Centres A–H*
All centres (A–I)†
New
1988
TABLE I
Rheumatology consultations during November in the former South West Regional Health Authority, 1988–1994
482
BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 4
483
KIRWAN: RHEUMATOLOGY WORKLOAD
TABLE II
Proportionate (%) distribution of patients seen by diagnostic group
Centre
Diagnostic group
A
B
C
D
E
F
G
H
I
(a) New patients
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Total number (100%)
(RA and polyarthritis)
22
24
18
16
8
3
2
7
92
42
16
22
18
8
10
10
10
8
51
39
0
22
23
16
8
1
1
29
96
45
0
13
20
27
14
1
8
16
97
33
25
7
20
3
8
5
14
17
59
27
17
19
24
20
5
5
2
7
150
43
6
17
28
19
11
0
4
17
54
44
11
8
13
14
16
1
5
32
237
20
21
7
22
31
10
3
2
3
58
29
(b) Follow-up patients
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Total number (100%)
(RA and polyarthritis)
15
50
21
5
3
2
2
3
351
71
4
51
18
1
3
4
6
13
172
69
5
63
18
0
3
3
1
7
255
81
7
44
27
1
2
1
6
13
627
70
7
48
15
1
2
4
2
20
294
63
5
52
24
4
5
1
3
5
353
76
4
44
33
1
2
2
4
9
226
77
6
44
16
7
7
5
5
10
631
60
9
34
32
12
2
5
2
5
176
66
the inclusion of private practice. Totals were reduced
by 1/22 in 1988, 1990 and 1994 to standardize for the
number of hospital working days in each month.
Differences based on these adjusted figures were
compared by Student’s t-test, a test of proportions or
a comparison between medians, as appropriate [6].
As an adjunct to the main survey, historical records
of booked out-patient clinics were scrutinized at one
centre to ascertain the number of patients currently
under hospital care at various times between 1988 and
1995. A printout of all bookings for the following year
had been made for clinic management purposes and
had been retained on file. The total number of
bookings recorded on each of the printouts was
counted. Earlier records of overall discharge rate and
length of follow-up appointment were also available
for this centre as they had been collected locally (using
the same methods as the main regional surveys) in
1990, 1991 and 1993, together with the new patient
waiting times which were also recorded in 1995. At this
centre, the number of general practitioner (GP) referral
letters received in January of each year was counted
from 1989 to 1995.
RESULTS
The recorded cases seen in the region, adjusted as
described in Methods, are shown in Table I.
Comparison of the 1988 and 1994 figures for Centres
A–H shows an overall increase of 31%, comprising
30% for follow-up cases and 36% for new referrals.
However, because two centres did not take part in all
the years of the survey, a more appropriate comparison
should include only Centres A–G. This shows a
sustained increase in the total number of patients seen
since the introduction of the NHS reforms in 1991. In
1994, there was an increase in the number of new
patients seen at the expense of a small reduction in
follow-up consultations compared to 1992.
The mean waiting time for new patient consultations
increased in Centres A–G (for which data are available
for all years of the survey) from 65 days in 1988 to 72
days in 1990, 74 days in 1991, 79 days in 1992 and 108
days in 1994, an overall increase of 66%. Including
data for Centres H and I in 1994 also results in a mean
waiting time of 108 days.
The diagnostic case mix in 1994 for each centre is
shown in Table II. For new referrals, there is clearly
variation in the proportion of patients with inflammatory polyarthritis, and reciprocal differences in the
proportion of soft-tissue rheumatism and back
problems. The variation is much less for follow-up
patients, indicating that the clinicians at each centre
tend to recall a relatively similar group of patients for
further review. Comparing the changes that have
occurred in the mixture of cases seen overall between
1988 and 1994 (Table III), there has been a substantial
and statistically significant increase in new patient
consultations with other diseases (8.2%) and a
concomitant reduction in polyarthritis consultations
(9.0%). However, because the total number of patients
seen has increased over this time, there has actually
been an 8% increase in the absolute number of such
patients seen. For the follow-up cases, there was a less
marked increase in the proportion with other diseases
(4.7%), but in addition small but significant increases
in soft-tissue rheumatism (1.7%) and back problems
(1.6%) resulted in a reduction of 5.7% in rheumatoid
arthritis (RA) and polyarthritis combined.
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BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 4
TABLE III
Change in case mix between 1988 and 1994 for all centres combined
Proportion (%) of consultations
New patients
Follow-up patients
Diagnostic group
1988
1994
Change
95% CI
1988
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Total number (100%)
(RA and polyarthritis)
14
22
21
17
10
3
43
10
564
43
12
15
19
17
11
3
5
18
894
34
−1.8
−7.3
−1.6
0.2
1.0
−0.2
0.6
8.2
−0.3
−5.6
0.1
1.8
2.2
0.5
1.4
9.5
−9.0
− 6.9 −11.1
−3.3
−9.1
−3.4
−1.4
−0.3
−0.9
−0.3
6.9
1994
9
55
20
2
2
4
2
5
2663
75
7
47
22
4
4
3
4
10
3085
69
Change
95% CI
−2.1
−7.6
2.0
1.7
1.6
−1.1
1.8
4.7
−0.8 −3.3
−5.5 −9.8
3.7
0.3
2.3
1.1
2.2
1.0
−0.3 −2.0
2.4
1.2
5.7
3.8
−5.7
−3.8 − 7.5
invariably for diagnostic groups with few patients,
except for Centre F, where there were few patients with
RA or polyarthritis seen in less than 26 weeks and a
relatively large proportion given follow-up appointments for 52 weeks. New patients were given follow-up
appointments for shorter time intervals than follow-up
patients with the same diagnosis (difference = 8 weeks,
P = 0.0014).
Additional detailed information available from
Centre A is shown in Fig. 1. In common with the region
as a whole, new patient waiting times have been
increasing in recent years. This centre has recorded a
steadily rising discharge rate and the length of
follow-up appointments has also been increasing.
During the period August 1987–January 1995, the
number of patients under the care of Centre A
increased by 111%. In spite of these increases in patient
throughput, the new patient waiting time has also
There were variations between centres in the
discharge rate for different diagnostic categories and
for new and follow-up patients. These are shown in
Table IV. There are striking variations in discharge
rates for new patients with back problems and
soft-tissue rheumatism, but variation in discharge of
osteoarthritis and inflammatory arthritis is much less.
For follow-up patients, discharge rates were very low
for all centres for the two most common conditions
(RA and polyarthritis).
The distribution of length of follow-up appointment
was not normal, and there was a strong tendency to
allocate appointments for 8, 12, 16, 24–26 and 52 weeks
(Table V). There was variation between centres in the
median length of follow-up, but there was considerable
overlap of the 95% confidence intervals in almost all
cases. Where one or two centres gave appointments
outside the range for all centres combined, this was
TABLE IV
Discharge rates (% of patients seen) in 1994 by centre and diagnostic group
Centre
Diagnostic group
A
B
C
D
E
F
G
H
I
A–I
95% CI for A–I
(a) New patients
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Combined
40
0
18
47
29
0
56
50
28
63
9
30
75
0
20
0
75
33
73
14
5
–
100
0
0
15
43
56
9
5
77
36
100
0
25
40
33
0
0
50
60
0
13
40
29
80
21
22
73
56
13
0
27
46
67
56
13
30
17
–
0
0
29
46
28
13
44
62
0
9
71
71
50
0
8
22
33
0
0
0
23
55
16
13
56
49
13
8
46
43
47–63
10–22
8–18
58–64
39–59
0–26
0–16
38–54
39–47
(b) Follow-up patients
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Combined
28
4.5
11
31
45
14
50
18
14
25
2.2
11
75
71
25
50
30
20
24
2.2
12
20
29
60
18
28
11
0
2.0
12
33
25
0
10
15
8.3
41
4.1
13
54
51
3.2
15
31
19
21
1.7
5.2
38
33
0
0
13
10
27
2.9
9.1
44
46
14
18
25
13
57
3.3
13
100
67
14
20
30
17
100
3.7
18
–
50
25
33
53
13
7.7
1.1
0
50
36
25
11
16
6.4
21–33
2.0–3.8
7.0–11.2
35–53
37–55
6.8–21.2
11–25
20–30
11.7–14.3
485
KIRWAN: RHEUMATOLOGY WORKLOAD
TABLE V
Mean length of follow-up appointment (weeks) given in 1994 by centre and diagnostic group
Centre
Diagnostic group
A
B
C
D
E
F
G
H
I
A–I
(a) New patients
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Combined
23.3
13.9
17.3
21.1
16.8
17.0
–
17.3
19.2
–
20.9
16.5
12.0
10.5
14.3
14.7
2.0
13.5
26.0
16.3
16.5
13.0
3.0
13.0
26.0
32.0
27.4
8.3
9.2
10.8
10.0
10.0
–
12.0
11.8
11.5
14.0
11.0
12.0
12.0
7.0
6.7
15.7
5.8
13.5
28.5
27.1
22.7
22.1
17.8
23.1
21.7
28.9
26.5
–
27.0
11.7
9.0
4.0
–
10.0
11.3
14.3
16.5
12.8
17.7
11.2
16.4
104.0
11.3
29.8
29.0
9.7
13.5
12.3
11.2
15.0
4.0
–
11.0
11.5
17.3
17.3
16.4
14.1
13.1
18.5
12.9
24.3
20.7
(b) Follow-up patients
OA
RA
Polyarthritis
Soft tissue
Backs
PMR
Other arthritis
Other diseases
Combined
25.0
22.1
20.4
21.7
29.3
11.3
21.7
20.3
22.1
25.7
22.5
27.2
–
26.0
10.0
21.7
–
19.9
–
12.3
19.7
–
13.8
17.3
10.5
46.4
15.6
22.2
16.4
18.0
14.0
15.1
13.3
26.6
18.7
18.1
18.1
12.6
17.9
8.0
11.0
11.6
19.0
16.5
14.6
28.8
26.0
26.8
28.8
41.2
37.5
33.0
23.4
27.4
21.3
6.9
20.3
21.0
15.0
17.5
31.2
15.2
14.2
27.9
18.8
21.4
13.5
32.1
13.9
20.5
35.2
21.8
20.4
19.5
18.3
12.4
12.0
14.9
16.7
19.3
17.9
22.6
17.7
20.6
16.3
27.3
14.5
24.1
22.1
19.6
increased by 245% from 55 days in 1990 to 185 days
in 1995. That this must result from increased referrals
is supported by the finding that in January of each year
from 1989 the numbers of GP referral letters received
by Centre A were 35, 44, 51, 59, 64, 67 and 70.
DISCUSSION
These results confirm, reinforce and take further
those published in a previous report [3], and reflect a
continuing increase in rheumatology patient workload
during the years 1988–1994. Most of this increase has
occurred since the introduction of NHS reforms in
April 1991 and represents an increase in the workload
of existing consultants, at least as much as the
investment of new resources ‘following the patient’ [1].
While new referrals in all diagnostic groups have
increased in absolute terms, the proportion of those
with polyarthritis has decreased because of a greater
increase in referrals of patients with soft-tissue
rheumatism and back problems, and those with
F. 1.—Additional detailed information available from Centre A. –Q– Discharge rate (%); –R– follow-up time (weeks); –q– new patient
waiting time (weeks); –W– number of patients under care.
486
BRITISH JOURNAL OF RHEUMATOLOGY VOL. 36 NO. 4
other diseases. The opinion of the participants in
the surveys is that these particularly include osteoporosis, but this has not been recorded as a separate
category.
Several strategies have been adopted to cope with
this rising demand. These include an increased
out-patient discharge rate, a lengthening of the time
between follow-up appointments, a slight reduction in
the follow-up:new ratio and an increase in the number
of patients seen by individual clinicians. In one centre
for which detailed figures are available, this has
resulted in a 111% increase in patients under care. In
spite of this increased activity, the time new patients
have to wait from referral to first consultation has
continued to rise alarmingly, and was 66% longer in
1994 than in 1988 for the region as a whole, and 245%
longer in 1994 than in 1990 for Centre A. Most of this
has occurred since the NHS reform of 1991, and can
only be explained by an increase in new patient referral
rate over and above the increased patient throughput.
The alternative explanation of a change in geographical
demography would be difficult to envisage in relation
to the large size and short time scale of the changes
recorded.
It is a legitimate question to ask whether
inefficiencies in discharge and follow-up policies at
some centres may be resulting in the unnecessary
review of some patients. Differences in discharge rates
and follow-up appointment times were recorded at the
different centres in 1994, but occurred mostly in groups
of patients which comprised a relatively small
proportion of those seen. It is possible, therefore, that
some attention to discharge and follow-up policies
might lessen the total increase in work of 31%, but the
benefit may be relatively small compared to the effort
that might be involved.
One centre (Centre F) had a follow-up pattern for
RA and polyarthritis which was different from the
other centres. Very few patients were seen again in less
than 26 weeks and a substantial minority were not seen
for 52 weeks. This contrasts with the pattern elsewhere
which included a substantial minority seen at 8–13
weeks, the majority at 26 weeks, and a very small
proportion at 52 weeks. These clear differences in the
overall pattern of follow-up suggest that there may be
a difference in disease severity in follow-up patients at
Centre F rather than simply differences in management
policies, but discharge rates for these disease categories
are relatively low at Centre F (12% compared to 20%
at Centre A). However, these differences warrant
further investigation through the collection of data on
disease severity, including measures of symptoms, the
extent of joint involvement, disability, disease duration,
age and gender.
It has only been possible to absorb the increasing
demand for hospital care of chronic arthritis in recent
years by rheumatologists working harder, patients
being seen less frequently and new patient waiting times
being allowed to rise. It seems likely that these
measures will soon reach saturation. Either more
resources will have to be found, new and cheaper
approaches to the long-term care of chronic arthritis
will have to be tested and implemented, or patients and
their GPs will begin to protest.
R
1. Secretaries of State for Health, Wales, Northern Ireland
and Scotland. Working for patients. London: HMSO,
1989.
2. Kirwan JR, Snow SM. Which patients see a rheumatologist? Br J Rheumatol 1991;30:285–7.
3. Kirwan JR, for the South West Advisory Committee for
Rheumatology. Effect of National Health Service
reforms on outpatient rheumatology workload. Br J
Rheumatol 1994;33:1181–3.
4. Haslock I. Working for patients? Br J Rheumatol
1989;28:185–6.
5. Coulter A, Bradlow J. Effects of NHS reforms on general
practitioners referral patterns. Br Med J 1993;306:433–7.
6. Gardner MJ, Altman DG. Statistics with confidence.
London: British Medical Journal, 1989.