As you will be aware, Lord Ara Darzi, the Parliamentary Under Secretary of State for Health, has been asked to identify a way forward for a 21st century NHS for England, which is clinically driven, patient centred and responsive to local communities. Phase 2 of the review is now underway, and Darzi’s final report is due to be published in June 2008.

 In Phase 1, Lord Darzi started to articulate a vision of an NHS that provides world class quality care in all its aspects; care that is fair, personalised, effective, safe and – above all - local. Within each Strategic Health Authority, groups of local clinicians and others have formed to consider the evidence for improved models of care across eight broad areas, one of which is long-term conditions. 

We are very concerned that the review does not appear to be considering arthritis as one of the key long-term conditions. We strongly believe that arthritis should form part of Lord Darzi’s review for the following reasons:

1. Arthritis affects large numbers of people

• More than seven and a half million people in England have arthritis.
• There are over 200 kinds of arthritis. Two of the most common forms are osteoarthritis (OA) and rheumatoid arthritis (RA).
• Osteoarthritis (OA) and rheumatoid arthritis (RA) are chronic degenerative diseases of synovial joints, leading to joint deformities, restricted movement and often chronic pain. Most people with arthritis will experience pain and difficulty moving around; others can suffer severe disability and incapacity.
• Arthritis is not just a disease of older people – it can affect people of all ages, including children. It is not clear what causes arthritis and there is no cure at present.

2. The financial and operational burden on the NHS is substantial

• The costs are colossal. In 2002 the estimated direct cost to health and social services was £5.5 billion. The cost of prescription costs alone added up to £341 million and hip and knee replacements cost £405 million.
• It has been estimated that in a year almost 1 in 5 of the adult population sees their GP for arthritis or a related condition.
• The cost implications of failing to effectively manage individuals can be seen clearly particularly for individuals with aggressive disease who rapidly become heavy users of healthcare resources.  The long term implications of this sub optimal management may result in a greater functional disability and possible increasing co-morbidities such as cardiac disease.

3. The impact and burden of disease on patients, families, carers and their daily lives is great

• Loss of employment and lost productivity is a significant issue for people with arthritis.
• For example, people with Rheumatoid Arthritis are likely to have their working life cut short at considerable personal cost.  A recent survey suggests that approximately 30% of people with RA have to stop working permanently because of their disease (and 59% of these do so within 6 years of diagnosis).
• Patients have also reported experiencing a range of challenges to their social support structures as a result of their condition.  These included difficulties in maintaining work, gaining appropriate benefits and costs related to adaptations (particularly when access to multi-professional teams is lacking).  These costs also impact on partners with an increasing burden on carers providing support.  The costs of moving home, home adaptations, traveling to hospital appointments and costs related to parking all add to the social impact on the individual.  

4. The financial impact on the individual is significant

• The financial cost to the individual is high. Delay in referral or receiving a definitive diagnosis/treatment can result in costs running into four figures per annum to the individual, particularly for those who are employed.
• In recent work undertaken by the National Rheumatoid Arthritis Society (2007 Mapping Project), total average medical costs per person ranged from £3,575 to £3,638 depending on length of time from diagnosis and using core economic data from 1996.  Direct costs included medical costs such as treatment costs, hospital costs and indirect personal costs such as transport and specialist aids, and came to an average for all participants, regardless of time from diagnosis, of £8,471.21 up to and including the first 3 years of diagnosis.

5. Arthritis is very important in health policy terms because….

• Whilst we are supportive of many recent NHS reforms – such as the prioritisation of long-term conditions and the emphasis on delivering care closer to patients’ home -  other reforms have the potential to destabilize and defragment services, which will ultimately compromise continuity and quality of care.
• The Musculoskeletal Services Framework (MSF), launched in October 2006, sets out new guidance to provide high quality and integrated services for people with musculoskeletal conditions in England. Once implemented, the framework will aim to improve assessment, diagnosis and treatment for people with arthritis and other musculoskeletal conditions in England. It is imperative that the MSF is implemented fully and consistently across the country.
• It is crucial that people with arthritis have access to specialist multidisciplinary care; recent initiatives, including clinic closures and the loss of specialist nursing posts, undermine this need.
• Research evidence has demonstrated the need to aggressively treat early rheumatological disease, the so called ‘window of opportunity’. This demonstrates the importance of encouraging primary care teams to ensure prompt referrals are made to a specialist.  The development of referral routes via Clinical Assessment and Treatment Services (CATS) together with the additional pressure to manage more patients in the community stresses the need for early signs of disease to be identified by healthcare professionals at all points of the individuals journey.
• Finally, it is vital that patients are actively engaged and consulted over the changes that affect them, including in the planning and evaluation of local musculoskeletal services.

Please complete the questionnaire at www.nhs.uk/ournhs to have your say in this consultation. You do not need to answer all the questions - you can skip questions and just provide feedback on the areas you would like to focus on.

Please note that the public questionnaire will only be available online until February 25th 2008 and the NHS staff/professional questionnaire will only be available until 15th February 2008.

PLEASE NOTE THAT THIS SURVEY IS ONLY CONCERNED WITH THE NHS IN ENGLAND