Arthritis New Zealand is calling for more rheumatologists to meet the recommended ratio of one full time equivalent rheumatologist in the public sector per 100,000 people.
Arthritis NZ advocates for
- additional funding for specialists to practice in the public system
- incentivising rheumatologists to practise within poorly serviced communities in New Zealand,
- improving opportunities for nurses to develop as nursing specialists in this field.
The Royal College of Physicians (RCP) recommends 1.16 full time equivalent (FTE) rheumatologists per 100,000 people in the public sector. In 2018 none of the 20 District Health Boards (DHBs) meet this guideline. New Zealand has a problem with filling specialist vacancies. In 2018, only four DHBs reached this level when private FTEs were included. The need for specialist rheumatologists is more keenly felt in rural areas than in the bigger centres.
People are experiencing long waiting lists and delayed access to rheumatologists. The faster patients are seen by a specialist, the more effective their treatment and management of their condition. The number of people with conditions such as arthritis is only going to grow.
Arthritis New Zealand wants to see an increase in the number of publicly funded rheumatology positions. The New Zealand Rheumatology specialist workforce would need to increase by 13 FTE rheumatologists to achieve the RCP recommendation. It takes at least 7 years to train a rheumatologist. New Zealand cannot afford to train specialists and then see them leave to work overseas because funds for public sector work is underfunded here.
We also recommend greater effort to recruit and train specialist nurses to support rheumatologists in their practice. Skilled specialist nurses are an important support service for specialists and patients with challenging chronic health conditions such as severe arthritis.
Why are rheumatologists important?
People with symptoms of inflammatory arthritis (IA), that is, arthritis that is caused by an immune system disorder, who see a specialist, often do not present early enough to gain maximum benefit from the medicines that can alter the course of their disease. These are called disease-modifying antirheumatic drugs or DMARDs.
The importance of rheumatology care for people with IA has been identified in research that shows continuous care by a rheumatologist is strongly associated with regular use of DMARDs and leads to improved health outcomes. Those who receive DMARDs in primary care, that is prescribed by GPs not specialists, are significantly less likely to continue with this treatment. Reviews of prognosis and outcome overwhelmingly support the contention that early IA care is optimised when treatment is managed by a rheumatologist, rather than a GP or other consultant.
Rheumatologists rely on the information supplied by the GP to triage patients with suspected IA and prioritise accordingly. The history of symptoms, clinical markers of inflammation, positive rheumatoid arthritis antibodies and radiological assessments are all important measures of urgency and used by rheumatology services to prioritise and manage waiting lists.
In New Zealand, where waiting lists are used to ration scarce health resources and monitor health system performance, referral to specialist services through managed and prioritised waiting lists may lead GPs to delay referral until a pre-determined threshold is reached for referral, especially because individuals will be referred back to the GP if the referral is deemed inappropriate (Cumming, 2013).
As of January 2015, the standard expected for waiting time in New Zealand for First Specialist Appointment (FSA) was reduced to four months after referral. The main aim of this maximum was to improve the consistency in the selection and prioritisation of patients, and for a greater proportion of patients to be treated in priority order and within prioritisation timeframes.
The quality of information the GP forwards to the rheumatologist can impinge on the acceptance of the patient for assessment and the quality of the triage.