The impact of COVID-19 on rheumatology referrals from general practice in England

Richard Armitage is a GP and Clinical Lead affiliated with the Division of Epidemiology & Public Health at the University of Nottingham. He is on Twitter: @drricharmitage

In the NHS, patients can be referred from general practice for specialist rheumatology assessment in secondary care. Referrals can be urgent, such as for suspected rheumatoid arthritis, systemic lupus erythematosus, and axial spondyloarthritis,¹ or routine, such as for suspected fibromyalgia, joint hypermobility syndrome, and multi-joint osteoarthritis.

NHS England publishes monthly data on national consultation² and referral³ activity in general practice. Between 01/10/2019 (earliest data available) and 29/02/2020, the average monthly number of consultations in general practice in England was 26,311,366, 80.2% of which took place face-to-face. Between the same dates, the average monthly number of rheumatology referrals from general practice in England was 31,590, of which 5,945 were urgent and 25,645 were routine. These baseline consultation and referral rates predate the COVID-19 pandemic, which triggered the first UK lockdown on 23/03/2020.

Between 01/03/2020 and 31/12/2020 (most recent data available), the average monthly number of consultations in general practice was 22,326,463, 53.7% of which took place face-to-face, figures 15.1% and 33.0% lower than their pre-pandemic baselines, respectively. Between the same dates, the average monthly number of rheumatology referrals from general practice was 21,874, of which 5,454 were urgent and 16,420 were routine, figures 30.8%, 8.3% and 36.0% lower than their pre-pandemic baselines, respectively.

In summary, the average monthly number of consultations in general practice, the proportion of consultations that took place face-to-face, and the average monthly number of rheumatology referrals from general practice, was 15.1%, 33.0%, and 30.8% lower than their pre-pandemic baselines, respectively. These data suggest a significant burden of unrecognised rheumatological disease exists within the English population, and is correlated with a lower consultation rate in general practice and substantially fewer opportunities for the physical examinations that are fundamental to rheumatological assessment. While the majority of these outstanding referrals are categorised as routine, such problems may be significantly debilitating and progressively severe. The substantial number of outstanding urgent referrals is likely to include destructive rheumatological disease that has so far gone untreated.

Clinicians working in general practice must be supported to actively seek and urgently identify patients with unaddressed rheumatological complaints, consult with them face-to-face and perform physical examinations that are safe from viral transmission, and ensure timely referral for specialist rheumatological assessment. Concurrently, rheumatology services should prepare for above-average caseloads that disproportionately consist of advanced disease, while public health practitioners should strengthen awareness campaigns to educate patients in the recognition of concerning rheumatological symptoms and timely medical help-seeking.

References

1. British Society for Rheumatology. Guidelines. https://www.rheumatology.org.uk/practice-quality/guidelines [accessed 17 February 2021]
2. NHS Digital. Appointments in General Practice. https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/general-practice-data-hub/appointments-in-general-practice [accessed 17 February 2021]
3. NHS Digital. NHS e-Referral Service Open Data. https://digital.nhs.uk/data-and-information/publications/statistical/mi-nhs-e-referral-service-open-data/oct-2019-to-december-2020/data-tables [accessed 17 February 2021]

Featured photo by Micheile Henderson on Unsplash