He makes three important points. “First, some European countries have more specialists in the community, as well as rheumatologists who mainly see RA patients, whereas UK rheumatologists usually deals with a wide range of musculoskeletal conditions.”
“Second, whilst there are variations, both in the UK and across the continent, we are generally more committed towards multidisciplinary care than other European countries, even though this approach to RA management is still relatively loosely structured compared with specialties like diabetes.
“Third, in the UK the recommended treatment for early RA is a combination of disease-modifying antirheumatic drugs, given within six weeks of diagnosis, rather than methotrexate monotherapy, as in the rest of Europe and in the US. But, for active RA, people in Europe can have high-cost biologics irrespective of the severity of the condition, unlike patients in England who must have very active disease to receive biologics.”

 

Improved, but not enough


On the whole, “the management of rheumatoid arthritis has significantly improved over the last 20 years,” says Scott. A study in BMC Musculoskeletal Disorders, of which he is a co-author, identified three key changes: intensive treatment with both disease-modifying antirheumatic drugs and biologics has increased, the number of people with active disease has fallen, and there are more remissions. Potential reasons for these improvements include treatments becoming more effective, patients receiving medical attention earlier in the disease course, and an increase in the number of rheumatologists.


But Scott says much still needs to be done. Disability levels remain unchanged. Despite the increased number of people receiving intensive early treatment, only about a third actually receive what recommended. The high level of active disease required for biologic therapy means treatment of intermediate rheumatoid arthritis is unnecessarily delayed. And “providing high-quality whole patient care is difficult given the sustained financial pressure the NHS is facing.”

 

Key interventions


There is a need for more intensive early treatment with fast-acting biologic drugs, says Scott. “They are costly, but prices are expected to come down, as more biosimilars are introduced. Bespoke medicine, whereby biologics are given only to the right patient at the right time, could help. But we cannot predict yet which biologic would benefit which patient. Importantly funders, healthcare providers and pharmaceutical companies should work together to find viable alternative ways to bridge the funding gap, and give people better care in a way that the NHS can afford.”