Large university hospital department with high volume of clinical research.

Serves large rural area, providing EIA clinics at main hospital site and in two community locations.

Small urban District General Hospital serving a socioeconomically deprived population with high prevalence of obesity and fibromyalgia.

Good shared care with most GPs: able to offer a community DMARD monitoring service based in GP practices and have local guidelines on shared care.

Covers a large geographical area and because of its efficiency, GPs used it for inappropriate referrals (especially as waiting times for routine appointments have increased).

Has benefited significantly from top up payments associated with the Best Practice Tariff.

Has a ‘good connection’ with GPs who initiate DMARD treatment and a shared care agreement for them to take on all responsibility for blood monitoring.

Some GPs are not available for ongoing support, and refer inappropriately: “anyone that they think needs to be seen urgently irrespective of whether its EIA”. (Pine 1, consultant)

Covers a large geographical area, some patients travel long distances to access the unit.

Has a shared care agreement with GPs but finds that the referrals received are either completed incorrectly/have missing information or are inappropriate.

Have provided some GP training and this has helped a bit, but overall find the GPs to be unsupportive.

GPs initiate DMARD treatment for some of the patients.

Good IT infrastructure; has gone ‘paper light’.

The team has helpful access to rooms for offices and clinical space.

Patients have good access to ultrasound and other diagnostic services.

Has good supportive manager whose business case for two new consultants and increasing the nursing team was successful.

Patients have good access to ultrasound and other diagnostic services.

Has their own patient database but are using paper notes and analogue tapes. One unit member commented: “we are living in the dark ages”. (Pine 4, secretary)

Shortage of clinical space which is unable to accommodate joint consultant-nurse clinics and is preventing the service from running more clinics.

The staff expressed feeling unsupported by hospital management; recently lost their hydrotherapy pool and have decreased day care unit capacity.

Has problems with their IT, using multiple systems that often crash which leads to staff still using paper notes.

Previously had a manager they felt could rely on if needed, but not meeting as frequently with current one.

Broad team structure with experienced nurses, a prescribing pharmacist and multidisciplinary support for patients with EIA.

AHPs are part of the team and accessed following a referral from the specialist nurse.

The team is supported by good administrative support including a database manager.

Broad team structure with an experienced nurse and good AHP support if referral for services are required.

Staffing has increased in recent years due to payment-by-results.

The complexity of the booking clerk’s role was not considered by management when recruiting, therefore patients with EIA are not always booked appropriately.

Understaffed: seen as a key barrier for patients accessing the EIA service.

Has a lack of AHP support, with no occupational therapist and is losing its physiotherapy support.

The team has a pharmacist and a very skilled sonographer who understands EIA well. The secretaries support the service by trying to fit patients into slots.

Has an effective service due to its formal and informal processes of communication.

Holds weekly meetings and has easy access to consultants in between meetings.

Clear leadership structure with consultants taking the lead.

Experienced nursing staff with nurse autonomy demonstrated by nurse-led clinics.

Weekly multidisciplinary meetings where there is good collaboration and information sharing to support managing complex patients.

Consultants take the lead and are very results focused.

Administrative staff actively support the pathway and help patients with queries.

Has ‘good ad hoc’ communication, facilitated by offices that are close together.

Clear leadership structure.

Has a good collaborative relationship with other departments.

Does not hold regular multidisciplinary team meetings for formal communication and collaboration.

Has a strong team focus on providing good service and care: “it’s something that we've kind of worked hard to make work and to make work for patients and I guess for research as well”. (Hawthorn 1, consultant)

Demonstrates innovative ways of using staff and attempts to support the patient in a holistic way, through collaboration and good communication formally and informally within the team.

Issues can be raised at different meetings and can be brought to the attention of senior staff at their weekly meeting.

Uses the National Audit as a tool for improvement.

The team has a strong team ethos: “I think it’s the enthusiasm of the team, it’s that face to face contact once a week that makes you feel as though you're part of the team and I think its valuing the input of each person within the team…” (Pine 2, consultant)

Is actively managing the patient clinic workload to accommodate rises and falls in demand.

During multidisciplinary meetings the staff demonstrates innovative ways in supporting the patient journey: “they are extremely innovative… they are constantly looking at how we do things better, the right patient in the right place at the right time and we’re not perfect, but I would like to say that, you know, the team works really, really hard to get it right”. (Pine 3, manager)

Good team relationships and enjoy working together.

Have regular business meetings and education meetings where ideas are discussed.

Does not have departmental meetings, so this impacts on ability to innovate but there is an expressed desire for this to take place.