Table 4

Illustrating the inter-relationships between domains and quality of EIA care with three case study unit exemplars

DomainCase study 1— Hawthorn—overall score: 22/22
“I think it [teamwork] is kind of our bread and butter (…) because I think the patients come out getting a good deal, I think other people kind of buy into that. (…) we’re all quite proud of the way it works and so I think that rubs off”. (Hawthorn 1, consultant)
Case study 2—Pine—overall score: 16/22
“Most of the things that stop us providing a really perfect service is logistics, so there aren’t any slots, there aren’t enough nurses necessarily, the patient lives 50 miles away because it’s a rural community and they don’t want to drive back again in a week’s time”. (Pine 5, nurse)
Case study 3—Willow—overall score: 5/22
It would be helpful if we could get patients in quicker, if we had a sort of more regular staff base, I still think we’d benefit from a further Consultant and a further Nurse again capacity wise”. (Willow 2, consultant)
  • 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.

Team composition
  • 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.

Team processes
  • 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.

Team psychosocial traits
  • 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.

  • AHP, allied health professional; DMARD, disease-modifying antirheumatic drug; EIA, early inflammatory arthritis; GP, general practitioner.