Table 5 Theme 3: Implementation issues (Knowledge and training needs; HCP roles)

1

“I’m not particularly aware of any risk prediction tools for patients who are still asymptomatic” PPN 06, GP

2

“I know we are looking into it and blood tests can predict which type of RA you’ve got which driver you have you know.” PPN 05, Rheumatology clinical nurse specialist.

3

“You can do a combination of tests and anti CCP antibodies obviously increases your risk of developing RA in the future and there are a variety of different HLA proteins but again, these aren’t widely used in clinical practice for the prediction of RA.” PPN 08, Rheumatologist

4

“I don’t really think we’ve got any tools at the moment really. Certainly not in clinical practice really, you know we have no screen tools, I guess if you know that somebody has particular risk factors, you know whether that’s, I guess gender, is it a sort of, or biological sectors as sort of, weak, well it’s not weak, in the sense of rheumatoid is more common in women than men, you know smoking, I guess there are certain things, but we really don’t have any screening tools in clinical practice at the moment.” PPN 18, Rheumatologist.

5

“I don’t know what you can do in terms of preventing RA but as far as I know there’s not much you can do.” PPN 12, GP

6

“Not very much, I would say. I mean I guess that I guess there might be lifestyle interventions, so for example in somebody who is high risk for example, or somebody’s got a strong family history, you know might be advisable for them to stop smoking, I suppose. In terms of drug treatments, I don’t know an awful lot, I think there have been some trials, but it’s not something I’ve looked at in any detail.” PPN 18, Rheumatologist.

7

“I know there have been studies done looking at giving intramuscular steroids for patients with symptoms and I mean positive serology but not actual joint inflammation. I know there is the APPIPRA study, but I don’t think the results are there yet.” PPN 03, Rheumatologist.

8

“The evidence base isn’t strong. I think there is some evidence that it [methotrexate] delays the time to onset but not that is changes the eventual outcome.” PPN 08, Rheumatologist.

9

“And so, it’s [counselling around treatment] very un-patient centred, and it doesn’t allow patients to discuss concerns. And it’s also heavily weighted on harm of drugs rather than benefits. So, that approach really wouldn’t work for this preventative medicine, because you’ve really, as I’ve said before, got this nuance of the patient and what the potential benefit is, again, you know which is going to be hard to get across, because it will be about not necessarily immediate gain but future gain, balance against the burden of side effects of medicine. So, I think it’s a very, doesn’t have to be a medic, but it’s a very skilled conversation.” PPN 17, Rheumatologist.

10

“I think general nurses might need a little bit more input you know, with those communication skills, the ability to handle this kind of information [risk information]” PPN 05, Rheumatology clinical nurse specialist.

11

“I think it’s just down to having those skills to manage that situation, knowing it might upset the patient and the patient being in denial […] so maybe a bit more training how to do that” PPN 05, Rheumatology clinical nurse specialist

12

“The only thing I would say in primary care that I would be willing to offer is like a lifestyle intervention, you know, going through risks and being able to say that you know, stop smoking, lose weight, they should be general lifestyle changes anyway that we recommend to everyone.” PPN 15, GP

13

“This [lifestyle intervention] is something we do all the time, every day and would do it sort of routinely with patients so smoking cessation is something that, yeah, it’s bread and butter general practice.” PPN 06, GP.

14

“Proper counselling is often better done by specialist nurses really than doctors. Doctors can be a bit blunt about these things sometimes.” PPN 07, GP

15

“I think nurse appointments. I don’t know for sure, but I believe are a bit longer and I hope that… they certainly seem to do in this trust and some others, they actually talk about those things [lifestyle interventions] and they talk about the importance of activity and things.” PPN 01, Rheumatologist.

16

With exercise, like I say, the physios should have an input. I think when we’re looking at that, perhaps more patients should have a chance to see a physio and get advice from that point of view and perhaps see the occupational therapist at the same time. PPN 04, Rheumatology clinical nurse specialist.

17

“Also, what the implications of that might be. So, and then equally, that healthcare professional needs to have the, you know, sort of skills and the knowledge to interpret the test correctly and then know what to do but I guess, you know I don’t think that necessarily needs to be a doctor, doesn’t necessarily need to be a rheumatologist, you can sort of see that other members of the team, nurses in particular, you know might be possible, they might be able to do this.” PPN 18, Rheumatologist.

18

“I would advise them [patient] that the GP would be the first point of call for assessment, and they will give you tests and if any of that was positive then the GP would refer them on.” PPN 05, Rheumatology clinical nurse specialist.

19

“I think it [a predictive test] would determine how quickly I would refer them. So obviously if they were positive and indicative of rheumatoid arthritis, I’d be more likely to refer them urgently. But it sounds like they need a rheumatology referral anyway.” PPN 16, GP