Table 6 Theme 3: Implementation issues (Resources; Guidelines; Patient factors)

1

“There are costs to the patient in terms of monitoring requirements and costs to the health service in terms of monitoring requirements, like chest x-rays and that sort of thing.” PPN 08, Rheumatologist

2

“Clearly, we’d be using very high-cost drugs thinking about rituximab for a much bigger proportion of the population and depending on the threshold at which you set your criteria for access to those drugs.” PPN 11, GP

3

“If you can demonstrate a marginal benefit people will say well that’s better than nothing […] and then you can persuade funders or insurance companies to allow that treatment to be used”, PPN 01, Rheumatologist

4

“The funding aspect, so getting CCG to pay for drugs for practice on diseases that they’ve not yet got might be a challenge”. PPN 05, Rheumatology clinical nurse specialist

5

“Ideally, in a properly funded service, you’d like to be proactive and the identifying people before they’ve developed something that’s going to cause them major problems, rather than waiting for them to get it.” PPN 09, GP

6

“You need to know quite a lot of detail about what the test is going to be able to do and how beneficial their treatment was in terms of cost benefit in reducing the need for services.” PPN 06, GP

7

“It would need to integrated properly into the system, you need pay the professionals properly to do it and you need to give them time to do it, you can’t just add it on with everything else, into the GPs contract without any recognition of extra workload. PPN 12, GP

8

“Do you need more clinic space? Do you need more secretarial support? Do you need more specialists in certain types of lab testing?” PPN 10, GP

9

“There are costs to patients in terms of monitoring requirements and costs to the health service in terms of monitoring requirements, like chest x-rays or that sort of thing.” PPN 08, Rheumatologist.

10

“Unless there was a very, very strong indication and very, very low risk of using these medications and a very clear, agreed pathway for CCG, whoever it will be at that time, with how it’s prescribed and given. PPN 06, GP

11

“I think in terms of existing services, I think the treatment could, you know streamlined and integrated efficiently within existing pathways for treatments that departments already have.” PPN 18, Rheumatologist

12

“I think predictive testing does have an important role, but I think it needs to be taken up and integrated into our national guidelines like NICE etc.” PPN 12, GP

13

“They then need to be integrated into recognised guidelines if you want them to be taken up by practitioners I think.” PPN 12, GP.

14

“[If] In their family we have a high risk of developing the disease, it’s important to get those patients seen and tested earlier rather than waiting for symptom onset or you know, the disease to establish.“ PPN 05, Rheumatology clinical nurse specialist.

15

“You’d be less inclined to give the treatment to a patient that’s 20 years old and is not going to get rheumatoid arthritis until they’re 80. You’d wait until they’re 79 to give them preventive treatment, wouldn’t you? PPN 03, Rheumatologist

16

“So, I think explaining risk, communicating risk is particularly difficult ‘cause I think you have to have quite a high level of health literacy and numerical literacy. I would take it on a patient-by-patient approach as to how I explain risk, especially when you’re getting into sensitivities and specificities of testing.” PPN 06, GP.