The findings of this national survey provide recent information regarding the inclusion of the five professional groups in rheumatology MDT. Despite being the cornerstone of the management of IA [3, 6], MDT provision in the UK is variable and, at times, only reaches the minimum definition for MDT care.
Our results show that all rheumatology departments have an MDT which comprises a rheumatologist and almost all have access to a nurse specialist but the inclusion of other allied healthcare professional groups is variable and podiatrists, in particular, are poorly represented. Only 17% of the surveyed departments meet the current national guidance [3, 6] by having the five professional groups represented in their MDTs.
Our data clearly demonstrate that access to the three professional groups (physiotherapists, occupational therapists, and podiatrists) is inadequate. Patients access these professional groups via three main routes: a referral by the general practitioner (GP), the rheumatologist (consultant), or hospital in-patient services. In 2009, an audit of acute trusts found that only 73% of acute trusts provided access to physiotherapists, 64% to occupational therapist, and 55 to podiatrists . For physiotherapy, a patient survey in 2011  revealed that 31% of patients had never been referred for physiotherapy. Among those who were referred, 32.2% waited for over 1 year to see a physiotherapist. Our data suggest that there was no improvement in the access to physiotherapists over four years and a little improvement in the access to occupational therapists. Our survey suggests that access to podiatrists by patients with RA is improving but is still poor despite national guidance [3, 6]. Previously, both an inception cohort  and the national survey  found that between 28 and 30% of patients with RA had access to a podiatrist.
While 99% of MDTs in our data have nurse specialist representation, we do not know if each centre has sufficient specialist nurses to meet the needs of patients. This is particularly important as the nursing staffing levels are linked with patient outcomes especially those related to initiation and escalation of treatments and monitoring of disease activity [10, 16]. However, we do not know the optimum staffing levels required to maximise patient benefit and this is an area for further research.
The high degree of regional variation in the provision of allied health professional services highlights the absence of some specialist services, such as physiotherapy, occupational therapy, and podiatry, in some departments. For example, the two centres surveyed in Northern Ireland reported no access to a physiotherapist or podiatrist. In the national survey conducted in 2006 , Northern Ireland also reported no access to podiatry, which is concerning as there has been little change in service provision over the last decade, despite the publication of national management guidelines.
Identifying how MDTs meet the care needs of patients was beyond the scope of this study, but the regional variations and unavailability of some MDT services may have implications to patients’ care and outcomes. The natural progression in IA is a decline in function and the evidence from several long-term conditions suggests that optimising MDT care promotes rehabilitation . Inequitable access to MDT care could mean that some patients might be referred to general physiotherapy, occupational therapy, or podiatry services, which may not have specialist rheumatology knowledge. This could delay patient access to specialist management and affect patient outcomes and productivity. Our findings suggest that UK rheumatology MDT composition may be more variable than in other Northern European countries. The study conducted by the Scandinavian Team Arthritis Register—European Team Initiative for Care Research (STAR-ETIC) collaboration  revealed large similarities in the composition of MDT teams across four Northern European countries (Sweden, The Netherlands, Denmark and Norway). Nine out of the 10 Rheumatology centres investigated included a rheumatologist, a nurse, a physiotherapist, an occupational therapist and a social worker in their MDTs, although provision of podiatrists, psychologists, and nutritionists varied . However, the STAR-ETIC study  did not report the national picture of MDT provision in these countries therefore, whilst their findings are interesting, they are unlikely to be representative of MDT provision in Northern Europe. The UK national guidance recommends access to MDT  and our data provide good evidence of the extent to which this standard has been achieved nationally. Efforts can now be directed towards addressing inequitable access to the MDT.
Our study has two main limitations. First, our data provide only cross-sectional information on the availability of the professionals included in the rheumatology MDT within the UK. However, this information will be useful and act as a baseline for future studies. Second, our data do not inform the level of coordination or the interaction of the members within the MDTs. The national guidelines [3, 6] do not specify the proportion of professional representation or the level of coordination within the MDT. This study has determined the composition of the MDTs and future research is required to determine the optimal configuration and interaction of rheumatology MDT to inform practice and policy.
In conclusion, this study shows that over three-quarters of rheumatology teams in the UK do not have all recommended professional groups represented in their MDTs thus fall short of the quality standards of care for people with IA. There is a high degree of regional variation in the composition and staffing levels of the rheumatology MDT and future studies should investigate the impact of these variations. Efforts should be directed towards improving equitable access to rheumatology specialist services to optimise outcomes for people with IA.