National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Source: data.gov.uk (2024-10-11)

National Early Inflammatory Arthritis Audit (NEIAA). The purpose of the NEIAA is to improve the quality of care for people living with inflammatory arthritis by measuring care provided to patients against the seven quality statements set out in NICE quality standard 33 (2013 version). 

The audit assesses seven key metrics of care provided for people with new symptoms of arthritis attending rheumatology services for the first time:

1. How quickly do primary care health professionals refer people suspected to have inflammatory arthritis?
2. How soon after referral are people seen in secondary care? 
3. How long does it take to start treatment?
4. Do patients receive timely education about their condition? 
5. Are treatment targets set and agreed?
6. Do patients have access to emergency advice? 
7. Are annual reviews taking place?

More information can be found on the audit website (www.arthritisaudit.org.uk)

National Early
Inflammatory
Arthritis Audit
State of the Nation
Summary Report 2024
October 2024
© 2024 Healthcare Quality Improvement Partnership (HQIP)
Data Collection Period: 1 April 2023 – 31 March 2024
Geographic Coverage: England and Wales
Geographical Granularity: Countries, Integrated
Care Boards, and Welsh Health Boards.

Contents
2 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Introduction
3
Infographic
5
Recruitment and demographics
6
Stakeholder engagement and patient-reported outcomes
8
Early inflammatory arthritis pathways and treatment timeliness
9
Remission and geographic variation
11
Employment and mental health
12
Rare autoimmune rheumatic disease diagnoses
13
The National Early Inflammatory Arthritis Audit (NEIAA) is commissioned by the Healthcare Quality
Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes
Programme (NCAPOP). HQIP is led by a consortium of the Academy of Medical Royal Colleges and
the Royal College of Nursing. Its aim is to promote quality improvement in patient outcomes and,
in particular, to increase the impact that clinical audit, outcome review programmes and registries
have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage,
and develop the NCAPOP, comprising around 40 projects covering care provided to people with a
wide range of medical, surgical and mental health conditions. The programme is funded by NHS
England, the Welsh Government and, with some individual projects, other devolved administrations
and crown dependencies. www.hqip.org.uk/national-programmes.
Dr Elizabeth Price, Clinical Lead, NEIAA; Consultant Rheumatologist, Great Western Hospital
Prof. James Galloway, Lead Methodologist, NEIAA; Professor of Rheumatology, King’s College London
Dr Edward Alveyn, Clinical Research Fellow, King’s College London
Callum Coalwood, Project Manager, British Society for Rheumatology
Jack Buck, Head of External Affairs, British Society for Rheumatology
Grainne Farrell, Clinical Audit Administrator, British Society for Rheumatology
Further information about the content of this report can be found in the online appendices.
In line with the NHS commitment to paperless 2020, this report is only available in a digital format.

Introduction
Inflammatory arthritis, including rheumatoid arthritis (RA), is a significant disease burden
in the UK, affecting over 400,000 people(1). Delays in treatment can lead to significant
disability, reduced quality of life, and loss of productivity in the workforce(2)(3). Treatment
delays for rare autoimmune rheumatic diseases (RAIRDs) such as systemic vasculitides
are also associated with adverse outcomes including permanent disability(4).
The NEIAA aims to improve the quality of care for people living with rheumatic diseases by
collecting demographic and care quality data on all eligible newly diagnosed patients over
the age of 16 in rheumatology departments across England and Wales. Diagnoses required
for enrolment in the audit include inflammatory arthritides, systemic vasculitides and
connective tissue diseases:
Table 1 – Diagnoses eligible for recruitment to the NEIAA.
3 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Eligible diagnoses
Early inflammatory arthritis
Connective tissue disease
Vasculitis
Rheumatoid arthritis
Systemic lupus
erythematosus
Giant cell arteritis
Psoriatic arthritis
Primary Sjögren’s
syndrome
Other large vessel vasculitides
(not giant cell arteritis)
Axial spondyloarthritis
Systemic sclerosis
ANCA-associated vasculitis
Undifferentiated
inflammatory arthritis
Idiopathic inflammatory
myopathies
Other small/medium vessel
vasculitides (ANCA-negative)
Undifferentiated/other
connective tissue disease
or overlap syndrome
Behçet’s syndrome
Data are collected over the first 12 months of care for all those recruited. These data assess
waiting times, time to treatment, clinical response to treatment, and patient-reported
outcomes.
Table 2 – Data collection requirements of the NEIAA.
Questionnaires
Rheumatoid-
pattern EIA
Other EIA/
RAIRDs
Clinician-derived
Demographics and referral
✓
✓
Diagnosis
✓
✓
Clinical baseline (first visit)
✓
✗
3-month follow-up
✓
✗
Patient-derived
Patient-reported outcome measures
(PROMs) at baseline, 3, 6, 9 and 12
months after diagnosis
✓
✓
BACK TO CONTENTS
➜

4 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
In addition to annual reports, we also provide rheumatology departments with near-real
time data on key NEIAA metrics, facilitating local and national quality improvement (QI)
initiatives. Further resources to support these processes can be found on our QI resources
webpage, including data analysis tools, case studies, video guides and template
documents such as driver diagrams.
BACK TO CONTENTS
➜
The performance of individual healthcare providers is measured against the National
Institute for Health and Care Excellence (NICE) quality standard [QS33] ‘rheumatoid
arthritis in over 16s’, last updated in 2020(5). Quality statement two (QS2) of this quality
standard is used for outlier analysis, as described in our outlier policy. Outlier status is
attributed to any unit whose performance against QS2 is three standard deviations or
greater below the national mean. Units are also treated as an outlier if they recruit fewer
than 11 patients into the audit.
Since the publication of our 2023 report, there have been three important changes
to the NEIAA.
The primary benchmarking metric changed to ‘the time
from referral to initiation of disease-modifying antirheumatic drugs
(DMARDs) for those with rheumatoid-pattern EIA’. In previous
years this metric was ‘the time from referral to first rheumatology
appointment’. This development reflects both the revised NICE
guidance, and the strong research evidence base suggesting that
prompt treatment of EIA improves patient outcomes(6)(7).
On 1 April 2023 NEIAA stopped recruiting cases of suspected EIA,
and from then, only confirmed cases of all eligible conditions have
been recruited.
In September 2023, NEIAA began collecting data at diagnosis for
some RAIRDs. The diagnoses included are common enough to
enable meaningful analysis and include the important rheumatic
diseases that can cause acute morbidity and mortality. The aim
of this additional data collection is to measure the time from
referral to assessment by rheumatology departments, and the
length of symptoms prior to referral, thereby monitoring whether
people living with RAIRDs are disadvantaged compared to those
with inflammatory arthritis. This change was introduced at the
request of the audit’s funders.
1
2
3

5 | National Early Inflammatory Arthritis Audit (NEIAA) State of the Nation Report 2024
National Early Inflammatory Arthritis Audit
State of the Nation Summary Report 2024 Infographic
Recommendations
Recruitment rates continue to improve post-pandemic
All eligible units entered some data in year six.
Year 1
(May 2018 –
May 2019)
Year 2
(May 2019 –
May 2020)
Year 3
(June 2020 –
March2021)
Year 4
(April 2021 –
March 2022)
Year 5
(April 2022 –
March 2023)
Year 6
(April 2023 –
March 2024)
20%
75%
of those who were unemployed at diagnosis said
this was due to their arthritis
of those who were employed at diagnosis said
they had to change their work after diagnosis
Most early inflammatory arthritis patients report that their symptoms significantly impact
their employment
Waiting times for Rare Autoimmune Rheumatic Diseases are highly variable (see list of diagnoses)
Year 5
Year 6
0
20
30
40
50
60
10
Treatment timeliness for early
inflammatory arthritis has improved
8000
6000
4000
2000
0
0
40
60
80
20
SLE
pSS
SScl
IIM
UCTD
GCA
LVV
(not GCA)
ANCA
ANCA
negative SVV
Behçets
Remission rates remain stable at 35%
but geographic variation persists
Percentage of patients treated within
six weeks
Mean number of days from
referral to appointment
Ensure consultant job plan guidance includes
allocated time for triage and pre-referral specialist
advice.
1
Ensure commissioned rheumatology services include
protected EIA clinics.
2
Produce a national guideline recommending that
people living with EIA are offered a DMARD on the
day of their diagnosis.
3
Improve regulatory oversight of individual healthcare
providers by utilising routine NEIAA data to
assess standards of care and ensure compliance
with quality standards.
4
Improve timely access to employment and
mental health support programmes for people living
with EIA.
5
Recruitment of people with confirmed EIA
0%
20%
40%
60%
Percentage of EIA patients in
remission at three months
Diagnosis
N=69
N=107
N=47
N=26
N=148
N=178
N=28
N=29
N=15
N=7

6 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Recruitment and demographics
Recruitment of people with conﬁrmed EIA
0
2000
4000
6000
8000
Year 1
(May 2018 –
May 2019)
7506
Year 2
(May 2019 –
May 2020)
Year 3
(June 2020 –
March 2021)
Year 4
(April 2021 –
March 2022)
Year 5
(April 2022 –
March 2023)
Year 6
(April 2023 –
March 2024)
5496
1830
5091
5440
5778
Demographics of people living with EIA
The demographic data of those included in the audit, and living with EIA, across the
different diagnoses reflects the known epidemiology of the diseases, as described below
for RA, psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA). The data highlight
that EIA affects a diverse population with significant variations in age, gender, ethnicity,
and employment status.

Gender distribution: People living with RA are predominantly female
(63.5%). Conversely, a smaller proportion of those diagnosed with PsA
(55.1%) and AxSpA (42.8%) are female.

Age distribution: The majority of people living with RA are aged 40–64
(46.7%). People living with PsA and AxSpA are notably younger, with a
significant proportion in the 25–39 age range (28.3% and 45.5% respectively).
In the general population of England and Wales, 20.2% are aged 20–39, and
32.1% are aged 40–64(10).
Key message 1
Increased engagement and data capture
Engagement with the NEIAA project is more widespread than ever, with all eligible units
returning some data since our last report, an increase from 96.4% to 100%. The number of
people presenting with EIA captured in the audit annually has increased since year three.
However, it is important to acknowledge that many cases are still not captured. While no
exact figures exist for the number of new cases of inflammatory arthritis in England and
Wales per year, extrapolation from recent epidemiological studies suggests the true incidence
of rheumatoid arthritis in these nations is likely greater than 20,000 per annum(8,9). This
suggests that NEIAA captures approximately one third of the cases eligible for enrolment.
Figure 1 – Recruitment of people living with confirmed EIA by year.
BACK TO CONTENTS
➜

7 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Metric (Target)
Year 5
Year 6
GP referral within
3 days (NICE
QS33* 2020;
QS1**)
Percentage of patients meeting target
56%
51%
Average delay between GP assessment and
referral
19 days
21 days
Rheumatology
appointment
within 3 weeks
Percentage of patients meeting target
39%
44%
Average wait time for specialist rheumatology
appointment
31 days
31 days
Start DMARD
within 6 weeks
(NICE QS33*
2020; QS2***)
Percentage of patients meeting target
52%
60%
Average time from referral to treatment
57 days
54 days
Remission by
3 months
Percentage of patients in remission by 3 months
35%
35%
*QS33: NICE Quality Standard 33: Rheumatoid arthritis in over 16s
**Quality Statement 1
***Quality Statement 2

Ethnicity: The majority of people across all EIA diagnoses are White,
with percentages ranging from 78.9% to 86.6%. This broadly reflects the
demography of England and Wales, where 81.7% of the population are
White(11). Other ethnicities were less common, yet present across all
EIA diagnoses, with the proportion of Asian people ranging from 7.3%
to 12.0%, the proportion of Black people ranging from 0.9% to 2.8%, and
those of other ethnic groups ranging from 3.2 to 6.0%.

Employment status: Compared to RA (44.7%), people living with PsA
and AxSpA are more likely to be in paid work of >20 hours per week
(64.7% and 73.8%, respectively).
Years 1 – 6
PROMs headline
50% employed at diagnosis.
Of those not in employment, 66% attributed this to their
symptoms. Of those in work, 20% had had to change their role
or hours due to their symptoms.
BACK TO CONTENTS
➜
Table 3 – Quality metric performance for patients referred with EIA.

8 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Stakeholder engagement is a critical component of QI methodology. Through the
involvement of key stakeholders, including patients, healthcare professionals and
administrative staff, we can gain a better insight into the factors that influence
healthcare delivery and outcomes. In 2023, we increased the proportion of data collected
directly from patients and have used this to understand the mental health and
employment status of individuals presenting with EIA and RAIRDs.
Since our 2023 report, the NEIAA team have systematically monitored departmental
engagement and performance in real-time, allowing for prompt and tailored support for
struggling departments. The NEIAA Clinical Lead conducted interviews with departments
throughout the year to identify specific issues and challenges, providing valuable
qualitative data to highlight key areas for improvement.
The key themes that emerged from these interviews included:

Unit engagement from senior leadership: Engagement from senior
leadership in rheumatology departments was essential for success. Units
with low engagement often expressed that contributing data to the audit
was not the best use of their department’s time, or did not value the role
of national audit. This lack of engagement hindered their participation
and performance in the audit.

Staffing levels: Adequate staffing, both from consultants and nurses, was
crucial. Under-resourced departments or those relying heavily on temporary
or locum staff often struggled to perform well. Consistent, permanent staff
were more likely to engage fully and contribute effectively to the audit.

Pathway management: Departments with non-specialist triage services
often found that patients were signposted to an incorrect clinic. Several
case studies during the year highlighted that rheumatology multidisciplinary
team led triage dramatically improved performance. This change reduced
bottlenecks and ensured more appropriate and timely referrals.

DMARD initiation: Variability in DMARD initiation practices was a significant
issue. Some hospitals relied on GPs in the community to start DMARDs, while
others referred people living with EIA to nurse-led clinics. Both methods had
the potential to introduce significant delays, often extending waiting times
by several weeks due to capacity bottlenecks.
Impact of stakeholder engagement
The stakeholder engagement activities conducted throughout the year demonstrated
that even departments initially resistant to participation could be reached and motivated
to contribute data. The remarkable achievement of engagement from all eligible units
this year and the increase in recruitment of eligible cases, despite change to the audit’s
data collection requirements, are directly attributable to these systematic and targeted
stakeholder engagement efforts, alongside the instrumental work of the Getting it Right
First Time programme.
Stakeholder engagement and patient-
reported outcomes
BACK TO CONTENTS
➜

9 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
The value of EIA pathways
In year six (1 April 2023 – 31 March 2024), 73% of confirmed cases were referred through an
EIA pathway. Referral via an EIA pathway was associated with a much higher likelihood of
being treated within six weeks compared to those referred via standard outpatient referral
pathways or other routes*. Units with a documented EIA pathway and protected EIA
clinics were more likely to meet quality standards(12). This highlights the importance of
correct triage to ensure patients are directed appropriately to maximise timely treatment.
Table 4 – Treatment timeliness performance by pathway.
Early inflammatory arthritis pathways
and treatment timeliness
Referral route
Treatment <6 weeks
95% CI
EIA pathway
62%
61 to 63%
Any other route
42%
41 to 43%
BACK TO CONTENTS
➜
Recommendation 1
Royal College of Physicians:
Ensure consultant job plan guidance includes allocated time for triage and
pre-referral specialist advice.
Recommendation 2
Integrated Care Boards and Welsh Health Boards:
Ensure commissioned rheumatology services include protected EIA clinics.
Improved treatment timeliness
The key metric used for measuring care quality and determining outlier status is the
proportion of people living with EIA who start DMARD therapy within six weeks of referral,
as described in our outlier policy. The proportion of eligible patients treated within this
timeframe was 8% higher than reported in year five.
Key message 2
Year 5 April 2022 – March 2023
Year 6 April 2023 – March 2024
51.8%
59.8%
48.2%
40.2%
Received treatment within 6 weeks
Did not receive treatment within 6 weeks
Figure 2 – Percentage of patients treated within six weeks in years five and six.
*(odds ratio 2.2; 95% confidence interval [CI] 2.1-2.4; p value <0.001)

10 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
30%
35%
40%
Probability of remission by 3 months
<2 weeks
2 to 4 weeks
4 to 8 weeks
>8 weeks
Time from referral to treatment
Adjusted for age, gender and disease severity at presentation
BACK TO CONTENTS
➜
Recommendation 3
British Society for Rheumatology:
Produce a national guideline recommending that people living with EIA are
offered a DMARD on the day of their diagnosis.
Figure 3 – Average time in days to treatment for EIA patients between years one
and six.
54 days
Year 1
47 days
Year 2
48 days
Year 3
56 days
Year 4
57 days
Year 5
54 days
Year 6
Average time to treatment improved between years one and three. While this decreased
in years four and five, performance has been maintained to pre-pandemic levels despite
service and workforce pressures.
The clinical implications of delayed treatment
Research has previously shown that early intervention improves outcomes. NEIAA data
support this, highlighting that, as time passes between referral and treatment initiation,
the chance of early remission declines. Figure 4 below shows that the probability of
achieving remission within three months of diagnosis is highest (almost 40%) when
treatment is initiated within two weeks of referral and decreases significantly as the time
to treatment increases. People living with EIA whose treatment is delayed by more than
eight weeks have the lowest probability of remission (around 30%).
Figure 4 – Relationship between remission rates and treatment timeliness across
all six years of NEIAA.

11 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Remission and geographic variation
Stable remission rates with geographic variation
Remission rates within 12 weeks of treatment remain stable at 35%, when compared to
all five previous years of NEIAA. However, geographic variation in remission rates persists
(see figure 5), highlighting the need for improved oversight of individual healthcare providers
to ensure consistent compliance with quality standards. There was also geographic
variation in the proportion of patients receiving treatment within six weeks (see figure 6).
Key message 3
Figure 5 – Percentage of EIA patients in
year six achieving remission by three
months, by Integrated Care Board and
Welsh Health Board.
Figure 6 – Percentage of EIA patients in
year six receiving treatment within six
weeks, by Integrated Care Board and
Welsh Health Board.
BACK TO CONTENTS
➜
Recommendation 4
Care Quality Commission and Health Inspectorate Wales:
Improve regulatory oversight of individual healthcare providers by utilising
routine NEIAA data to assess standards of care and ensure compliance with
quality standards.
20%
40%
60%
Percentage of EIA patients in
remission at three months
0%
40%
60%
80%
Percentage of EIA patients receiving
treatment within six weeks
0%

12 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Employment and mental health
Key message 4
Burden of EIA on quality of life and employment
PROMs data confirm the significant burden of EIA symptoms on patients’ quality of life
and employment. The majority of people living with EIA are of working age, and a very
high proportion report serious impacts of the disease on their contribution to the workforce.
Figure 7 – Impact of EIA on employment in year six.
56%
44%
Rising mental health concerns
There has been an increase in patient-reported mental health symptoms, continuing a
trend over the last six years. A majority of patients at presentation report mental health
assessment scores which indicate symptoms of major depression or anxiety. While the
burden of mental health symptoms appears to decrease between baseline and three
months across all years, since year four this improvement has been less marked.
Figure 8 – Percentage of patients at baseline and three months with mental health
assessment scores indicating symptoms of major depression or anxiety, by year.
Key message 5
0
20
40
60
80
100
Percentage of patients with
probable depression or anxiety
Year 1
(May 2018 –
May 2019)
Year 2
(May 2019 –
May 2020)
Year 3
(June 2020 –
March 2021)
Year 4
(April 2021 –
March 2022)
Year 5
(April 2022 –
March 2023)
Year 6
(April 2023 –
March 2024)
55%
56%
58%
59%
62%
60%
47%
42%
40%
34%
37%
47%
Percentage of EIA patients with probable depression or anxiety:
at baseline
at 3 months
BACK TO CONTENTS
➜
20%
75%
Employed
at diagnosis
Unemployed
at diagnosis
of those who were unemployed at diagnosis said
this was due to their arthritis
of those who were employed at diagnosis said they
had to change their work after diagnosis
Recommendation 5
Department for Works and Pensions, Department of Health and Social Care, NHS England
and Welsh Health Boards:
Improve timely access to employment and mental health support programmes
for people living with EIA.

13 | National Early Inflammatory Arthritis Audit State of the Nation Summary Report 2024
Rare autoimmune rheumatic disease
diagnoses
Variable waiting times for RAIRD diagnoses
Key message 6
Since recruitment of the RAIRD diagnoses began, patients have been recruited for every
diagnosis. Waiting times for the RAIRD diagnoses are highly variable. People living with
rare rheumatic diseases with a high clinical urgency (e.g. vasculitis) have shorter waiting
times, on average. Those living with other rare rheumatic diseases (e.g. Sjögren’s syndrome
and scleroderma) are waiting longer for diagnosis. This report provides the first-ever
national benchmarking for these diseases in England and Wales.
Figure 9 – Waiting times for patients with RAIRD diagnoses recruited since
September 2023.
BACK TO CONTENTS
➜
Diagnosis
SLE
Systemic lupus erythematosus
pSS
Primary Sjögren’s syndrome
SScl
Systemic sclerosis
IIM
Idiopathic inflammatory myopathies
UCTD
Undifferentiated/other connective tissue disease or overlap syndrome
GCA
Giant cell arteritis
LVV (not GCA)
Large vessel vasculitides (not giant cell arteritis)
ANCA
ANCA-associated vasculitis
ANCA negative SVV
Other small/medium vessel vasculitides (ANCA-negative)
Behçets
Behçet’s syndrome
0
40
60
80
20
SLE
pSS
SScl
IIM
UCTD
GCA
LVV
(not GCA)
ANCA
ANCA
negative SVV
Behçets
Mean number of days from referral
to appointment
Diagnosis
Conclusion
Since our previous report, recruitment and treatment timeliness have improved. However,
remission rates remain stable, and EIA symptoms continue to significantly impact mental
health and employment. Our five recommendations aim to enhance the quality of care
for people living with EIA, reduce variation in care provision and outcomes, and ensure
compliance with quality standards.
N=69
N=107
N=47
N=26
N=148
N=178
N=28
N=29
N=15
N=7

British Society for Rheumatology
Bride House
18–20 Bride Lane
London, EC4Y 8EE
xx-xxxx-xxxx
rheumatology.org.uk
arthritisaudit.org.uk