In the past years there has been a shift in the paradigms of public health, with changes in the process of optimizing economical and human resources, transforming health institutions into sustainable, efficient and profitable models of management.

But, what is meant by sustainability? The term ‘sustainable’ is derived from the Latin word “sustinere”, which means to “sustain or hold firm”. Although this term has been linked mainly to environmental processes, it is also applied to industrial, corporate and business subjects. From a human prosperity perspective, and according to the Brundtland report, sustainable consists in satisfying the needs of the current generation without sacrificing the capacity of future generations to satisfy their own needs.1 Sustainability is intertwined with concepts such as autonomy, system's equilibrium, effective use of resources and quality and efficiency indicators.

Sustainability has become the central axis of a model of social well being, which translated into a health setting is seen in the royal decree-law of sustainability of the National Health System of 2012 (BOE 24 April),2 a mandate that obliges all those responsible, both health providers and professionals, to act according to said rules.

Our specialty cannot stand outside this reality, in spite of having important limitations for its application: first, that determined by the target population of our specialty: the chronic patient, older in age and with several associated diseases; second, the elevated and exaggerated cost of drugs; third, the merely palliative component of assistance and pharmacologic care needed by the patient. However, the abovementioned limitations, far from being contrary factors, must serve as an argument for putting a better value on sustainability when referring to our specialty, taking into account the progressive growth of the target population, the increase in their survival and the associated health care and drug-related expenses.

At this point, an inevitable question arises: Is rheumatology a sustainable specialty? In order to respond, the problem has to be seen from different points of view: health assistance (diagnosis, treatment, management), health planning and professional resource formation, aspects that are intimately related.3

From a diagnostic standpoint it is important to recall the protocol of indications for a rational use of densitometry developed by some members of our society in collaboration with primary care, whose strict application would redistribute many incorrect referrals, especially those sent by specialties far removed from the field of osteoarticular pathology.4

Another clear example is related to the abuse of some imaging tests, such as CT or MRI. After rheumatologists started using musculoskeletal echography (MS), there are no doubts that this is a first choice test which avoids the use of other more sophisticated and costly techniques. The implementation of a technique such as ultrasound is obviously a safe bet regarding savings, efficiency and sustainability. Recently, MS echography is being used even for the diagnosis of some disease's remission, which leads to a better control of the same and the reduction, on occasion, of unjustified or unnecessary treatments.5,6

Another aspect which has meant a huge advance in rheumatology is related with the birth and expansion of monographic and/or multidisciplinary clinics for the early diagnosis/treatment of certain diseases, concretely early onset rheumatoid arthritis, early onset spondyloarthritis, pediatric rheumatology, uveitis or shared clinics with dermatologists/pneumologists. In addition, the development of virtual clinics with primary care and other specialties is a very promising proposal. Most of these monographic clinics are providing clear benefits for early diagnosis, with the resulting improvement in the quality of life, productivity, reduction in complications and survival.7 In this same sense we find that the high-resolution clinics, in which evaluation by a rheumatologist comes frequently reinforced with tests such as densitometry, echography, optic microscopy and capillaroscopy, are an initiative of great usefulness and value in the short and long term.

From a therapeutic standpoint, rheumatology has become an “economically onerous” specialty. The administration of certain treatments is an expensive short-term investment, although profitable and effective in the long term. In this sense, we have advanced considerably since the use of therapeutic strategies, such as “treat to target”, based on a strict control and intensive treatment, adjusted to concrete objectives,8,9 something that undoubtedly allows for important functional improvements and less medium and long-term complications.10

Studies have recently started to improve risk management and adjust and rationalize biologic therapies,11 through drug intensification programs, used outside the technical insert, with the consequent progressive reduction in the dose and/or spacing of the intervals, in a clear example of how the clinician intervenes with his experience in the profitability and sustainability of the system.

Clinical management has also produced considerable advances. One of the first steps materialized with the appearance of rheumatology day hospitals. This has transformed the panorama of the specialty in such a way that patients currently hospitalized are less than 15%–20% of the total patients attended in a conventional hospital strategy. This has evidently moved management forward with a secondary decrease in costs.

A more advance example of efficient and sustainable management is the “biologic drug units”. It is another professional initiative where the interaction between professionals involved (rheumatologist, hospital pharmacist, managers and drug industry) is fundamental. A step further is constituted by the so-called “shared risk” between hospitals and drug industry, a new, and very innovative concept that will unquestionably help for the sustainability of the system.

An interesting aspect regarding sustainability is the development of specialized nursing units. For the past few years, it has been proven that the collaboration and support of nurse training programs for the attention of the chronic rheumatic patient have important advantages, both assistance and management wise. This is especially visible in more relevant or prevalent diseases, such as rheumatoid arthritis, spondyloarthritis, connective tissue disease and osteoporosis.

Another very relevant issue is related to disability and the reduction in work productivity. In this sense, the Community of Madrid put into effect, some years ago, a management program for the study and control of temporal disability payment due to MS disease. This study proved that the implementation of essential measures in the early diagnosis and effective control of the musculoskeletal system by the rheumatologist was clearly beneficial.12,13 These results show another example of the contribution to the “sustainable development” from the initiative of a Rheumatologist.

At this point it is important to point out the participation of the rheumatologist in musculoskeletal diseases’, concretely the Strategic Rheumatology Plan for the Community of Madrid14 and in the National Strategy for Rheumatic Diseases, developed by the Ministry of Health and the SER. Although still in an initial phase, we are convinced that both plans will originate substantial assistance and management benefits at all levels. In a more general setting, the integrated assistance process that have been started in different regions have as of yet undefined results.

Regarding human resources, Madrid's rheumatologists have recently promoted the development of a program on planning and adaptation of human resources through an electronic tool based on a validated predictive model.15 This instrument is another example of clinical management that should be considered for rationing and adapting expenditure with respect to chapter I.

At a formation level it is important to consider the significant contribution for the continued training of rheumatologists and specialists that professionals ourselves carry out through different scientific societies through the organization of courses, workshops, symposia and other accredited activities, adding value and significantly saving money to the health system.

Finally, we believe that the rheumatologist is an essential figure in the coordination of the musculoskeletal disease with primary care and other specialties (musculoskeletal units) and, from our point of view, should be the main impulse and dynamic guiding assistance and research of a great part of musculoskeletal diseases. In this way, sustainability of attention and planning of these diseases would be improved.

In summary, rheumatology is a specialty that has transformed in the past few decades and has become a consolidated and mature specialty. We currently have before us the opportunity and challenge to redesign a renovated and modern specialty, adapted to current socioeconomic requirements regarding sustainability, in spite of the limitations inherent to the specialty, through the application of “reasonably sustainable plans and programs”, many of which have been or are being used in many of our hospitals.