Quality standard


This quality standard covers diagnosing and managing gallstone disease in adults. For more information see the topic overview.

In this quality standard, the term 'gallstone disease' refers to stones in the gallbladder or common bile duct, and the symptoms and complications they cause.

Why this quality standard is needed

About 15% of adults are thought to have gallstone disease. Of these, around 80% have asymptomatic gallbladder stones (stones that are only found in the gallbladder and that cause no symptoms). They are often found by investigations for other conditions, and adults with asymptomatic gallbladder stones may never develop symptoms or complications.

There is variation within the NHS in how asymptomatic gallbladder stones are managed once they have been diagnosed. Some adults are offered treatment to prevent symptoms and complications developing. Others are offered a watch‑and‑wait approach, and only have active treatment once the stones begin to cause symptoms.

Around 20% of people with the condition have symptomatic gallstone disease. The symptoms of gallstone disease range from mild, non‑specific symptoms that can be difficult to diagnose, to severe pain and/or complications that are often easily recognised as gallstone disease by healthcare professionals.

Adults with mild, non‑specific symptoms of gallstone disease may think their symptoms are caused by other conditions, or they may be misdiagnosed and have unnecessary investigations and treatment. This can have a negative effect on their quality of life and can be an unnecessary cost for the NHS. There is a need to identify whether there are any specific signs, symptoms or risk factors for gallstone disease and the best method of diagnosing it.

There are a range of endoscopic, surgical and medical treatments available to treat gallstone disease. Surgery to remove the gallbladder (cholecystectomy) is the most common way to treat biliary pain or cholecystitis caused by gallstones and is one of the most commonly performed surgical procedures in the NHS. Based on data from Hospital Episode Statistics there were 69,333 cholecystectomies performed in the UK in 2013/14. Of these, 64,347 were laparoscopic cholecystectomies.

The quality standard is expected to contribute to improvements in the following outcomes:

  • quality of life for adults with gallstone disease

  • acute admissions for adults with gallstone disease

  • length of stay for adults with gallstone disease

  • readmission rates for adults with gallstone disease

  • surgical complication rates for adults with gallstone disease.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16


Overarching indicators and improvement areas

3 Helping people to recover from episodes of ill health or following injury

Overarching indicator

3b Emergency readmission within 30 days of discharge from hospital (PHOF 4.11*)

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

i Physical health‑related procedures

4 Ensuring that people have a positive experience of care

Overarching indicator

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to in‑patients personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicator

5b Severe harm attributable to problems in healthcare

Improvement areas

Improving the culture of safety reporting

5.6 Patient safety incidents reported

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

Indicators in italics are in development

Table 2 Public health outcomes framework for England, 2013–16


Objectives and indicators

4 Healthcare public health and preventing premature mortality


Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities


4.11 Emergency readmissions within 30 days of discharge from hospital (NHSOF 3b*)

Alignment across the health and social care system

* Indicator shared

Patient experience and safety issues

Ensuring that care is safe and that adults have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to gallstone disease.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for gallstone disease specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole gallstone disease care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with gallstone disease.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality gallstone disease service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with gallstone disease should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source(s) on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with gallstone disease. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.