Introduction

This quality standard covers the assessment and management of osteoarthritis in adults aged 18 years and over. It does not cover the replacement of hip, knee or shoulder joints in adults with osteoarthritis, because this will be included in a future NICE guideline and quality standard. For more information see the topic overview.

Why this quality standard is needed

Osteoarthritis is the most common form of arthritis and a leading cause of pain and disability worldwide. Pain, reduced function and effects on a person's ability to carry out their day‑to‑day activities can be important consequences of osteoarthritis. Pain is associated with changes in mood, sleep and coping abilities.

The Arthritis Research UK report Osteoarthritis in general practice estimates that the number of people with osteoarthritis in England is around 7.3 million, with a higher prevalence in women than in men. The prevalence of osteoarthritis increases with age, although contrary to popular belief it is not caused by ageing. There are complex genetic, environmental and lifestyle risk factors for osteoarthritis. The number of people in England with osteoarthritis is likely to increase because of an ageing population and rising levels of obesity. For example, the Arthritis Research UK report projected an increase of 3.8% per year in the number of people with osteoarthritis of the knee between 2010 and 2020 (from 4.7 to 6.5 million).

Osteoarthritis has a significant negative impact on the UK economy because of the large number of people with the condition, the impact on their quality of life and ability to work, and their need for healthcare, social care and welfare benefits.

Current treatments for osteoarthritis focus on managing symptoms such as pain, because there is no medication that has been proven to prevent the disease or modify its course. Recommended core treatments for osteoarthritis are physical activity and exercise, weight loss if the person is overweight or obese, and providing verbal and written information to increase the person's understanding of the condition. Medication is also used to help manage pain. Most hip and knee replacements are as a result of osteoarthritis.

Osteoarthritis is usually managed in primary care, but often it is not managed in the same way as other long‑term conditions, with patients presenting to their GP as and when they need to rather than having regular reviews. There is often a lack of adequate symptom control among people with osteoarthritis. The Royal College of Surgeons' report Is access to surgery a postcode lottery? highlighted the differences in referral rates for hip replacement across clinical commissioning groups.

This quality standard focuses on improving the overall care of adults with osteoarthritis and the management of their condition, to improve symptom control, promote self‑management and improve consistency of referral for consideration of joint surgery. This quality standard applies across the whole care pathway, but it will mainly be used in primary care by GPs and allied healthcare professionals.

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

  • quality of life for people with long‑term conditions

  • prevalence of disability

  • management of chronic pain

  • self‑management of long‑term conditions

  • patient experience of primary care.

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 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015−2016

Domain

Overarching indicators and improvement areas

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions (ASCOF 1A**)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with longterm conditions

2.2 Employment of people with long‑term conditions (ASCOF 1E**, PHOF 1.8*)

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care

i GP services

4d Patient experience characterised as poor or worse

i Primary care

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

* Indicator shared with the Public Health Outcomes Framework (PHOF)

** Indicator complementary with the Adult Social Care Outcomes Framework (ASCOF)

Table 2 The Adult Social Care Outcomes Framework 2015−2016

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life (NHSOF 2**)

Outcome measure

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1I Proportion of people who use services and their carers, who reported that they had as much social contact as they would like (PHOF 1.18*)

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

Aligning across the health and care system

* Indicator shared with the Public Health Outcomes Framework (PHOF)

** Indicator complementary with the NHS Outcomes Framework (NHSOF)

Table 3 Public Health Outcomes Framework 2013–2016

Domain

Objectives and indicators

Vision: To improve and protect the nation's health and wellbeing and improve the health of the poorest fastest

Outcome measure

Outcome 1) Increased healthy life expectancy, i.e. taking account of the health quality as well as the length of life

1 Improving the wider determinants of health

Objective

Improvements against wider factors which affect health and wellbeing and health inequalities

Indicators

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services (NHSOF 2.2*, ASCOF 1E**)

1.9 Sickness absence rate

1.18 Social isolation (ASCOF 1I**)

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.12 Excess weight in adults

2.13 Proportion of physically active and inactive adults

2.24 Injuries due to falls in people aged 65 and over

4 Healthcare public health and preventing premature mortality

Objective

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

Indicators

4.13 Health‑related quality of life for older people

4.14 Hip fractures in people aged 65 and over

Alignment across the health and social care system

* Indicator shared with NHS Outcomes Framework (NHSOF)

** Indicator complementary with the Adult Social Care Outcomes Framework (ASCOF)

Patient experience and safety issues

Ensuring that care is safe and that people 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 osteoarthritis.

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 source for quality standards that impact on patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

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

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 osteoarthritis 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 osteoarthritis 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 on specific types of training for the topic that exceed standard professional training will be considered during quality statement development.

Role of families and carers

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