Quality statement 7: Core treatments before referral for consideration of joint surgery

Quality statement

Adults with osteoarthritis are supported with non‑surgical core treatments for at least 3 months before any referral for consideration of joint surgery.

Rationale

Core treatments for adults with osteoarthritis are: verbal and written information to support a better understanding of the condition, activity and exercise, and weight loss if the person is overweight or obese. Core treatments support the person to self‑manage their condition and help to relieve symptoms. It is therefore important that these treatments are tried before a surgical solution is explored. Currently a relatively low proportion of people referred for possible joint surgery progress to hip or knee replacements, and ensuring that core treatments are tried first will help to reduce referrals that may not be needed. People who do go on to have surgery are likely to have improved outcomes if core treatments are undertaken pre‑operatively.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with osteoarthritis are supported with non‑surgical core treatments for at least 3 months before any referral for consideration of joint surgery.

Data source: Local data collection.

Process

Proportion of adults with osteoarthritis referred for consideration of joint surgery who were supported with non‑surgical core treatments for at least 3 months.

Numerator – the number in the denominator who were supported with non‑surgical core treatments for at least 3 months.

Denominator – the number of adults with osteoarthritis referred for consideration of joint surgery.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GPs, community healthcare providers and hospitals) ensure that policies and processes are in place so that adults with osteoarthritis are not referred for consideration of joint surgery until they have been supported with non‑surgical core treatments for at least 3 months. Hospitals should provide information to commissioners about inappropriate referrals and referrals for people who have not been offered 3 months of core treatments.

Healthcare professionals ensure that they do not refer adults with osteoarthritis for consideration of joint surgery until the person has been supported with non‑surgical core treatments for at least 3 months.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with osteoarthritis are not referred for consideration of joint surgery until they have been supported with non‑surgical core treatments for at least 3 months. Commissioners should consider audits of people referred for consideration of joint surgery to ensure that the patient record shows that they were supported with core treatments for at least 3 months before referral.

What the quality statement means for patients, service users and carers

Adults with osteoarthritis are given information, and are advised and supported to exercise and (if appropriate) lose weight to help with joint pain and stiffness, for at least 3 months before any referral for possible joint surgery.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.2.5 (key priority for implementation) and 1.6.1, and expert opinion

Definitions of terms used in this quality statement

Core treatments

Core treatments for osteoarthritis include:

  • ongoing verbal and written information about the condition and its management

  • advice on physical activity and exercise for muscle strengthening and general fitness

  • support to lose weight if the person is overweight or obese.

[Adapted from Osteoarthritis (NICE guideline CG177) recommendations 1.2.5, 1.3.1, 1.4.1 (key priorities for implementation) and 1.4.3]

Support with non‑surgical core treatments

Healthcare professionals will need to make a judgement about the best way to encourage people to participate in exercise, because this will vary for each person depending on their needs, circumstances and self‑motivation, and may change over time. Support to increase physical activity and exercise will include advice and information, which may include information about local services such as physiotherapy or exercise classes, groups and facilities.

Support to help someone with osteoarthritis to lose weight should focus on diet and physical activity, and may also include pharmacological and surgical interventions. The level of support should be determined by the person's needs, and be responsive to changes over time. Weight management programmes should be delivered by a trained professional. They should include behaviour change strategies to increase physical activity and encourage healthy eating. Pharmacological and surgical treatment options should be considered only after dietary, exercise and behavioural approaches have been tried and evaluated.

[Adapted from Osteoarthritis (NICE guideline CG177) recommendations 1.2.5, 1.4.1 (key priorities for implementation) and 1.4.3, and Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (NICE guideline CG189) recommendations 1.2.11, 1.4.1, 1.4.4 and 1.10.1, and expert opinion]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs (including any learning disabilities) when providing information and support for adults with osteoarthritis. This should include providing printed information for people who cannot access information online and providing information in accessible large print and easy read formats where needed.

All adults with osteoarthritis should be encouraged to exercise. If age, comorbidities, pain severity or disability are seen as a barrier, the person may need specific advice and support to encourage participation, and should be advised that exercise may improve their symptoms.

When referring adults with osteoarthritis to a weight loss service, any potential difficulties in accessing services, which may include distance, disability and financial obstacles, should be taken into account.