Quality statement 8: Referral for consideration of joint surgery

Quality statement

Healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.

Rationale

There is currently considerable variation in the criteria used to decide whether an adult with osteoarthritis is eligible for referral for consideration of joint surgery in England, with no evidence to support the range of scoring tools used and the decisions made. The person with osteoarthritis should be given support and advice by their healthcare professional to reach a shared decision on whether surgery is likely to be beneficial, based on the severity of their symptoms, their general health, their expectations of lifestyle and activity, and the effectiveness of any non‑surgical treatments. Ensuring that inappropriate scoring tools are not used will improve equality of access to surgery.

Quality measures

Structure

Evidence of local arrangements to ensure that healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.

Data source: Local data collection.

Process

Proportion of adults with osteoarthritis referred for consideration of joint surgery whose referral is based on a scoring tool.

Numerator – the number in the denominator for whom the referral decision is based on a scoring tool.

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

Data source: Local data collection.

Outcome

Patient‑reported health outcomes for adults with osteoarthritis.

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 scoring tools are not used to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. Decisions on referral thresholds should instead be based on discussions between patient representatives, referring clinicians and surgeons.

Healthcare professionals ensure that they do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. Commissioners should not restrict referral pathways on the basis of arbitrary referral thresholds, but should ensure that thresholds are agreed with patient representatives, referring clinicians and surgeons.

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

Adults with osteoarthritis who are considering joint surgery discuss this with their healthcare professional to decide if it is right for them, and are not denied a referral because they have not met particular requirements.

Source guidance

  • Osteoarthritis (2014) NICE guideline CG177, recommendations 1.6.2 (key priority for implementation) and 1.6.5

Definitions of terms used in this quality statement

Scoring tools

The use of orthopaedic scores and questionnaire‑based assessments to identify people who are eligible for referral for consideration of joint surgery has become widespread. These usually assess pain, functional impairment and sometimes radiographic damage. The commonest are the New Zealand score and the Oxford Hip or Knee score. Many (such as the Oxford tools) were designed to measure population‑based changes after surgery, and none have been validated for assessing appropriateness of referral.

[Adapted from Osteoarthritis (2014) NICE guideline CG177, full guideline section 11.1.7]

Equality and diversity considerations

Age, sex, obesity, smoking, disability (including learning disabilities) and comorbidities should not be barriers to referral for consideration of joint surgery.