Implementing the NICE Osteoarthritis Guidelines in Primary Care: A Role for Practice Nurses

At the time of publication there was evidence that core recommendations were not currently in everyday use in general practice (Porcheret et al., 2007). However, publication of such recommendations alone is insufficient to change practice and there is limited evidence on the feasibility of implementing core OA treatments in primary care consultations (Mamlin et al., 1998, Peat et al., 2001; Rosemann et al., 2006). A team of researchers and practitioners based in the Arthritis Research UK Primary Care Centre at Keele University, UK, have developed an implementation plan for the core recommendations in UK primary care. This study, Managing Osteoarthritis In Consultations (MOSAICS), is currently being evaluated in eight general practices across the North-West Midlands, as part of a National Institute of Health Research programme grant (grant number: RP-PG-0407-10386). Evidence suggests that practice nurses are the healthcare professionals most likely to provide self-management support for patients with chronic disease (Macdonald et al., 2008), and predominantly for patients with conditions linked to the NHS Quality and Outcome Framework (QoF). While recognizing that a broader multidisciplinary team (e.g. physiotherapist, occupational therapist, podiatrist, and rheumatology nurse) could offer established programmes of care based on the core recommendations, practice nurses can offer OA consultations early in their presentation. A linked GP–nurse model OA consultation was developed and specific training in promoting self-management using a patient-centred approach was delivered. A guidebook was developed by patients and health professionals for patients with OA (Grime and Dudley, 2011). GPs were offered updates on OA and this helped to guide them in referring patients with a diagnosis of OA to a specially trained practice nurse, who could offer treatment sessions focused on issues of importance to the patient, with an emphasis on core treatment options, pain management and goal setting. A training programme for practice nurses was developed and piloted. The training took place over four days and was focused on patient-centred consultations, goal-setting and giving information and advice on exercise and physical activity, weight management and pain relief. The practice nurses were also instructed on a brief joint screen but not detailed physical examination techniques. Simulated patients, who were trained for consultations about OA, were used to allow the practice nurses to try out new skills and familiarize themselves with the model OA consultation. Both the pilot and the full training programme were evaluated. The new practice nurse clinics are currently being implemented in four practices for patients referred by their GP with a working diagnosis of OA. The clinics offer up to four consultations over a three-month window. Traditionally, despite its prevalence, OA management is not seen as a high priority for primary care, and patients believe that little can be done (National Institute of Health and Clinical Excellence, 2008). However, the NICE guidance stresses the probable therapeutic gains of positive self-management, and the MOSAICS study was the first to develop a system for delivering these core messages. Our preliminary evaluations suggest that the training programme enables practice nurses to feel more confident in offering positive messages about OA and the core treatments. Implementation of OA guidelines has received worldwide attention, and other initiatives [e.g. Getting a Grip on Arthritis in Canada, the Better Management of patients with OsteoArthritis (BOA) programme in Sweden, the Beating osteoARThritis (BART) programme in the Netherlands and the eumusc.net programme across all EU member states] are all examples of high-quality evidence-based initiatives. The NICE recommendations are currently being updated and new guidelines will be published 2013. These guidelines will be supported by measures to evaluate quality care and will give further support to health professionals when implementing the recommendations. This paper presents independent research commissioned by the National Institute for Health Research (NIHR) Programme Grant (RP-PG-0407-10386). The views expressed in this paper are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

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