 NICE Step 3 management of knee pain or disability is mainly related to clinical need and influences other than socio-economic factors seem to drive referral and management for people who consult primary care. A substantial group of patients with persistent and severe knee pain or disability appear to be managed within primary care and do not get referred on. This finding may be due to reluctance to refer by the GP, or to be referred by the patient. As conservative treatments aim to manage (not cure) pain, it may be expected that people continue to report persistent and severe pain.
Our study showed that most of the older adults who consult primary care with knee pain receive a Step 3 intervention. Guidelines suggest these should only be considered when further treatment is needed. This group may have needed further treatment, although we do not have reliable data on their use of Step 1 or 2 treatment as these are not routinely coded in GP records. It is previously recognized that clinical practice for OA does not reflect guideline recommendations [22,37].
Older people were less likely to be referred to secondary care, and a possible reason may be comorbidity. However, 44% of those aged 575 years who had been referred had a record of TKR compared with 21% of those  Reporting persistently severe knee pain www.rheumatology.oxfordjournals.org [21,23,25]. However, rates of referral to physiotherapy or other specialists were lower in these self-report studies. Previous estimates of health care for knee pain may, therefore, be underestimated. We found no relationship between referral and either individual socio-economic status or local area deprivation. These findings are in agreement with Thorstensson et al. [9] who found deprivation was not associated with help seeking behaviour although urban living was. Mitchell et al. [23] found that those referred on by the GP did not have more self-reported severity and there were differences in patients' beliefs about their illness, income and economic circumstances. That survey had a 34% response rate so the results may be affected by selection bias. Jordan et al. [21] found no difference in the use of paracetamol or NSAIDs according to socio-economic groups, although those in higher social class groups had a higher use of physiotherapy services. In Solomon's study of 160 people with knee or shoulder problems, education levels or medical insurance type were not related to referral to a rheumatologist or orthopaedic surgeon [24]. Numbers may not add to 755 due to missing data. a Adjusted for other presented variables; b at follow-up survey; c based on SOA, divided into 20% of SOAs least deprived and 20% of SOAs most deprived; d based on the largest BMI recorded at baseline and follow-up survey; e at baseline or follow-up survey; f hip, low back, foot/ankle, hand, neck; g self-report.

Strengths and limitations
We have undertaken an extensive manual search of general practice records including free text that GPs can enter. We also used multiple data sources and searched over a 10-year period. This time frame enabled a comprehensive and long-term assessment of management in primary care. We have not, however, been able to study patient factors such as illness perceptions, and these alongside beliefs about effectiveness of treatment have influenced uptake of care in previous studies [23,42].
Our analyses only covered Step 3 (outer circle) of the NICE guidelines as data on Steps 1 and 2 are variable within medical records. Broadbent et al. [43] highlight this problem. They used nine quality indicators to measure the quality of recorded primary care treatment. There was variation from 17 to 30% in recording related to provision of information for OA and 'considerable scope for improvement in the recording of high-quality care' (p. 839).
There was some evidence of social inequity in receiving a TKR with those of higher social class or living in areas of lower deprivation more likely to receive a TKR. The number of TKRs, however, were small, hence the results were not statistically significant and so caution is needed. Also some people may have had a TKR before the start of the study. The majority of people, however, receiving a TKR in our study received it after the follow-up survey.
Another potential limitation of our study is the study setting, which was three general practices in North Staffordshire. While the general practices cover a range of socio-economic areas (a rural affluent town, a semi-rural mixed deprived area, a urban deprived area), the scope for assessing area deprivation differences may be limited. There was some survey non-response at 3 years. However, the data in Fig. 2 are standardized to the England and Wales population and the non-response is unlikely to affect the associations reported here.

Implications for research and clinical practice
Overall, we found that the inequalities that exist for joint replacement surgery do not seem to exist in earlier Numbers may not add to 755 due to missing data. a Adjusted for other presented variables; b at follow-up survey; c based on SOA, divided into 20% of SOAs least deprived and 20% of SOAs most deprived; d based on largest BMI recorded at baseline and follow-up survey; e at baseline or follow-up survey; f hip, low back, foot/ankle, hand, neck; g self-report. management of this condition. Our findings are both encouraging and worrying. On the one hand, people seem to be getting primary care treatment according to clinical need. On the other hand, non-significant differences exist at the later stages of treatment, for those arguably in most need. This disparity has also been shown elsewhere [14,44]. The development of local appropriateness criteria for patients thought to be in need of joint replacement (that is owned by both GPs and surgeons), has been suggested as one potential way to reduce these inequalities, together with a focus on capacity to benefit [17]. The reasons for continuing disparities in the provision of TKRs require further research. Many patients with severe knee pain or disability do not get referred on. One study highlighted referral status had no association with improvement of pain and function at 12 months [24]. Whether or not there are unmet needs for care in the group who remain managed in primary care requires further study.
Further research is also needed into the provision of management options covered in Steps 1 and 2 of the NICE guidelines, but this relies on more detailed recording of care in primary care settings. Quality indicators may help with this, but as Hunter et al. [37] note those developed hitherto have not been widely adopted. We agree with the suggestion that system-level initiatives may be needed to improve recording and care for OA in primary care [43].

Conclusion
In conclusion, social inequalities in the management and referral of knee problems in primary care were generally not observed, although there were some trends towards differences in likelihood of TKR. Most of the older adults who consult primary care with knee pain receive at least one Step 3 intervention from the NICE OA guidelines. A large group of people with continuing severe problems are managed solely in primary care. Inequalities in care for knee pain in older adults seem to be related to the provision of surgery only, at the point of uptake, and not within preceding management and referral in primary care.

Rheumatology key messages
. Half of the people with severe knee pain or disability do not get referred to secondary care.. Primary care management and referral are based more on clinical need than patient characteristics.Another environmental activist, Igor Kharchenko, was detained Wednesday and charged with disobeying a police officer on a street near the route of the Olympic torch relay. He was sentenced to five days in jail.
A third activist, Yulia Naberezhnaya, an Echo Watch board member, said in an interview that she intended to leave Sochi during the Olympics to avoid winding up in jail.
“I don’t feel comfortable here. I don’t feel safe,” Ms. Naberezhnaya said.
Russia and Olympic officials say the games will be carbon-neutral. Experts say, um, no.
Seth Godin and Blindboy from The Rubberbandits are on the same page: weird is the new normal. We’re seeing creativity being used to create something, share it, gather a group of people around it.
Seth Godin, in We Are All Weird, wrote how artists (authors, founders of movements, musicians…) can and should focus on a real audience. They don’t have to be bland and make bland art.
Blindboy, in his podcast episode Vincent Fist (about an hour into the episode), celebrated how Irish music is in a fantastic place. His view was similar to Godin’s, that weird is the new normal.
Blindboy spoke how Irish musicians had been hoping to get get signed up for a record deal. They Americanised their music, made it average, trying to appeal to the biggest base possible. Now, though, there’s not much a record label can do for a standard musician. Musicians are better off building a direct connection with their fans, which in a way frees them to create the art they were compelled to make in the first place. They have the confidence to be themselves, because they’re no longer bought into the idea of selling your rights to a record company. The result, said Blindboy, is musicians who are Irish and not trying to hide that they are Irish.
Kneecap is part of the new weird. Bhíos ag buzzáil tar éis a gig i Luimneach. They’re an Irish language hip hop group, getting thrown out of their own gigs for political statements they’re using to help publicity. At the Limerick gig, the crowd were singing along to their