What is.? series The NHS and HTA Implementing NICE guidance ● The National Institute for Health and Clinical Excellence Norman Evans BPharm (NICE) was established to provide national guidance on the
promotion of good health and the prevention of ill health. NICE
guidance is integral to a standards-based healthcare system. ● NICE issues four types of guidance: technology appraisals, clinical guidelines, public health guidance and interventional Salman Rawaf MD PhD procedures. ● Implementation of NICE guidance helps to ensure consistent
improvements in people’s health and equal access to healthcare;
however, there are many known challenges to implementing NICE
● Key elements to successful implementation are: board support
and clear leadership, provision of a dedicated resource (a NICE manager), support from a multidisciplinary team, a systematic approach to financial planning and implementing guidance,
and a process to evaluate uptake and feedback. ● NICE has set up a programme to help support implementation of its
guidance and many practical resources are now available on its
● General implementation tools include a guide to help
organisations implement its guidance, advice on how to change
practice and how to overcome barriers, as well as a ‘forward planner’. ● Guidance-specific implementation tools include slide sets, audit
support tools, costing tools, implementation advice and
● Other useful resources available on the NICE website are the ‘shared learning’ database with examples of local implementation projects
and the ‘evaluation and review of NICE implementation and evidence’ (ERNIE) database. Implementing NICE guidance Implementing NICE guidance Introduction
care and treatment of people with specific
The National Institute for Health and
diseases and conditions. They are based on
Clinical Excellence (NICE) was set up as a
the best evidence available, taking account of
special health authority in April 1999. It was
established to provide national guidance on
the promotion of good health and the 3. Public health guidance prevention of ill health in a robust and
The NICE Centre for Public Health Excellence
reliable way. It has grown considerably since
develops guidance on the promotion of good
health and the prevention of ill health for
source of clinical standards based on clinical
those working in the NHS, local authorities,
and cost-effectiveness in England, Wales and
the wider public and voluntary sector. There
are two types of public health guidance.
NICE guidance and clinical guidelines are
● Interventional guidance provides recommendations on activities provided
system. They have a key role in supporting
by organisations to help to promote or maintain healthy lifestyles; for example,
performance of healthcare organisations is
exercise promotion. ● Programme guidance deals with broader
national targets but, increasingly, on whether
activities for the promotion of good
they are delivering high quality standards
health and prevention of ill health; for
across a wide range of areas, including NICE
example, mental health promotion or strategies to give up smoking.
(formerly, Healthcare Commission), in its
4. Interventional procedures
a procedure used for diagnosis or treatment is
used routinely. An interventional procedure is
NICE guidance
a procedure for diagnosis or treatment that
involves making an incision to gain access to
the inside of a patient’s body or using
1. Technology appraisals
Technology appraisals provide guidance on
electrosurgery (diathermy and coblation) for
tonsillectomy, where NICE cautions against
excessive use of diathermy and highlights the
procedures. They consider the clinical and
cost-effectiveness of the technologies.
obliged to provide funding for recommended
countries in the UK. The applicability is
technology appraisals, usually within three
months unless advised by NICE that a longer
period of implementation may be necessary. Implementation strategy
whatever steps are necessary to promote the
ensure consistent improvements in people’s
health and equal access to healthcare. Putting
2. Clinical guidelines
Clinical guidelines recommend appropriate
everyone – patients, NHS organisations,
Implementing NICE guidance Table 1. Applicability of NICE guidance in the UK6 Technology Clinical Interventional appraisals guidelines procedures guidance
* With advice from NHS Quality Improvement, Scotland
** With advice from the Department of Health, Social Services and Public Safety, Northern Ireland
● Plan in advance for the issue of NICE guidance ● Ensure that funding and other resources are available when needed
considerable challenge. In 2005, the Audit
● Develop coherent arrangements for implementation involving all key players in the local health economy, covering resources, training and any infrastructure requirements
implementation of clinical guidelines was
● Take steps to disseminate and promote guidance to clinicians ● Assess the uptake of guidance locally, and identify and try to overcome any barriers to implementation
guidelines, competing priorities, a lack of
● Take steps to let patients know that the
resources and a lack of organisational support. guidance is being implemented.9
Action to support implementation should not
partnership needs to be established to share
evidence-based practice is at the heart of NICE
the workload. There is no ideal strategy of
guidance. Clear leadership helps to promote a
intervention that will guarantee effective
recognises that implementation is an area
implementation rests with the chief executive
where the NHS requires a range of support
consulted widely on how best to achieve this.
public health or medical director. For example,
the different guidelines issued by NICE on
smoking10 are fully taken into account by
directors of public health in the development
of their local smoking cessation services.
Regulation Scheme will bring NICE guidance
incentive schemes aligning the Quality and
Principles of
with NICE guidance and Payment by Results.8
implementation Implementing NICE guidance ● Board support and clear leadership ● Clinical governance and audit ● The provision of a dedicated resource (a ● Commissioning and general NICE manager) management ● Support from a multidisciplinary team ● Patients and the public ● A systematic approach to financial ● Co-opted members with specific skills as planning necessary.9 ● A systematic approach to implementing guidance ● A process to evaluate uptake and feedback (audit).9
crosses the primary/secondary care interface. The NICE manager
ensures a standardised approach to guidance.
It also helps to ensure seamless care across
the interface. One of the philosophies that
should be fully understood and adopted by
the team is that any new technology is cost-
● Horizon scanning and forward planning
effective and will reduce the unit cost of
● Disseminating guidance to relevant
intervention in the long term. Hence, most, if
not all, initial investments are cost-effective in
● Arranging educational events ● Co-ordinating financial plans ● Ensuring effective monitoring and A systematic approach to financial feedback planning ● Producing regular reports for the board.9
successful implementation of NICE guidance. The multidisciplinary team
have strong multidisciplinary teams reporting
recommends that organisations should aim to
to the board. Often the team will have other
develop a sustainable approach to financial
functions within the organisation such as
planning and outlines steps that should be
clinical governance or audit. The team should
meet regularly to consider all new guidance
financial plan should be developed detailing
and identify relevant leads and networks to
all the activities for the forthcoming financial
year. It should be based on the cost estimates
guidance. The multidisciplinary team should
for implementing technology appraisals and
the future resource requirements for clinical
● Reduce duplication of work across the
guidelines and public health guidance. The
health economy ● Ensure compliance with core and
guidelines should also be included in the plan
developmental standards1
(see What is world class commissioning?11 for
● Ensure effective audit and monitoring
more information). Comparative costing is an
arrangements
excellent tool to understand the impact of a
● Ensure effective forward planning
new innovation on the health service, the
● Ensure appropriate financial arrangements are in place.9
templates, which can be used to predict costs
teams should have no more than 15 members
and savings. The financial impact associated
● Nursing
technology appraisal can be estimated at local
● Clinical medicine
and at national level, and an example (TA 101:● Pharmacy/medicines management Docetaxel for the treatment of hormone-● Finance refractory metastatic prostate cancer) is shown
● Public health Implementing NICE guidance Box 1. Implementation of NICE technology appraisal 10112,13 Case study: NICE technology appraisal (TA) 101 – docetaxel for the treatment of hormone-refractory prostate cancer
Docetaxel (Taxotere®, sanofi-aventis) has been recommended as a possible treatment for men with hormone-refractory metastatic
prostate cancer who are well enough to look after themselves with only occasional assistance. Treatment should be stopped at
the end of a planned course of up to ten cycles of doctaxel, or earlier if serious side-effects occur or the disease worsens.
NHS bodies should make funding available within three months. A group should be established as outlined in Box 2, linking in
with the local cancer network to facilitate implementation of treatment.
A costing report and template are available to help health communities assess the likely impact of the principal recommendations
on their local population. The report estimates both national and local impact, based on assumptions about current practice and
how this might change following implementation. Using a stepwise approach it is possible to arrive at a cost for the local
Costing template for docetaxel (TA 101) National costing summary: Local costing summary: implementation in England implementation in South-West London*
metastatic prostate cancer requiring treatment
* Population from all primary care trusts in South West London Cancer Network
§ Based on the assumption that: 40% of patients receive prednisolone alone (annual cost: £29/patient); before TA 101, 60% of patients receive mitoxantrone plusprednisolone (annual cost: £4,817/patient); after TA 101, 45% of patients receive docetaxel plus prednisolone (annual cost: £9,065/patient) and 15% receivemitoxantrone plus prednisolone
NB Costs do not include any hospital-negotiated discounts or other health benefits
Evaluating uptake and feedback Practical steps for
NHS organisations are required by the Care
implementation
NICE has set up a programme to help support
implementation of its guidance. A wide range
of practical resources is now available on its
domains for NICE are core standard C5 and
support is generic and will apply to different
types of guidance, while other tools are
implementation by a primary care trust.14
Implementing NICE guidance Box 2. Process for the management of NICE implementation14 Quality and clinical governance manager: ● Receives monthly e-notification from NICE ● Uploads information onto PCT database ● Emails NICE database and forward planner to NICE working group, directors and associate ● Receives reports from commissioned services on NICE implementation and enters onto ● Supports NICE working group ● Prepares reports for risk and clinical governance committee. NICE working group: ● Decides relevance of guidance for PCT ● Obtains financial appraisal of potential impact of implementation and impact on budgets ● Identifies appropriate lead for each piece of relevant guidance ● Reports monthly to the risk and clinical governance committee on compliance, exceptions NICE lead: ● Establishes baseline review of guidance and returns it to quality and clinical governance ● Develops action plan if applicable ● Forms implementation group/ works with LITs ● Provides exception reports ● Provides progress reports to NICE working group. Risk and clinical governance committee: ● Oversees the delivery of NICE guidance ● Receives monthly reports from NICE working group ● Reports to the board.
Adapted from Surrey PCT’s Policy And Framework For The Implementation of NICE Guidance As A Commissioner OfServicePCT: primary care trust; LITs: local implementation teams
General implementation tools
which sectors are likely to be affected and
other national policies as well as to meet
Commission. It has also published advice
indicative costs for England for guidance
on how to change practice, offering practical
advice to managers and clinicians on how to
Guidance-specific implementation
NICE has also developed a ‘forward planner’, which summarises published and
The following support tools, which relate to
Implementing NICE guidance Slide sets Conclusion
presents formidable challenges to healthcare
early awareness of guidance. They highlight
organisations. Proper planning is essential for
The slides can be edited for local use if
In future, it is likely that NICE guidance
Audit support tools
together, possibly aligning with the Quality
contracts. It is also likely that the assessment
of NICE compliance will be carried out by the
References Costing tools
1. Department of Health. Standards for Better Health.
www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati
These help to assess the financial impact of
onsPolicyAndGuidance/DH_4086665 (last accessed 4 March 2009)
implementing the guidance. They comprise a
2. Healthcare Commission and National Institute for Health and
Clinical Excellence. The role of NICE guidance in the Healthcare
national costing report and a costing template
Commission’s assessment activities.
www.cqc.org.uk/_db/_documents/The_role_of_NICE_guidance_
to identify local costs and savings (see Box 1
in_the_Healthcare_Commissions_assessment_activities_July_
3. National Institute for Health and Clinical Excellence. A guide to
Implementation advice
4. National Institute for Health and Clinical Excellence. The legal
implications of NICE guidance. www.nice.org.uk/niceMedia/pdf/
This signposts support available nationally,
Legal_context_nice_guidance.pdf (last accessed 4 March 2009)
5. National Institute for Health and Clinical Excellence.
Electrosurgery (diathermy and coblation) for tonsillectomy.
www.nice.org.uk/nicemedia/pdf/ip/IPG150guidance.pdf (last
6. Coppell A. Bridging the Gap. Pharm Manage 2008; 24: 3–7.
7. Audit Commission. Managing the financial implications of NICE
guidance. www.audit-commission.gov.uk/reports/
NATIONAL-REPORT.asp?CategoryID=&ProdID=CC53DDFE-42C8-
49c7-BB53-9F6485262718 (last accessed 4 March 2009)
8. Department of Health. The Pharmaceutical Price Regulation
Commissioning guides
www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_091
9. National Institute for Health and Clinical Excellence. How to
commissioning, including needs assessment
put NICE guidance into practice. A guide to implementation for
www.nice.org.uk/media/848/D0/HowtoputNICEguidanceintopract
iceFINAL.pdf (last accessed 4 March 2009)
10. www.nice.org.uk/search/guidancesearchresults.jsp?keywords=
Evaluating the uptake and
Smoking&searchType=guidance (last accessed 28 April 2009)
11. Sobanja M. What is world class commissioning? London:
impact of NICE guidance
Hayward Medical Communications, 2009.
12. National Institute for Health and Clinical Excellence. Docetaxel
for the treatment of hormone-refractory metastatic prostate cancer.
It is important to know whether guidance is
www.nice.org.uk/guidance/index.jsp?action=download&o=33348
13. National Institute for Health and Clinical Excellence. Costing
expected. It is necessary to establish how
template and costing report. Docetaxel for the treatment of
hormone-refractory metastatic prostate cancer.
www.nice.org.uk/guidance/index.jsp?action=download&o=33354
trends. NICE has two helpful resources on its
14. Policy And Framework For The Implementation of NICE
website. The ‘shared learning’ database
Guidance As A Commissioner Of Service.
www.surreyhealth.nhs.uk/doc.aspx?id_Resource=610 (last accessed
15. National Institute for Health and Clinical Excellence.
Commissioning guides - supporting clinical service redesign. ‘evaluation and review of NICE
www.nice.org.uk/usingguidance/commissioningguides/ (last
implementation and evidence’
16. National Institute for Health and Clinical Excellence. How to
(ERNIE) database18 is a source of
change practice: understand, identify and overcome barriers to change.
www.nice.org.uk/media/D33/8D/Howtochangepractice1.pdf (last
uptake of guidance and provides references
17. www.nice.org.uk/usingguidance/implementationtools/
forwardplanner/forward_planner.jsp (last accessed 4 March 2009)
to external reviews, such as those by the Care
18. www.nice.org.uk/usingguidance/evaluationandreviewofnice
implementationevidenceernie/evaluation_and_review_of_nice_
implementation_evidence_ernie.jsp (last accessed 4 March 2009)
What is.? series Implementing NICE guidance
This publication, along withthe others in the series, isavailable on the internet atwww.whatisseries.co.ukThe data, opinions and statementsappearing in the article(s) hereinare those of the contributor(s)concerned. Accordingly, thesponsor and publisher, and theirrespective employees, officersand agents, accept no liabilityfor the consequences of any suchinaccurate or misleading data,opinion or statement.
Published by Hayward MedicalCommunications, a division ofHayward Group Ltd.
Copyright 2009 Hayward Group Ltd.
Riociguat Riociguat is an investigational, oral treatment that was discovered and developed by Bayer to target a key molecular mechanism underlying pulmonary hypertension (PH). Riociguat is being investigated as a new and specific approach to treat different types of PH.1, 2 PH is a severe, progressive, life-changing and life-threatening disorder of the heart and lungs in which the blo
PATHOZYME PROGESTERONE Ref OD487 Enzyme Immunoassay for the quantitative determination of Progesterone in human serum or plasma. Store at 2oC to 8oC. DO NOT FREEZE. For in-vitro use only. INTRODUCTION MATERIAL REQUIRED BUT NOT PROVIDED Progesterone is a C21 steroid which is synthesised from both Micropipettes: 100l, 200l, 1000l and 5000l tissue and circulating cho
What is.? series
What is.? series