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Pillarsvle.netWhat is.? series
The NHS and HTA
● 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
● 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
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.
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
Table 1. Applicability of NICE guidance in the UK6
* 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
● 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
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
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
● Board support and clear leadership
● Clinical governance and audit
● The provision of a dedicated resource (a
● Commissioning and general
● Support from a multidisciplinary team
● Patients and the public
● A systematic approach to financial
● Co-opted members with specific skills as
● A systematic approach to implementing
● A process to evaluate uptake and
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
● 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
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
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
● 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
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
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
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.
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