Gillian Leng

How effective are national
strategies for getting evidence into
practice?
Dr Gillian Leng
Deputy Chief Executive, NICE
Areas to cover
• Getting NICE guidance into
practice
– Challenges
– National strategy
• Impact of the strategy on:
– Levers for change
– Use of practical support
– Uptake of recommendations
• Summary and future
challenges
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Challenges of implementing NICE guidance
Results from 683 clinicians and managers
And we‟ve published a lot of guidance!
Products Numbers
Cancer service guidance 10
Clinical guidelines 113
Interventional procedures 353
Technology appraisals 173
Medical technologies 6
Diagnostics guidance 1
Public health 35
Safety solutions 2
Total 693
Excludes superseded guidance
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The NICE implementation strategy
Four principles:
• Raise awareness
– Disseminate and communicate
effectively
• Motivate and encourage change
– Use „levers for change‟
• Provide practical support
– To remove some of the practical
barriers
• Evaluate impact and uptake
– To determine effectiveness of the
strategy
Levels of influence
Individual
components
Organisational
components
External
factors
Individual:
training and
education, audit
and feedback,
performance
assessment etc
Organisational:
leadership,
processes,
planning etc
External:
social,
economic,
political etc
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Improved dissemination - NICE pathways
1. To bring together related
guidance, between and within
topics
2. To link other products – audit
tools etc
3. To provide a useful format for
commissioners
4. To improve digital formatting for
easier access via third parties
Easier, quicker access to the
evidence
Navigating pathways
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Recommendations appear on the right
Motivating – using „levers‟
Organisational level
• Inspection mechanisms
– Process for guidance use required
• Commissioning
– Use of evidence and indicators in contracts
• Financial incentives
– QoF, tariff etc linked to guidance
• Avoiding litigation
– Lower premia if guidance used
Individual level
• Education
– CPD and revalidation linked to guidance
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Generic
• „How to‟ guide
• Forward planner
• Shared learning database
• Field team
Guidance specific, eg:
• Costing tools
• Slides sets
• Audit criteria
• Commissioning guides
Practical support tools
Annie
Coppel
Chris Connell
Stephen Judge
Gillian Mathews
Steve Sparks
Evaluating impact and uptake
• Routinely collected national data
• Published research
• Inspection reports
• Patient surveys
• National audits
Deborah Bent
Jane Moore
ERNIE – Evaluation and Review of NICE Implementation Evidence
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Impact of the strategy on:
Levers for change
Use of practical support
Uptake of recommendations
Levers: avoiding litigation
• A key function of the NHS Litigation Authority (NHSLA) is to
“contribute to the incentives for reducing the number of negligent or
preventable incidents”.
• The NHSLA aims to achieve this through an extensive risk
management programme.
• Compliance with NICE guidance is the focus of criterion 5.8 Best
Practice – NICE of the NHSLA standards.
– Level 1 - approved documentation for responding to NICE
guidance
– Level 2 - compliance with the approved documentation
– Level 3 - monitoring compliance with the minimum
requirements
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Acute trust levels achieved
Levers: financial incentives
The QOF is a voluntary incentive scheme for GP practices in the UK, rewarding
them for how well they adhere to agreed indicators – based on NICE guidance
Example of the national achievement levels for the following QOF indicator:
The percentage of patients age 18 years and over on drug treatment for epilepsy
who have a record of seizure frequency in the preceding 15 months
National achievement for the QOF epilepsy indicator shows levels of achievement
have remained consistently high since the inclusion of the indicator in the QOF
National achievement of the epilepsy indicator
2006/07 95.6%
2007/08 95.6%
2008/09 95.6%
2009/10 95.3%
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Practical support: guidance into action
What happens in practice - results from 683 clinicians and managers
Cost impact: informing local business cases
Example: updated guideline on hypertension
Recommended:
If the clinic blood pressure is 140/90 mmHg or higher,
offer ambulatory blood pressure monitoring (ABPM) to
confirm the diagnosis of hypertension
Challenge:
Resistance to this during guideline consultation because
of the additional expense of purchasing new equipment
Need to convince clinicians of the longer term benefits
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Cost impact report highlights savings
Initial equipment cost offset by lower rate of diagnosis
£10 000 000
£5 000 000
£0
-£5 000 000
-£10 000 000
-£15 000 000
-£20 000 000
Year 1 Year 2 Year 3 Year 4 Year 5
Change in diagnosis cost Change in treatment cost Net resource impact
Practical tools: do they save time?
Results from a survey of clinicians and managers
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Practical tools: do they prompt action?
Results from a survey of clinicians and managers
Uptake of recommendations
Has NICE guidance had any impact?
• NICE has an ongoing programme
of monitoring data on uptake –
from external sources
• Examples of data on uptake for:
– Workplace and public health
– Bariatric surgery
– Diabetes management
– Antibiotic prophylaxis
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Uptake of PH guidance for the workplace
Advice on how to improve activity, diet and smoking rates
• An audit of 282 trusts in
England – employ a total of
900,000 NHS staff:
– 32% had a policy to
support physical activity
– 15% had a policy to help
reduce obesity
– 73% had a plan to
support employees stop
smoking
Uptake of guidance on bariatric surgery
Advice to provide surgery in selected cases of obesity
Rate of bariatric surgery (per 100,000 population)
Rate per 100,000 population
8
7
6
5
4
3
2
1
0
TA46: Obesity
(morbid) surgery
(July 2002) -
replaced by CG43
CG43: Obesity
(December 2006)
99-00 00-01 01-02 02-03 03-04 04-05 05-06 06-07 07-08 08-09
Source: HES on-line
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Uptake of guidance on diabetes
Percentage of people registered with diabetes who achieved NICE
defined treatment targets – national audit 2009/10
90,00 %
80,00 %
70,00 %
60,00 %
50,00 %
40,00 %
30,00 %
20,00 %
10,00 %
0,00 %
66,50 %
28,20 %
Glucose Control HbA1c
≤ 7.5 per cent
(59mmol/mol)
60,70 %
69,30 %
78,30 %
75,20 %
Blood Pressure 140/80 Cholesterol

…and no change in rates of endocarditis
Proportion of infective endocarditis cases recorded each month with a code for streptococci
or staphylococci as cause.
Red lines represent moving average figure for cases every three months
Thornhill M H et al. BMJ 2011;342:bmj.d2392
©2011 by British Medical Journal Publishing Group
Summary and future challenges
• The evidence for effectiveness of
implementation efforts at a
national level remains imperfect
• NICE will continue to refine its
approach in line with the research
base, and with feedback
• Future challenges for NICE:
– Reorganisation of the English NHS
– New national bodies and „levers‟
– Focus on standards and indicators
– Reduced funding for healthcare
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“Change is not made without
inconvenience, even from worse to
better”
Richard Hooker,
1554-1600
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