NICE and Public Health: The First Two Years

Mike Kelly Val MooreUKPHA Annual Conference 2007

Edinburgh

When we started

• At the beginning we had a clear model to build on• Imperative to work across appraisals, guidelines and public

health• Build on the work of Cochrane, CRD, and evidence based

medicine• Build on the work of the Health Development Agency

Two types of public health guidance

Programme guidance• 18 months

• Programme Development Group (PDGs)

Intervention guidance

• one year

• Public Health Interventions Advisory Committee (PHIAC)

• Public health intervention guidance: recommendations on types of activity usually provided by local health organisations.

• Public health programme guidance: broad strategic activities for the promotion of good health and the prevention of ill health. This guidance may focus on a topic (e.g. maternal and child health), a disease cluster (e.g. obesity), or on a particular setting (e.g. schools or workplaces) .

Age, sex & hereditary

factorsAgriculture

and food

Production

Education

Work environment

Housing

Health

care

services

Water & sanitation

Unemployment

Living & working conditions

Topic Selection

• Suggest a topic!• Engagement with stakeholders• Public Health Topic Selection Panel• Ministerial referral

Interventions• Promoting physical activity in

primary care (March 06)• Smoking cessation in primary

care (March 06)• Preventing teen conceptions

and STIs (Feb 07)• Physical activity in the

workplace• Substance misuse and

vulnerable young people (March 07)

• Children and mental well being X2

• Mental health and the workplace

• Mental health and older people

• Preventing the uptake of smoking in children

• Alcohol and children in school• Reducing mortality in highly

disadvantaged communities• Supporting the smoking ban

(April 07)

Programmes

• Maternal and child nutrition• Smoking cessation services• Behaviour change• Physical activity and the

environment• Obesity (Dec 06)

• Community engagement• Physical activity, play and

sport in pre school and school aged children

• Health literacy in schools with reference to sex education

• Long term sickness incapacity

Key learning

• The distinction between programmes and interventions not in practice always easy to sustain.

• Scope drift – from stakeholders - from the advisory committees

• The key importance of scoping down

Key learning from the review process• Limited national capacity• Limited understanding of NICE – constructed as

methodologically rigid• More NICE than NICE• Critiques of our methods – real and imagined• Problems of taking a sequential approach –

effectiveness – cost effectiveness - equity

Key learning about making recommendations

• Deriving the evidence statements is difficult in itself• Too much detail and the advisory committee gets

overwhelmed• Too little detail and begins to operate at too high a

level of generality/banality• Tendency to huge amounts of information• Must get the economics into the analysis from the

beginning

Assessing Cost Effectiveness

Probability of rejection

Cost per QALY (£’000)

20 30 40 50 60

0

1

The reality of guidance development

• Absence of good trials• Absence of good qualitative data• Patchy and poor grey literature• Very limited economic analysis and absence

of cost data

• The research doesn’t exist• The research doesn’t say what you thought it

said• The research doesn’t answer the question• The research is of poor/dreadful quality

methodologically• There isn’t a qualitative or grey literature to fill

the gaps• The findings are utterly equivocal

• Formulation of primary research studies reflect the interest of researchers rather than the needs of the public or of guideline developers.

• Large gap between researchers and practitioners and policy makers

Absence of good process, implementation and content data

• How an intervention was done and what problems arose in doing it

• What was done – the content of the intervention so that it might be replicated

• How it might be implemented in non experimental settings

• Local infrastructures/context data

• How to make sense of non UK data

Inferential reasoning

• The evidence as a framework of plausible possibilities

• The evidence as a starting point for intervention not an imperative or a recipe

• The importance of inference and the importance of making those inferences explicit

Guidance products

• full guidance (web only)

• quick reference guide (QRG)

• evidence reviews, economic model, fieldwork report, minutes (web only)

• implementation support

Additional theoretical issues

• The precise nature of the causal pathways not well understood so knowing where to intervene s sometimes very difficult.

• What kind of effects and effect sizes might reasonably be expected?

• What are the intervening and mediating variables?

• The ways in which interventions work in different segments of the population not well understood

Beyond the NHS

• Local government

• The education sector

• The private sector

Topic referred to NICE by Department of HealthS

cop

ing

(6 -

8 w

eeks

)

Iden

tify

su

bje

ct

spec

ialis

ts/e

xper

ts a

nd

co

-op

tees

fo

r P

HIA

C

Identify stakeholders & encourage registration

Draft scope

Stakeholder consultation on draft scope

(4 weeks)

Select project team

Dev

elo

pm

ent

(24

wee

ks)

Val

idat

ion

(14

wee

ks)

Sig

n o

ff a

nd

pu

bli

ca

tio

n(6

we

ek

s)

Final scope

Iden

tify

fie

ldw

ork

p

arti

cip

ants

Develop synopsis of evidence

Guidance Executive review and signoff

Draft recommendations

Develop technical reports

Final Guidance

Undertake fieldwork (4 weeks)

Pro

jec

t P

lan

nin

gDH consultation

Stakeholder consultation on evidence synopsis and

invitation to submit evidence (4 weeks)

PHIAC 2nd MeetingReview fieldwork, submitted evidence and consultation

comments, then draft guidance

Stakeholder consultation on draft recommendations

(4 weeks)

Reviews of evidence completed by contractors/CC

(16 weeks)

Draft guidance

1st PHIAC meeting to review evidence then draft recommendations

Review stakeholder evidence

Topic referred to NICE by Department of Health

Sco

pin

g(6

– 8

wee

ks)

Invite community membership of PDG

Develop draft scope

Select project team

Dev

elo

pm

ent

(48

wee

ks)

Val

idat

ion

(16

wee

ks)

Develop final scope

Iden

tify

fie

ldw

ork

par

tici

pan

tsApprox 6 PDG meetings to consider reviews of

evidence

Form PDG in consultation with Chair

Pro

jec

t P

lan

nin

g

Stakeholder consultation on draft scope

(4 weeks)

Identify PDG Chair

Scope consultation meeting

PDG Drafting meeting to develop recommendations

Sig

n o

ff

an

d

Pu

bli

ca

tio

n (6

we

ek

s)

PDG Review meeting to consider fieldwork,

submitted evidence and consultation

comments, then draft guidance

Guidance Executive review and signoff

DH Consultation

Identify stakeholders & encourage registration

Stakeholder consultation on draft recommendations

(4 weeks)

Produce fieldwork report

Undertake fieldwork (6 weeks)

Draft recommendations

Reviews of evidence and economic appraisal

Draft synopsis of evidence and economic appraisal

PD

G A

cti

vit

y

Stakeholder consultation on evidence synopsis and invitation to submit evidence

(4 weeks)

Final Guidance

Final draft guidance produced

Review stakeholder evidence

Visit www.nice.org.uk

The NICE Implementation Strategy

UKPHA - March 2007

And feedback from the first 200 days‘in the field’

The right topics are the critical foundation for successful implementation!

How NICE guidance is selected:

• You and the public

• Consultation workshops

• Topic selection panels

What topics do you think NICE should cover with its public health guidance in the future?

• What setting? What issue? Target audiences?• Is there uncertainty about what works? • Could it make a real difference to public health

outcomes? • Do you think resources are being wasted?

NICE implementation strategy

• Effective dissemination

• Supportive environment

• Implementation tools

• Shared learning

• Evaluation

How to put NICE guidance into practice – Key messages

• Core standards and the Healthcare Commission. • Key principles such as board support and leadership,

multi-disciplinary team, a systematic approach and dedicated resource

• Step by step process • Advice for

commissioners

Step by step process

• Check relevance and promote awareness

• Identify a lead• Identify a group• Do a baseline assessment• Assess cost• Develop an action plan• Review and monitor

Slide Sets

To assist with local awareness raising and dissemination

www.nice.org.uk/slidesets

Implementation advice

• Developed through a nationally

convened planning group

• And validated by users in the field

• Practical

• Advisory

NICE audit criteria e.g. from the 11 suggested criteria for obesity

Public Health

Documented healthy eating policies for LA and NHS staff and services

Clinical care

% identified adult patients with BMI>30, documented multi-component weight management plan

NICE Costing tools

1. National cost impact

reportNational

PopulationStandard

AssumptionsStandard

AssumptionsLocal

Assumptions

Total weighted population 182,545 182,545Weighted population as percentage 0.36% 0.36%

Adult in-patient service staff headcountClinical Staff 52,730 191 191

Non-clinical staff 9,500 34 34Emergency department staff headcount

Clinical Staff 18,050 65 65Non-clinical staff 6,100 22 22

Management of violence training - In-patient psychiatric settings

Cost per trainer day £194 £194 £194Ratio of students to 1 trainer, headcount 12 12 12Average attendance rate, % 80% 80% 80%Back fill costs £95 £95 £95

Current clinical staff trainingPercentage of currently trained staff 50% 50% 50%Percentage of backfill provided 100% 100% 100%Length of training course, days 3 3 3Number of courses 2636.5 9.5 9.5Course costs £1,534,443 £5,529 £5,529Backfill costs £7,514,025 £27,154 £27,154

Current non-clinical staff trainingPercentage of currently trained staff 25% 25% 25%Percentage of backfill provided 50% 50% 50%Length of training course, days 1 1 1Number of courses 237.5 0.9 0.9Course costs £46,075 £175 £175Backfill costs £112,813 £408 £408

Selected Population

5. Make any necessary alterations to the costing assumptions (highlighted in blue) by clicking on the buttons on the right.

6. Click NEXT to go to recurrent costing assumptions sheet.

Costing assumptions - non-recurrent costs

Next

Edit

Edit

Cost impact of NICE guideline on the management of violent and disturbed behaviour

- England

2. Spreadsheet template to help

local users assess local

impact

Cost of optimum care less cost of current care

= resource impact

Resource impact can be either a cost (+) or saving (-)

Shared Learning sitehttp://www.nice.org.uk/page.aspx?o=shared.learning

• 'Doing Well' (by people with depression) Greater Glasgow & ClydeDec-06

• Community Heart Failure Service Medway PCT

• Criteria for Management of NICE Guidance Sheffield PCTs

We want to include implementation examples from non NHS audiences as well

The NICE field team patches (England)

What we offer..

• Updates and advice to help the senior management implement NICE guidance

• Problem solving, by sharing examples of how organisations have worked together to implement guidance

• Advice on how to use the NICE support tools

• A chance to feedback to NICE on local issues, ideas and suggestions

The visit strategy (to end Feb 07)

Planned Completed

PCTs 152 116

SHAs 10 10

Acute Trusts

172 147

MH Trusts 59 51

(LA’s 150 16)

NHS Total 393 325 (83%)

Key themes from the NHS

• The ‘compulsory-straight-away’ guidance is easier to implement than Clinical Guidelines or PH Guidance

• Knowledge of tools patchy - but when explained, welcomed

• Commissioning is a huge opportunity• Huge demand for shared learning

Local Authorities – emerging findings

• Awareness of NICE is low • Mechanisms for handling

guidance are not common• Format of guidance may need

adapting• Many services commissioned jointly

and from voluntary groups and private sector

However there are real opportunities

• NICE Guidance fits with LA priorities

e.g. dementia, child depression, sexual health, obesity, smoking cessation

• Health, and resource efficiency, are of increasing concern

• Potential mechanisms for implementation

exist e.g. LAAs, OSC, Health Groups• Audit Commission ‘line of enquiry’

• NICE generally welcome

What would help bring NICE guidance to the attention of non NHS audiences?

• Social care• Children’s services• Voluntary and community sector• Professional groups• Issue champions and leaders (entrepreneurs)• Workplaces• …………………

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the Implementers’ bulletinwww.nice.org.uk

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