NICE guidance and

implementation

Gillian Mathews

Implementation Consultant, NICE

Meeting 18 weeks and other challenges

Today’s journey

• Introducing NICE

– Guidance and cardiac disease

– Care pathways and 18 weeks

• Implementing guidance

• The way forward

What is NICE?

The National Institute for Health and

Clinical Excellence (NICE) is the

independent organisation responsible

for providing national guidance on the

promotion of good health and the

prevention and treatment of ill health.

• Public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

• Health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS

• Clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

We produce guidance in three areas

Core principles of all NICE guidance

• Comprehensive evidence base• Expert input• Patient and carer involvement• Independent advisory

committees• Genuine consultation• Regular review• Open and transparent

process.

Technology appraisals

Cardiac related appraisals include...

• Heart failure - cardiac resynchronisation

• Acute coronary syndromes – clopidogrel

• Angina and myocardial infarction – myocardial perfusion scintigraphy

• Cardiovascular disease – statins

• Dual-chamber pacemakers for the treatment of symptomatic bradycardia

• Myocardial infarction – thrombolysis

• Arrhythmia - implantable cardioverter defibrillators (ICDs)

• Acute coronary syndromes - glycoprotein IIb/IIIa inhibitors

• Ischaemic heart disease – coronary artery stents

Assessing Cost Effectiveness

Probability of rejection

Cost per QALY (£’000)

20 35

0

1

Coronary artery stents (review) Final appraisal determination• Drug-eluting stents are recommended for use in percutaneous

coronary intervention for the treatment of coronary artery disease, within their instructions for use, only if: – the target artery to be treated has less than a 3 mm calibre or the

lesion is longer than 15 mm,

and

– the price difference between drug-eluting stents and bare-metal stents is no more than £300.

• This FAD is now subject to one appeal, which will be heard on 14 April 2008.

• Final guidance will published following the outcome of the appeal

Interventional Procedures

Some cardiac IPs…• Short-term circulatory support with left ventricular assist devices as

a bridge to cardiac transplantation or recovery• Dynamic cardiac monitoring• Cryoablation for atrial fibrillation in association with other cardiac

surgery (also radiofrequency, microwave and high intensity focused ultrasound ablation)

• Endoaortic balloon occlusion for cardiac surgery• Balloon dilatation of pulmonary valve stenosis• Balloon valvuloplasty for aortic valve stenosis in adults and

children• Partial left ventriculectomy (the Batista procedure)• …and many more…

Implementing Interventional Procedures Guidance• IP guidance addresses the safety and efficacy of interventional

procedures – not their cost effectiveness

Research only – use only in the context of research governance

Do not use – evidence on safety and efficacy does not support use

May be used with special arrangements for consent, audit and clinical governance

May be used with normal arrangements for consent, audit and clinical governance

Clinical guidelines

Completed guidelines• Chronic heart failure• Hypertension• Myocardial infarction: secondary prevention • Type 1 diabetes • Type 2 diabetes• Atrial fibrillation• Prevention of venous thromboembolism (surgical inpatients)

Guidelines in development• Lipid modification• Acute chest pain• Prevention of venous thromboembolism (all patients)

What has all that got to do with 18 weeks?

Secondary prevention of MI

• Lifestyle • Cardiac rehabilitation after an acute MI • Drug therapy – after an MI in the last 12

months • Drug therapy – after a proven MI in the past

(more than 12 months ago)

Recommendation reminders

Core tasks

Translating“evidence”

Recommendations

Implementation/change in practice

The implementation programme

What are the main barriers to implementation?

• Clinician distrust

• Lack of organisational

support - structures and

processes

• Resources (or lack of them)

The NICE implementation programme

Three key aims - to:

• Motivate and inspire

• Provide practical support

• Evaluate impact and

uptake

Local leadership is essential

Motivating - integrating

• Clear, easily accessible guidance

• IT systems

• Education – CPD

• Financial arrangements – funding

direction, tariff and the QoF

• Practice-based commissioning

• Inspection processes

Embed in important relevant initiatives

Practical support

• ‘How to’ guide and ‘How to change practice’

• Educational tools

• Forward planner

• Shared learning database

• Commissioning guides

• Topic specific tools

• Implementation consultants

Implementation Consultants

• Six consultants based in the field - the ‘local face’ of NICE

• Providing people implementing NICE guidance with updates, advice and support for local implementation strategies

North EastGillian Mathews

EastVal Moore

London & South EastSteve Sparks

South WestJayne Chidgey-Clark

WestChris Connell

North WestJenny Lewis

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 (-)

Total cost

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Cardiac resynchronisation therapy for heart failure

Key factors driving uptake of new medicines in acute trusts

NICE

Clinical attitudes and preference

Funding and financial status

National prioritiesPharma Industry

activity

Patient preference and adviceLow

Importance

HighImportance

From: Medicines and Industry Strategy Group report

Inspection results - appraisals

Self assessment results – NHS Trusts

2005/06 2006/07

Compliant 84.6% 89.3%

Insufficient assurance

11% 7.87%

Not met 4% 2.79%

Source: The Healthcare Commission, Annual Health Check

Evaluating uptake

• Evaluation and Review of NICE

Implementation Evidence (ERNIE)

• Searchable database providing

information on the implementation

and uptake of NICE guidance

• Studies graded as:• practice appears to be in line with

guidance

• practice appears not to be in line with

guidance

• doubts about or mixed impact

% High cost vs low cost statins

HIG

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Hypertension guideline

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ACE inhibitors Angiotensin-II receptor antagonists

Beta-blockers Calcium-channel blockers

Thiazides and related diuretics

Source: ePACT.net

NICE Guideline consultation - new pharmacological section

NICE Guideline published

HCC Service Review on Heart Failure

Source: The Healthcare Commission, Service Review on Heart Failure (July 2007)

Evidence-based treatment and monitoring

“Processes to assess the broader needs of patients were generally

comprehensive and in line with the recommendations in the NICE

guideline.”

Outcomes for patients

“wide variation in the level of observed [adjusted] re-admission and

mortality across PCTs in England”. “such variation reinforces the

need to apply the NICE guidelines much more assertively.”

The way forward

• NICE guidance can help your service to run better

• Commissioners are becoming more interested in compliance

• Implementation efforts are required at a national and local level

• Use the implementation tools to support the local strategy

• Please ask us for help!

Questions and discussion

gillian.mathews@nice.org.ukfieldteam@nice.org.uk

www.nice.org.uk