professor peter littlejohns: nice current practice and future direction

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NICE current practice and future direction Professor Peter Littlejohns Clinical and Public Health Director, NICE

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Page 1: Professor Peter Littlejohns: NICE current practice and future direction

NICE current practice and future direction

Professor Peter Littlejohns

Clinical and Public Health Director,

NICE

Page 2: Professor Peter Littlejohns: NICE current practice and future direction

Summary of presentation

• Give a brief overview of the current role and functions of NICE

• NICE‟s role in the future

• Potential impact of changes on national and local priority setting

Page 3: Professor Peter Littlejohns: NICE current practice and future direction

The National Institute for Health and

Clinical Excellence (NICE)

NICE is the independent organisation

responsible for providing national

guidance on the promotion of good

health and the prevention and treatment

of ill health. It was established in 1999

as a Special Authority and in 2005 it was

expanded to include the functions of

Health Development Agency. In 2012

(subject to legislation) it will become the

National Institute for Health and Care

Excellence and cover social care

Page 4: Professor Peter Littlejohns: NICE current practice and future direction

• 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

including interventional procedures,

diagnostics and devices

• Clinical practice – guidance on the

appropriate treatment and care of people

with specific diseases and conditions

within the NHS.

The Institute encourages cost effective practice by

issuing guidance in three areas

Page 5: Professor Peter Littlejohns: NICE current practice and future direction

Core principles underpinning

all NICE guidance

• Comprehensive evidence base

• Expert input

• Patient and carer involvement

• Independent advisory committees

• Genuine consultation

• Regular review

• Open and transparent process

Page 6: Professor Peter Littlejohns: NICE current practice and future direction

William Blake – English Poet and Artist

“God forbid that truth

should be confined to

mathematical

demonstration ”

NICE makes scientific and social values judgements

Page 7: Professor Peter Littlejohns: NICE current practice and future direction

Social value judgements : NICE‟s principles

Provide the ethical basis for:

NICE‟s focus on evidence and cost-effectiveness

NICE‟s openness about its decision-making

Cover factors to be considered in addition to

cost-effectiveness

Support NICE’s response to equality legislation

Page 8: Professor Peter Littlejohns: NICE current practice and future direction

Principle 1 – level of evidence

NICE should not recommend an intervention (that is, a treatment, procedure, action or programme)

if there is no evidence, or not enough evidence, on which to make a clear decision. But NICE may

recommend the use of the intervention within a data collection or research programme if this will

provide more information about the effectiveness, safety or cost of the intervention.

Principle 2 - the “value” of the intervention

Those developing clinical guidelines, technology appraisals or public health guidance must take

into account the relative costs and benefits of interventions (their „cost effectiveness‟) when

deciding whether or not to recommend them.

Principle 3 – equity as well as efficiency

Decisions about whether to recommend interventions should not be based on evidence of their

relative costs and benefits alone. NICE must consider other factors when developing its guidance,

including the need to distribute health resources in the fairest way within society as a whole

Page 9: Professor Peter Littlejohns: NICE current practice and future direction

Principle 5 – extent of autonomy

Although NICE upholds the right of individuals to make their own decisions about their care, this

should not lead NICE to recommend interventions that are not effective and cost effective enough to

provide the best value to users of the NHS as a whole.

Principle 6 - consultation

NICE should consider and respond to comments it receives about its draft guidance, and change it

where appropriate. But NICE must always use its own judgement to ensure that what it recommends

is cost effective and takes account of the need to distribute health resources in the fairest way within

society as a whole.

Principle 4 – justify above and below “threshold”

NICE sometimes expresses the cost effectiveness of an intervention as the „cost (£) per quality adjusted life

year (QALY) gained.‟ This is based on an assessment of how much the intervention costs and how much

health benefit it produces compared to an alternative. If NICE decides not to recommend use of an

intervention with a cost per QALY gained within or below the range £20,000 to £30,000 per QALY gained, or

decides it will recommend use of an intervention within or above this range, it must explain the reasons why

Page 10: Professor Peter Littlejohns: NICE current practice and future direction

Principle 7 – justification of any restrictions

NICE can recommend that use of an intervention is restricted to a particular group of people within

the population (for example, people under or over a certain age, or for women only), but only in

certain circumstances. There must be clear evidence about the increased effectiveness of the

intervention in this subgroup, or other reasons relating to fairness for society as a whole.

Principle 8 – address inequalties

When choosing guidance topics, when developing guidance and when supporting people who are

putting the guidance into practice, NICE should actively consider health inequalities, such as those

associated with sex, age, race, disability and socioeconomic status

Page 11: Professor Peter Littlejohns: NICE current practice and future direction

A short history of NICE

0

50

100

150

200

250

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11

Diag

MD

QS

NHSE

QOF

PH

IP

CG

TA

Technologies

QOF

Public health

Interventional

Procedures

Clinical

guideline

s

Quality

standards

Page 12: Professor Peter Littlejohns: NICE current practice and future direction

Summary of presentation

• Give a brief overview of the current role and functions of NICE

• NICE’s role in the future

• Potential impact of changes on national and local priority setting

Page 13: Professor Peter Littlejohns: NICE current practice and future direction

NICE’s new role in the NHS Outcomes Framework

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

Page 14: Professor Peter Littlejohns: NICE current practice and future direction

NICE’s new role in the NHS Outcomes Framework

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

Page 15: Professor Peter Littlejohns: NICE current practice and future direction

Quality Standards

• A set of specific, concise statements that act as

markers of high-quality, cost-effective patient care.

• Derived from the best available evidence such as NICE

guidance and other evidence sources accredited by

NHS Evidence,

• Developed in collaboration with the NHS and social

care professionals, their partners and service users,

• Address three dimensions of quality: clinical

effectiveness, patient safety and patient experience.

Page 16: Professor Peter Littlejohns: NICE current practice and future direction

Overview of Quality standards

development

Topic

Evidence Source

NICE or other NHS evidence accredited source

Guidance Recommendations

Quality Statements

Quality Measures

Requires

Generates

Distilled into

Produce

Page 17: Professor Peter Littlejohns: NICE current practice and future direction

Current Work Programme

2009-2010 – Pilot Phase 2010-2011

Dementia CKD

VTE – Prevention Diabetes (Adults)

Specialist Neonatal Care Depression (Adults)

Stroke Glaucoma

End of Life Care

Heart Failure

Breast Cancer

Alcohol Dependence

Patient Experience (x2)

COPD

Page 18: Professor Peter Littlejohns: NICE current practice and future direction

Future Work Programme

• 31 new topics referred to be developed over the next

2-3 years:

– Based on existing NICE guidelines

– Developed as we update or develop new guidelines

• Core Library of c 150 topics to be developed over next

5 years.

Page 19: Professor Peter Littlejohns: NICE current practice and future direction

NICE’s new role in the NHS Outcomes Framework

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

Page 20: Professor Peter Littlejohns: NICE current practice and future direction

NICE’s new role in the NHS Outcomes Framework

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

Page 21: Professor Peter Littlejohns: NICE current practice and future direction

NICE’s new role in the NHS Outcomes Framework

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORK

Domain 1

Preventing

people from

dying

prematurely

Domain 2

Enhancing

the quality

of life for

people with

LTCs

Domain 3

Recovery

from

episodes of

ill health /

injury

Domain 4

Ensuring a

positive

patient

experience

Domain 5

Safe

environment

free from

avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning

Outcomes

Framework

Commissioning

Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of qualityD

uty

of q

ualit

y

tariffstandard

contractCQUIN QOF

5

6

Duty of quality

Page 22: Professor Peter Littlejohns: NICE current practice and future direction

Value Based Pricing

The UK Government view:

“We need a system that encourages the

development of breakthrough drugs

addressing areas of significant unmet need.

And we need a much closer link between the

price the NHS pays and the value a new

medicine delivers, sending a powerful signal

about the areas that the pharmaceutical

industry should target for development.”

“Over the next three years we will be moving

towards a new system of pricing for

medicines, where the price of a drug will be

determined by its assessed value.”

Page 23: Professor Peter Littlejohns: NICE current practice and future direction
Page 24: Professor Peter Littlejohns: NICE current practice and future direction

Summary of presentation

• Give a brief overview of the current role and functions of NICE

• NICE‟s role in the future

• Potential impact of changes on national and local priority

setting .

Page 25: Professor Peter Littlejohns: NICE current practice and future direction

Patient confidence that they will receive the most effective care

Page 26: Professor Peter Littlejohns: NICE current practice and future direction

Action at all levels of the system

Page 27: Professor Peter Littlejohns: NICE current practice and future direction

NICE range of products to save money

All NICE Guidance

Cost saving guidance

“Do not do” database

Referral database

NHS Evidence QIPP page

Commissioning Guides

Costing Tools

Public Health

National Prescribing Centre

Clinical Uncertainty databases

Page 28: Professor Peter Littlejohns: NICE current practice and future direction

The researchers conclude that not adhering to

NICE guidelines cost the hospital $418,000

because of inappropriate use of diagnostic tests in

the Gynaecology department alone

Page 29: Professor Peter Littlejohns: NICE current practice and future direction

“low value” interventions

Page 30: Professor Peter Littlejohns: NICE current practice and future direction

The Federation of Surgical Speciality Associations (FSSA), an organisation which represents the nine major surgical specialities in the UK, is concerned that lists of surgical procedures and interventions, deemed of low clinical effectiveness or of "lower value", are being used by PCTs to limit access to certain procedures. A large number of local lists exist, but there is no authorised Dept of Health list

Page 31: Professor Peter Littlejohns: NICE current practice and future direction

NICE lessons on disinvestment

• Many lists tend to highlight single interventions in comparison to one alternative,

and do not take into account the entire clinical picture or review the comparators to

the same extent. For many patients, disinvestment will necessitate an increased

usage of a comparator or re-engineering of the clinical pathway. Such decisions

should be supported by rigorous evaluations of the costs and consequences of a

variety of alternative courses of action. Clinical guidelines, or dedicated

disinvestment reports, may therefore be a more suitable.

• Many lists are based ( if based on evidence at all) on an absence of evidence

rather than evidence of a lack of efficacy and effectiveness

• Clinicians often want more data to say “No” than to say “Yes”

• Due to the lack of available NHS/UK data often difficult to ascertain current NHS

activity. Where NHS data exists it is often not coded at the level of detail required.

• Lists are often based on “values” and not “scientific judgements”

Page 32: Professor Peter Littlejohns: NICE current practice and future direction
Page 33: Professor Peter Littlejohns: NICE current practice and future direction

Thank you for your attention