How effective are national strategies for getting evidence into practice?

Transcription

1 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 1

2 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appraisals 173 Medical technologies 6 Diagnostics guidance 1 Public health 35 Safety solutions 2 Total 693 Excludes superseded guidance 2

3 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: training and education, audit and feedback, performance assessment etc Individual components Organisational: leadership, processes, planning etc Organisational components External factors External: social, economic, political etc 3

4 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 4

5 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 5

6 Practical support tools Generic How to guide Forward planner Shared learning database Field team Guidance specific, eg: Costing tools Slides sets Audit criteria Commissioning guides Annie Coppel Chris Connell Stephen Judge Gillian Mathews Deborah Bent Jane Moore Steve Sparks Evaluating impact and uptake Routinely collected national data Published research Inspection reports Patient surveys National audits ERNIE Evaluation and Review of NICE Implementation Evidence 6

7 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 7

8 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/ % 2007/ % 2008/ % 2009/ % 8

9 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 9

10 Cost impact report highlights savings Initial equipment cost offset by lower rate of diagnosis Year 1 Year 2 Year 3 Year 4 Year 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 10

11 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 11

12 Rate per 100,000 population 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) TA46: Obesity (morbid) surgery (July 2002) - replaced by CG43 CG43: Obesity (December 2006) Source: HES on-line 12

13 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 % 66,50 % 60,70 % 69,30 % 78,30 % 75,20 % 50,00 % 40,00 % 30,00 % 28,20 % Type 2 Type 1 20,00 % 10,00 % 0,00 % Glucose Control HbA1c 7.5 per cent (59mmol/mol) Blood Pressure 140/80 Cholesterol <5.0mmol/l Uptake of guidance on antibiotic prophylaxis Advice not to give for routine dental procedures Total number of prescriptions for antibiotic prophylaxis (amoxicillin 3 g or clindamycin 600 mg) dispensed each month by type of prescriber. Thornhill M H et al. BMJ 2011;342:bmj.d by British Medical Journal Publishing Group 13

14 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.d 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 14

15 Change is not made without inconvenience, even from worse to better Richard Hooker,