Q&A: Guide to NICE

Questions by: The PCDS Committee

Q: What forms of guidance does NICE provide?
NICE produces a range of evidence-based guidance covering health and social care.

Guidelines make evidence-based recommendations on a wide range of topics, from preventing and managing specific conditions and improving health and managing medicines in different settings, to providing social care to adults and children, and planning broader services and interventions to improve the health of communities. These guidelines aim to promote integrated care where appropriate (e.g. covering transitions between paediatric and adult services and between health and social care).

Technology appraisals (TA) assess the clinical and cost effectiveness of health technologies, such as new pharmaceutical products, but can also include devices and diagnostic agents. This is to ensure that all NHS patients have equitable access to the most clinically and cost-effective treatments. Once NICE recommends a treatment “as an option”, unless otherwise specified, the NHS must make sure it is available within 3 months of the TA publication date.

Medical technologies guidance helps the NHS adopt clinically effective, cost-saving new technologies rapidly and consistently, and covers devices such as debridement pads for managing acute or chronic wounds and laser treatment for enlarged prostate glands. Diagnostics guidance evaluates tests, imaging and measurement technologies that might be used for diagnosis, clinical monitoring and screening. Those which are clinically and cost effective are recommended, such as a system for monitoring blood glucose.

Interventional procedures guidance recommends whether procedures, such as laser treatments for eye problems, are effective and safe enough for use in the NHS, but it does not say that the procedure should be funded.

Quality standards are concise sets of statements, with accompanying metrics, designed to drive and measure priority quality improvements within a particular area of care. These are derived from the best available evidence, particularly NICE’s own guidance and, where this does not exist, from other evidence sources accredited by NICE. An example is the Diabetes in adults (QS6) published in August this year (NICE, 2016a), which sets out seven statements to help commissioners, healthcare professionals, social care and public health practitioners and service providers improve the quality of diabetes care that they deliver.

NICE also produces versions of clinician guidelines for the public called Information for Patients, which also highlight points about management and care that patients and their families or carers may find helpful to discuss with their doctor or nurse.

Q: What are NICE Pathways?
NICE Pathways map all of NICE’s guidance, providing an easy-to-use, intuitive way of accessing a range of clinical, public health and social care information from NICE online. The information provided in the NICE Pathways is interactive, flexible and more adaptable than the old NICE quick reference guides, which are no longer produced. NICE Pathways visually represent all of NICE’s recommendations on a topic, linking to other relevant topics to create a network of information. This allows users to navigate the breadth and depth of NICE recommendations on any subject through interactive topic-based diagrams. For example, within the pathway “Type 2 diabetes in adults overview” (Figure 1), users can quickly navigate to a section on foot care, which brings together all relevant recommendations from the guideline on diabetic foot problems and other related recommendations, such as the NICE medical technology guidance on using Debrisoft debridement pads for diabetic foot ulcers.

Q: How do I keep up-to-date with the latest guidance published by NICE?
The best way to stay updated with the latest guidance and information from NICE is to sign up for our monthly newsletters “NICE News” and “Update for Primary Care” (at http://bit.ly/2ctvjlr). We regularly update our website news pages (www.nice.org.uk) with overviews on guidance, consultations and developments at NICE, and you can also follow our Twitter feed at @NICEcomms and Facebook page.

Q: What other guidance related to diabetes management in primary care is being developed by NICE?
NICE has set up a standing update committee for diabetes, which would enable more rapid updates of discrete areas of the diabetes guidelines, as and when new and relevant evidence is published. The guidelines Type 2 diabetes in adults: Management (NG28; NICE, 2015), and Type 2 diabetes: Prevention in people at high risk (PH38; NICE, 2012) will both be considered by this committee.

Q: There is a growing ageing population in the UK – are there plans to develop specific diabetes guidance for the management of older, frail people with type 2 diabetes?
NICE has not been asked to produce guidance in this specific area, but the issue here is about the ability to benefit, which means considering if a person might benefit from risk-reduction in the longer term, and subsequent impacts on any other conditions. Our current guideline on managing type 2 diabetes in adults (NG28; NICE, 2015) needs to be implemented in the context of the multimorbidity guideline (NG56; NICE, 2016b). We will be updating the latter as soon as new relevant evidence enables us to clarify the adjustments that should be made for frail, older people. In the meantime, guideline NG28 (NICE, 2015) highlights that when caring for older adults with type 2 diabetes, particular consideration should be given to their broader health and social care needs. Older people are more likely to have co-existing conditions and to be on a greater number of medicines. Their ability to benefit from risk-reduction interventions in the longer term may also be reduced, so the guideline notes that there needs to be a flexible approach.

Q: Since the Type 2 diabetes in adults: Management guideline (NG28) was produced, new evidence on the management of diabetes has been published. How does NICE incorporate new evidence into guidelines?
When we develop guidelines we take into account all the evidence available at the time, and then we periodically review all of our guidelines to see if updates are needed. Typically, 2 years after publication we undertake a formal review of any new relevant evidence that has been published, and carefully consider whether recommendations should be amended. In addition, clinicians are expected to prescribe in line with any changes to the drug safety information as published by the regulatory bodies.

The standing update committee for diabetes will enable more rapid update of discrete areas of the diabetes guidelines, as and when new and relevant evidence is published. The current update of NG28 (NICE, 2015) is specifically looking at the role of sodium–glucose cotransporter 2 inhibitors and cardiovascular disease prevention.

Q: What are the challenges that NICE and clinicians using the guidelines may encounter?
NICE guidelines are based on the best available evidence and are produced by clinical and lay experts on the topic considered. NICE guidelines are clear that treatment and care should take into account individual needs and preferences. Recommendations outline best practice on the care and services that are suitable for most people with a specific condition, but they do not replace the clinical responsibilities of clinicians. As we develop the approach to shared decision-making, guidelines provide a source for consideration of the options and are not intended as an order.

Q: Other than guidelines, what else does NICE produce that I can use in clinical practice?
NICE has developed some patient decision aids aimed at improving patient-centred care for everyone and ensuring that shared decision-making becomes an essential part of medical practice. Patient decision aids can support shared decision-making by presenting information about the risks and benefits of particular options in such a way that they can be discussed by patients and healthcare professionals (e.g. “Type 2 diabetes in adults: controlling your blood glucose by taking a second medicine – what are your options?”) More information and links to the other aids can be found at www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/shared-decision-making. These tools are not currently developed routinely but have been positively received by the clinicians who have used them.

The quality standard service improvement template (QSSIT) is a tool that provides instant access to quality standards from NICE. The user can select up to 10 topics for quality improvement and produce a baseline assessment and an action for each topic. The QSSIT creates an audit spreadsheet for each topic, which automatically charts progress as data are inputted. User feedback suggests that the QSSIT is easy to use.

Baseline assessments tools (BATs) are intended to be used by organisations to assess their performance against NICE guidelines, like the QSSIT does for quality standards, and are produced and published at the same time as all new and updated guidelines. The NICE Lead for an organisation conducts a monthly check for newly published NICE guidance that is applicable to their organisation. They then work with a clinical member of staff to complete the BAT for the guideline and use this to report at board level as “NICE assurance”*. Many use a traffic light rating system (red, amber and green) to show where they comply, almost comply or where improvement is required. From contact with NICE leads, we know that these tools are used on a regular basis.

NICE also produces the audit publication planner, which is updated on a monthly basis and lists the details of current and future national audit publications and, where possible, shows if any NICE guidance or quality standards have been measured in the audits. Feedback indicates that the planner will be useful in helping organisations to identify their performance against guidance and quality standards, and will use this information for quality assurance reports and Board reports.

Q: How do I become involved in contributing to NICE guidelines?
The participation of health and social care professionals, patients and lay experts is essential to helping NICE produce robust guidance. We encourage people with knowledge about the topics being considered to get involved in one of a number of ways. People can apply to join one of our guidance committees, either as a standing member or as a topic expert. NICE gives details of all committees looking for new members on the website, and often on our Twitter and Facebook channels. Alternatively, people can contribute to guidelines during public consultations. We ask people with an interest in the draft recommendations to submit their views on the proposals, either through their organisation if it is registered as a stakeholder, or via another registered stakeholder organisation that most closely represents their interests.

Also, NICE’s advisory committee meetings are open to the public to observe. So while observers can not contribute during the meeting, it provides an insight into the issues that are discussed and considered when developing guidance.

Q: What are the roles for NICE in relation to primary care and how will this evolve over the coming future?
Our major role remains in developing guidelines for application in primary care. As part of this focus, we are setting up a GP reference panel to ensure that our guidelines address the issues of most importance to GPs.

*NICE assurance is where staff measure how their organisation performs against NICE recommendations and quality measures, which is then reported at board level.