Professor Peter Littlejohns: NICE current practice and future direction
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Transcript of Professor Peter Littlejohns: NICE current practice and future direction
NICE current practice and future direction
Professor Peter Littlejohns
Clinical and Public Health Director,
NICE
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
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
• 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
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
William Blake – English Poet and Artist
“God forbid that truth
should be confined to
mathematical
demonstration ”
NICE makes scientific and social values judgements
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
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
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
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
A short history of NICE
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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
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
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
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
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.
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
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
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.
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
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
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
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.”
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 .
Patient confidence that they will receive the most effective care
Action at all levels of the system
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
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
“low value” interventions
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
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”
Thank you for your attention