Memorandum by Bandolier (NC 107)
THE QUESTION
The issue is this: when a person interacts with
the NHS, how can the NHS deliver a service that:
1. Reflects the best use of important, valid
evidence.
3 Is delivered efficiently and without undue
waste.
Moreover, the delivery of the service has to
assure that lacunae of poor practice, or even dangerous practice,
do not occur.
These are great questions, because they are
central to the problems of the NHS in recent years. Solutions
may need to be radical, but can also be sensible and acceptable
to the great majority of NHS staff. The impact of evidence-based
medicine over the last 10 years has demonstrated that we do things
that don't work and are harmful, and that we fail to do things
that are beneficial and safe. The impact of waste is considerable.
For instance, hospital acquired infection consumes the resources
of over 20 400-bed hospitals, and adverse drug reactions another
15. At least half of this is preventable.
THE DIAGNOSIS
The problems are that the system hinders implementation
of good practice, that artificial budgetary parameters prevent
joined-up practice, and that individuals who deliver good practice
are not valued. It is worth examining examples to understand,
at least in part, the problems.
The system
Academic medicine values impact factors. These
measure the prestige of journals that publish scientific papers.
HEFCE reviews of university departments makes great play of the
number of scientific papers published and the prestige of journals
in which publish them. The thrust is for new science. Trying to
get a paper on effective service delivery published in a high
impact factor journal is almost (though not quite) impossible.
In the USA we have seen some really important papers, but from
one or two institutions like Harvard's department of Public Health
and Policy.
The result is understandable—that NHS
staff wanting to develop their careers academically do "scientific"
research. Academic medicine is too much divorced from service
delivery and improvement. Those that do not, do no little or no
research. There is little culture of quality improvement. The
Commission for Health Improvement is a welcome improvement, but
at the moment it is more of a stick rather than a carrot.
Another problem is that the individual professions
have their own paths to advancement. This includes the usual "paper
chase" of additional qualifications and continual education.
Yet service is delivered by multi-diciplinary teams; there is
no mechanism for team training or building to improve service
delivery.
NICE has been criticised: it is not national,
it isn't an institute, it has little to do with clinical medicine,
and it is unlikely to be excellent. How could it live up to the
name within it's limited budget and scope? The UK as a whole has
too few people actively engaged in the kind of research that is
needed for NICE to succeed. "Evidence" is too often
regarded as a discipline where everything is known, whereas the
truth is that though we have a good beginning there are many areas
where we just don't know enough.
EVIDENCE
Evidence is poorly collected. Most papers on
evidence use methods and terms of little value to people delivering
service. Most of the outputs from evidence, including the Cochrane
Collaboration, are in a form (odds ratios, for instance) that
most people just do not understand. Much of the evidence-base
is just wrong. In some areas, like diagnosis, we have yet to even
make a start on producing useful evidence. Much health economics
is not evidence-based, wrong, or just plain useless because it
is not understood. Operational research, vital to a huge organisation
like the NHS, is a new concept to most in the NHS, despite being
an important discipline since the late 1930s.
The bottom line is that the NHS does not provide
tools for people to do a better job, nor encourage systems that
allow them to do so. Despite this, almost everyone in the NHS
wants to do a better job and is frustrated to a greater or lesser
degree that it seems so hard.
A SOLUTION
What the NHS needs to do is to embrace quality
improvement in its widest context. This will be no mean feat,
because the NHS is enormously complex, and the potential for mistakes,
or just not getting it absolutely right, is huge. What we need
are the following:
1. To provide top-down rules for basic standards
of care in key areas. NSFs do this very well.
2. To provide the right tools to allow individuals
to improve the NHS.
3. To exploit the fundamental good will of
NHS employees.
4. To create a culture of quality improvement.
It is the last three that are not being dealt
with currently.
Quality must at the top of the NHS agenda, as
is now recognised. That is not to say that quantity is not important,
but we waste so much in the NHS through lack of quality that a
quality agenda should automatically deliver more quantity in any
case.
People will be motivated to provide better quality
services when they know and trust the evidence, when they know
what the clinical and economic consequences will be for their
organisation and the NHS, and when they are given help in making
a new service work or an existing one work better.
The prime mover should be an enlarged, strengthened
and independent NICE. It has to be enlarged because there is a
big job to do. It must be strengthened because it does not command
the respect it must command. It must be independent because quality
has to be seen to be the most important aspect and to take quality
out of the political agenda. The whole of new NICE has to emphasise
"people, products, processes". An outline of the proposed
system is shown in the Figure.
1. Proposals should have a price attached,
and for the proposals outlined below a projected budget is given.
NICE needs a budget of about £100 million a year. Not all
of this need be new money and there will be clear initiatives
already extant that could become part of an enlarged NICE.
2. The new NICE should set out to be:
— National—truly encompassing
all of England & Wales.
— An Institute—it should become
the NHS's University, providing relevant training and education
for people in the NHS.
— Relevant to clinical practice—it
need to examine issues the NHS needs to solve now, and that includes
issues relevant both to parts of the NHS and to its users.
— Excellent—setting standards
for evidence, management, economics, diagnosis and service delivery.
3. The new NICE will set out to deliver
best evidence, in quantity, and to commission research where needed.
It will do this by setting up a number of units:
— Evidence institute. This will be
a single centre to produce the evidence needed by the NHS. This
could be reviewing new information or existing information. It
will employ people with knowledge of clinical trials, EBM, mathematical
modelling, health economics and operational research. The aim
would be not only to provide a bigger, better version of what
NICE is supposed to be now, but it will also respond to issues
that arise in the NHS and where evidence is needed now for better
practice. Information from the evidence institute should be made
available to all (public and professionals) on the Internet.
The institute will be a major training supplier
for the NHS. PCOs and Trusts will be expected to second individuals
for periods between 3 and 12 months for EBM training to take back
the skills to their employer. Research would be commissioned outside
the evidence institute only exceptionally; if it were commissioned
it would be directed to units known to be able to respond fast
and well.
Diagnostic institute. Diagnosis includes clinical
diagnosis, laboratory tests and imaging. Much more needs to be
done to help professionals, especially in primary care, to make
faster and more accurate diagnosis using a variety of methods.
In this context diagnosis also means effective rules for referral.
Our knowledge is so thin that this needs a separate initiative,
linked with at least one major teaching hospital.
Quality and service delivery institute. The
UK desperately needs a unit like the Health Policy and Management
Department at Havard. We need UK-based thinking, recognising UK
problems, and coming up with UK solutions. The new NICE will encourage
the use of system re-engineering, EFQM, and similar initiatives.
It will more effectively promote systems research and development
within the NHS to provide NHS solutions for NHS problems.
Patients and consumers institute. The new NICE
will be expected to obtain patient and consumer input and integrate
it into its work. This should not just be discussion with advocacy
groups, self-selected. It should involve new research into outcomes.
Many outcomes used in clinical trials are chosen without regard
to patient of service requirements. This makes defining whether
a treatment is effective or cost effective difficult.
4. The new NICE will need to engage NHS
employees locally in their communities. Each PCO and Trust will
therefore have a NICE ambassador. The ambassadors will communicate
the objectives and products of NICE in their institution, but
will be conduits to NICE about NHS quality issues that need responses
now. NICE ambassadors should have annual budgets of £50,000
to spend on facilitating projects in their institution, or for
training, or other relevant items.
These ambassadors will not only network with
NICE at the centre, but will also form local networks at county
or strategic health authority level. This will help coordinate
actions between PCOs and Trusts for joined up local quality improvement.
They will coordinate local training and initiatives.
At some intermediate level there should also
be NICE Academies further to promote coordination and communication.
The present NHS Regions may be too large for this, which may be
better done at a sub-Regional level. The new NICE Academies should
have annual budgets of about £1 million to spend on facilitating
projects, for training, or other relevant business.
PCOs represent the future. But they will need
resourcing to do this properly. A significant part of the enlarged
NICE budget will be spent on promoting evidence, quality and delivery
at the PCG level. This should include financial and career incentives
for ambassadors.
5. Each PCO or Trust Chief Executive will
have to demonstrate each year that their organisation has undertaken
a number of initiatives in quality improvement or control. Some
may be simple, others complicated, but together they must show
a continual improvement in quality for the institution. Chief
executives may be expected to designate quality improvement officers,
who could also serve as ambassadors for their institution, but
the responsibility for delivery resides with the CE.
6. Recognition and reward are key elements
presently missing from the delivery of better services. The new
NICE will institute a system of local and national awards for
quality and service delivery. These will be available for projects,
teams and individuals. In the new NHS these will be as important
as further degrees, qualifications and scientific publications
in individual advancement.
7. Commissioning projects will be the joint
responsibility of the new NICE, in association with its ambassadors,
and with research units. This will ensure that research is relevant
to the NHS. Other inputs would be from the DoH, Welsh Assembly,
NHSE, and NHS litigation sources, but the final decision should
rest with the new NICE.
8. Information delivery will need to have
an element of push from the new NICE. Keeping the NHS informed
is vital. A policy must be developed that will deliver knowledge,
education, the quality message, and the message that if you are
not in you are out. This need not be heavy, and shouldn't be glossy.
WHAT ELSE
IS NEEDED?
There are several other things that are needed,
one essential and the other desirable.
A. The essential thing is electronic communication.
All the new NICE material will be available to everyone on the
Internet or PCO or Trust Intranets, and in detail so that professionals
and public can see and appreciate the evidence on which decisions
are based. It could be an important part of the NeLH. Putting
material on the Internet is easy and cheap, and involves no special
skills, and it should be the responsibility of NICE.
There is no need to invent new systems for information.
We do, however, need to ensure that new developments in electronic
information handling can be disseminated. The main problem is
the lack of useful information, not delivery systems.
B. Industry must be brought into the project.
UK healthcare industries are way ahead of their European or American
counterparts in their knowledge management, but are often controlled
from countries outside the UK where the evidence imperative is
less well understood. There is an absolute need that healthcare
industries be actively engaged in evidence development and understanding.
It will help the NHS, but it will also confer commercial advantage
on companies embracing evidence quality. It is not at all unlikely
that joint research projects would take place.
C. Because many technologies will be pharmaceutical,
regulatory authorities in the UK, European Union, and the USA
will be relevant to NICE. Clinical trials done for regulatory
reasons and using methods demanded by regulators may be inadequate
for clinical practice decisions. This may have to be remedied.
FINAL THOUGHTS
The comments in this paper concentrate on what
NICE could be rather than on what it is and does now.
What NICE is doing now is important, as is how
well it accomplished that task. But NICE as presently constituted
is likely to fail to make any lasting impression on the NHS, and
will be a source of friction with healthcare industries. That
is not a criticism of the staff of NICE, but a recognition that
it could not succeed. There is too much to do, the problems are
too complex, and the requisite expertise in the UK limited.
Is NICE necessary? Absolutely, but the scale
of the task requires consideration of NICE in a different context,
not one of rattling off advice that too many will disagree with,
but taking the longer view. The NHS deserves consideration of
how to do the best for the health of the UK, in terms of technologies
and service delivery. That is a big task. It will require time,
resources, inspired leadership and the patient building up of
a cadre of gifted experts working together across several disciplines.
December 2001
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