4 Clinical guidance and quality standards
Clinical guidance
52. Alongside health technology appraisals, NICE's
main outputs are its clinical guidelines and, since the passage
of the Health and Social Care Act 2012, its quality standards.
NICE told us in its memorandum:
NICE's quality standards are connected into the commissioning
and delivery system for health and social care through the various
incentive and payment programmes, including the Quality and Outcomes
Framework (QOF) for primary care, the Commissioning Outcomes Framework
(COF) and the Commissioning for Quality and Innovation (CQUIN)
payment framework. They will be used by the NHS Commissioning
Board, with whom we have begun to develop a close working relationship,
to drive its commissioning processes. Quality standards also provide
the opportunity for NICE to support better integration of services,
by linking related health, social care and public health standards
and by addressing broader topics, such as patient experience and
end of life care.[42]
53. On clinical guidance, NICE said:
NICE's clinical guidelines give advice on the most
clinical- and cost-effective approach to the management of individual
conditions. Our guidelines, and those produced by other organisations
that are accredited by NICE, form the basis of NICE's quality
standards, and as such play a vital role in showing commissioners
and providers of services what high quality care looks like.[43]
54. There are a number of issues relating to
guidance and standards. One is consistency; the clinical guidance
represents best practice but it is not universally applied across
the country. Should therefore NICE guidance be mandatory? Our
evidence suggested not. Professor Smith, for example, suggested
that information about the QALY gains of a particular treatment
in different circumstances should be provided and a statement
"as to what would usually be expected as the criteria for
offering treatment".[44]
Sir Andrew Dillon told us:
We don't have the executive power to require the
guidance to be applied. [Sir Michael] earlier talked about the
particular force around technology appraisals through the NHS
Constitution and the funding direction. Everything else that comes
out of NICE is guidance. We had to argue the case for doing so
with those who need to engineer it into their daytoday
professional and managerial practice. That is what we have been
doing through our implementation of services since about 2004.
We provide a lot of tools that lay out the clinical and the business
case for the adoption of the guidance and we pursue that directly
with providers from a national level and through a small field
team that we have, who are able to engage directly locally with
providers and commissioners.[45]
55. Professor Weale argued that one reason why
national best practice guidance often did not translate into implementation
at local level was because of the restrictions imposed by budgets:
It may come back to the question about the distinction
between what, in principle, is a costeffective intervention
on the one hand and the fact that the hitherto PCTs are dealing
with global budgets. If you are in a situation of having a global
budget and find at the margin that you can't afford everything,
then something has to go. It is pretty well researched now and
we know that one of the things that PCTs do is adapt their referral
criteria in order to be able to keep within their budgetary limits.[46]
56. Professor Smith argued that the extent to
which guidance should become a requirement rather than remaining
purely as guidance depended on the evidence underlying each piece
of advice:
Where the evidence is strong on costeffectiveness,
and where it is very clear which patients would benefit and which
would not so that you can also specify clinical thresholds for
who should receive treatment, the principle of national solidarity
and the certainty in those sorts of situations should lead to
a fairly clear mandatory requirement to follow that guidance.
At the other extreme, where evidence is very insecure and, also,
the capacity to benefit of different patients might be very different
depending on things like their level of sickness, age and so on,
then you have to start thinking about a more nuanced guidance
at the local level, with information given to local providers
but not necessarily making it mandatory. Nevertheless, whatever
approach you adopt, we believe quite strongly that public reporting
of what is done locally—so that variations can be explored,
explained and justified—is absolutely central, whatever
the degree of [compulsion].[47]
57. We recommend that NICE clinical
guidance should continue to be guidance rather than instruction.
There will always be local variations and doctors and their patients
must be able to come to individual judgements about what is the
best treatment. Clinical guidance also needs to evolve and allow
for innovation.
58. The Committee does recommend,
however, that a clinician or commissioner who decides to depart
from NICE guidelines should be expected both to report and explain
the departure. Local and individual discretion is valuable and
right - but it should be exercised in a disciplined and accountable
manner.
59. Relevance of guidance is also very important.
Sir Michael Rawlins emphasised the need to keep it up-to-date:
...we have to review it, otherwise people will lose
confidence in it, quite apart from the fact that it is dated.
If they see it has been issued six years ago, doctors or nurses
will think, "It can't be up to date." We do have a programme
of renewal, revision and re-looking at it on a routine basis.[48]
60. We consider that guidance
is a process not an event, and therefore a regular re-examination
of guidance is clearly very important to ensure that it remains
best practice.
Quality standards
61. Sir Andrew explained that quality standards
are derived from clinical guidelines and are designed to act as
a higher level guidance for commissioners. Professors Smith, Littlejohns
and Weale argued that NICE has an important role to play in the
new commissioning structures, and that quality standards could
be instrumental in helping to provide consistency across the NHS.
It would certainly make no sense for Clinical Commissioning Groups
to develop their own standards; they should build on these. The
NHS Commissioning Board should ensure that familiarity with and
use of NICE quality standards is included as part of its accreditation
programme for Clinical Commissioning Groups.
42 Ev 39 Back
43
Ibid. Back
44
Q 80 Back
45
Q 146 Back
46
Q 74 Back
47
Q 69 Back
48
Q 151 Back
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