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A practical approach to implementing guidelines

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Author Ann Shuttleworth, BA, is clinical editor, Nursing Times.

Ann Shuttleworth describes the practical support and tools that are available to help nurses implement NICE guidelines.

Since it was set up in 1999 NICE has changed the face of the NHS. The information it disseminates helps to ensure that all patients have access to care based on the latest evidence, and that NHS funding decisions on treatments are consistent across England and Wales. It has also helped to eradicate the wide variations in care that were common when clinical practice was often governed by the preferences of individual practitioners.

Meeting the recommendations of NICE guidance can help NHS organisations ensure they achieve the requirements set out in the Department of Health’s Standards for Better Health – the core and developmental standard covering NHS healthcare provided in England. The extent to which they do this is assessed by the Healthcare Commission in its annual health check.

Why implement NICE guidance
While NHS organisations are expected to take all guidance from NICE into account, they are only required to provide funding and resources for medicines and treatments recommended in technology appraisals within three months of publication.

There is no mandatory funding requirement attached to other types of guidance as the time it takes to implement guidance will vary between organisations, depending on their practice. It will also vary between guidelines depending on resources needed to implement the guidance and the change required to current practice. As such it would be difficult to apply one timescale to all guidelines.

Guidance offers organisations an opportunity to examine their performance and check how well they are complying with best practice. NICE does not undertake primary research but pulls together evidence that is already available that most health professionals will not have time to read and digest themselves.

‘It is often about sharing information we already have rather than disseminating completely new information,’ says Mary McClarey, head of clinical effectiveness and research at Plymouth Teaching PCT and formerly a non-executive board member for NICE. ‘For example, the recent guidelines on caring for acutely ill patients in hospital stressed the importance of not transferring patients in the night unless it is unavoidable. The importance of this simple principle is often overlooked, but being moved in the night can be extremely disorienting and distressing for patients, particularly if they are confused.’

Disseminating guidance
While there are still many conditions and treatments awaiting guidance, the institute has already produced a vast body of work. Last year it produced over 80 pieces of guidance and it looks set to produce a similar number this year.

It is vital that this information is disseminated effectively so that it reaches the people who need to put it into practice.

Each NHS organisation has a person with overall responsibility for ensuring guidance is acted upon – often the clinical governance manager will be sent all new material, while those responsible for implementing the recommendations can subscribe to Into Practice, an electronic bulletin for implementers. Practitioners can also keep up to date by registering on the NICE website to receive email alerts on topics of interest as well as a monthly newsletter.

Support for implementation
NICE’s work extends beyond simply producing and disseminating guidance. The institute has a team of 30 implementation advisers and consultants, from a range of clinical and managerial NHS backgrounds, which supports organisations in putting the guidance into practice.

’We take very seriously the need to support organisations in implementing NICE guidance. There is no point in putting all the effort into producing it if nothing is done with it,’ says Gillian Leng, implementation director at NICE, who manages the implementation team.

The implementation advisers develop tools to support organisations in implementing guidelines as well as advice on the practicalities of putting guidelines into practice.

The tools include slide sets, which can be downloaded from the NICE website, that offer an overview of the guideline concerned. In addition, costing tools are available to enable PCTs to work out the likely costs of implementing guidelines and technology appraisals. The costings are based on populations and incidence of particular conditions but can be tailored to reflect local circumstances. Knowing the likely costs, along with the impact of implementation in reducing future healthcare needs enables services to make business cases to have implementation funded by their PCT.

For example, the tool on the use of alteplase in the treatment of ischaemic stroke works out the incidence of the condition, how many people are likely to need the drug, depending on whether implementation targets are achieved and, from that, potential savings, for example from reduced hospital stays.

‘One of the barriers to implementation of NICE guidance is that there is often a perception that they will be very expensive,’ explains Ms Lucy Betterton, associate director of external communications at NICE. ‘The costing tools enable services to see exactly what costs are involved – and what savings are likely in the future.’

Other implementation support can be seen in Box 1.
The implementation team has also set up a shared learning database on NICE’s website. This enables practitioners to share examples of good practice in implementing guidelines – and enables others to learn from problems encountered.

‘We don’t just want people to share their experiences if they went well,’ says Ms Betterton. ‘It can be as valuable – and often more – if they can say “don’t do it this way because this is what happened to us”. Problems can be learning experiences in many cases.’

Implementation consultants
The implementation team does not simply produce information and tools. It also has six regionally based implementation consultants from a range of NHS backgrounds, whose job is to engage with NHS organisations in their regions, offer practical support in implementing NICE guidance and ensure they are aware of the tools developed by the team (see Box 1).

‘We’re the local face of NICE,’ says Jayne Chidgey-Clark, implementation consultant for the South West region – one of two consultants from a nursing background. ‘We’re not experts on all the individual guidelines, but we can advise on general issues related to implementation. If people have more specific difficulties we can get advice from the development team for that particular guideline.’

Organisations can also give the consultants feedback on NICE guidance and other materials.

‘It might be something relatively small, like “can you look at how this is phrased, because it wasn’t quite clear to us”, or a suggestion to improve one of the implementation tools,’ says Dr Chidgey-Clark.

She emphasises that NICE wants nurses to engage with it and to get involved in shaping its future directions. They can do this by contacting their NICE consultant directly or through the governance manager or NICE lead in their trust.

‘Nurses have a key role in implementing guidance,’ says Dr Chidgey-Clark. ‘It’s their business to see that it is being implemented, and to point out where it’s not being done. They can do that in a variety of ways. For example, if guidance on diabetes isn’t being followed they might start by talking to the multidisciplinary team first. If that isn’t effective they could contact the person in their trust who is in charge of that particular piece of guidance, or they can get more directly involved by joining the working group set up to implement it.’

NICE guidance has given nurses increased influence over the way in which care is delivered. They are often the professionals best able to see where care standards are inadequate and, if relevant guidance exists, it offers them a powerful way of making sure that their concerns are acted upon.


Box 1. Tools for implementation

-A team of implementation advisers support organisations putting guidelines into practice;
-Implementation slide sets are available on the NICE website;
-Costing tools are available to help PCTs work out the costs of implementing particular guidelines;
- Forward planner sets out forthcoming guidance;
- ‘How to’ guides;
- E-alerts to inform organisations of new guidelines and appraisals;
- Into Practice – an electronic bulletin aimed at those responsible for implementing NICE guidance;
- Best practice advice.



‘Nurses can have a real influence’

Mary McClarey says Plymouth Teaching PCT takes an active approach to disseminating information on NICE guidelines and technical appraisals, and ensuring they are acted upon.

‘We send out the quick reference guide for each guideline or appraisal to the relevant clinicians in a monthly bulletin. They are asked to assess how well they are meeting the key recommendations and to reply within a month – they can also ask for help at this point.’

The PCT also organises workshops that give clinicians the opportunity to look at guidelines and how to meet them. Where appropriate, other organisations may also attend, such as acute trusts, social services and GPs. Commissioners have also attended some events, which Ms McClarey says is helpful as they can often move money around to where it can be used most effectively.

‘These events put nurses in a powerful position,’ says Ms McClarey. ‘They can say how any suggestions made will affect patient care, so they can have a real influence on how guidelines are implemented.’

Ms McClarey believes that while NICE was initially very medically oriented, its focus has now shifted.

‘Latterly its agenda has broadened out considerably and its work is much more relevant to nurses than it once was,’ she says. ‘In fact the last seven sets of guidelines have been extremely relevant to nurses. Many of the recommendations are around the environment of care and how it should be delivered.

‘The other significant standard-setting programme nurses are engaged with is Essence of Care, and they can draw on evidence from NICE guidance to measure how well, or otherwise, basic care is being delivered.’


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