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Leadership: Taking the Lead on Implementation

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Author Adrian O’Dowd, MA, is freelance medical writer.

Dr Gillian Leng, implementation director at NICE, believes that nurses are vital for successfully implementing NICE guidelines. In an interview with her, Adrian O’Dowd finds out how nurses can become more involved in the implementation process.

Mention guidelines, guidance or official recommendations and many nurses might groan at the thought of more bureaucracy. But when it comes to NICE, putting its guidance into practice can mean a world of difference to patients and their care.

NICE produces some 15 new clinical guidelines every year, as well as technology appraisals and public health guidance, which have a significant impact on the NHS and how it looks after patients. But all this good work means little if the guidance is not implemented properly and actually used by staff.

A team within NICE is dedicated to making sure implementation of guidelines happens and is supported. Its head, Dr Gillian Leng (pictured), NICE implementation director since 2004, knows that making sure nurses are involved is the secret of success.
After qualifying and spending time as a junior doctor, Dr Leng spent a year in general practice, then got into research in Edinburgh and was involved in the Cochrane Collaboration. She formally trained in public health and worked as a public health consultant at Bedfordshire Health Authority before joining NICE in 2001 as guidelines programme director.

‘I did a lot of work with Cochrane and it is a very rigorous organisation but it stops short of providing guidance for practitioners whereas NICE has the opportunity to do that,’ says Dr Leng.

Her interest in evidence-based practice stems from differences of opinion she would encounter from medical colleagues: ‘My interest goes back to studying medicine where I was aware that there often wasn’t evidence for what was being practised and [there was] variation in what different doctors would recommend,’ she says.

Her current role is to support the use of NICE guidance throughout the NHS and beyond. As she says: ‘That’s about best patient care and best practice and the philosophy is ensuring that NICE guidance is core to what organisations see as improving quality of care and patient safety.’

The need for such support emerged after NICE held a series of workshops in 2003 with NHS staff when, in Dr Leng’s words: ‘Increasingly, people were looking to NICE to provide some implementation support.’

Her work can be summarised under three themes:
• Motivating and inspiring people to implement guidance (through working with others such as the Department of Health, Healthcare Commission, royal colleges and patient organisations);
• Practical support (through costing tools, commissioning guides and ‘how to’ guides);
• Evaluating recommendation uptake to ascertain what is and is not working, and any barriers.

At the heart of this process are nurses. As Dr Leng says: ‘I have involved nurses at every stage of work that has developed. They were invited to the original workshops and I think they have a key role in helping us work through what the barriers to implementation are.

‘Nurses are very good implementers and good practically on the ground, on the wards or wherever else, in getting things done.

‘For example, we have an external reference group that has nurse membership and we have planning meetings when guidance is coming out for consultation and we always make sure we have nurses around the table at that point.’

Dr Leng also directly employs several nurses on her team and says: ‘I am working with the RCN on drawing up a memorandum of understanding to identify how we work together and what the RCN can do in terms of their education and training programmes, [and] routes of dissemination to support implementing our guidance.’

Some of the nurses working at NICE will be involved with draft guidance to identify the key issues, implementation barriers and useful areas of support. Dr Leng also has a team of six implementation consultants, including two with a nursing background, covering England.

‘They are there to provide advice, support and information rather than hands-on input on a day-to-day basis,’ she says. ‘They are busy people and have been out and about for a year now and during that time, we’ve seen increasing contact from staff in the NHS.’
The benefits of NICE’s guidance are clear, Dr Leng believes: ‘It’s about providing best practice in line with best evidence and therefore best patient care. If you are following NICE guidance, patients should be receiving optimal care.

‘NICE produces guidance that I genuinely think is as good guidance as you possibly can get in terms of the robust process that we go through, the evidence that is reviewed, [and] the people that are consulted and are involved in developing it.

‘If the guidelines are implemented nationally, then there will be less variation in care too, so a patient can be sure that wherever they go, they will receive the same level of care and there won’t be “postcode prescribing” going on.’

But barriers do exist, she admits: ‘There are potentially a huge number of barriers and one of those that comes to my attention most frequently is clinical resistance. It tends to be around specific recommendations that for some reason people feel might not be appropriate or surprises them.

‘Our recommendations are evidence based and it’s difficult for clinicians to be aware of all the evidence in a particular field so, if sometimes the evidence suggests something that clinicians might not be expecting, it can present a bit of resistance.

‘But clinicians are also the best at driving change so it’s important that we work with them during the development process.’

A lack of organisational support can also hinder implementation.

‘You can have a clinician wanting to take change forward but they might find that the management structures are not supportive. That is becoming less of an issue than it used to be because most organisations have processes in place to implement NICE guidance.’

Resources are a perennial problem and Dr Leng adds: ‘People will always say there isn’t enough money.

‘But there has been an Audit Commission report that looked at financial planning for implementation of NICE guidance and it was very clear where organisations were planning ahead on an annual basis to put money aside to implement our guidance and improve patient care.’ In these organisations the resources were not the barrier they were in other places, where forward planning did not occur.

NICE now has a forward planner on its website that highlights what is coming out in the future with costs to make it easier for organisations to plan ahead.

Evaluation of how well guidance is being implemented is carried out using the ERNIE (Evaluation of Reviews of NICE Implementation Effectiveness) system as well as external sources – local audits, research, feedback from the Healthcare Commission and patient organisations.

NICE published a booklet on how to implement its guidance in 2005 and a new guide will be published in December. The new guide will focus on overcoming barriers to change. Copies can be obtained at the NICE conference or from NICE’s website.

There are many sources of help for nurses – NICE’s implementation team, the implementation consultants and NICE’s website.

‘It should be clear on the website how they can get in touch with the implementation team and we very much welcome that contact,’ says Dr Leng. ‘We’ve always got new guidance topics coming out and the more feedback we can get from the field the better.
‘They can also contact their local implementation consultant who will be able to put them in touch with other people working in that field if that is helpful.’

Locally, nurses can play their part by becoming involved in clinical governance or clinical governance committees.

‘On a more day-to-day basis at ward level, I’ve seen some excellent examples of nurses either involved in developing protocols or monitoring on a regular basis, feeding back to staff how well they are implementing guidance or any change,’ she says.

‘I would love them to do more on a local basis. Nurses are great at getting things done.’

Dr Leng concludes: ‘I think nurses can find it difficult to ensure every guideline is implemented as it is hard on an individual level and you do need overarching support from the organisation, but they can be very powerful voices to ensure that organisational support is forthcoming.’

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How nurses can become involved in implementing NICE guidance

- Nurses can become involved locally and nationally. Information, tips, guides and good examples are available on www.nice.org.uk.
- There is a shared learning database on NICE’s website with examples of good ideas: www.nice.org.uk/page.aspx?o=sharedlearning
- More details of the NICE Implementation Programme can be found at: www.nice.org.uk/page.aspx?o=280304
- Contact details of NICE implementation consultants are available at: www.nice.org.uk/page.aspx?o=ImplementationCons

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