Development of Clinical Practice Development of Clinical Practice Guidelines for the NHSGuidelines for the NHS

Dr Jacqueline Dutchak, DirectorDr Jacqueline Dutchak, Director

National Collaborating Centre for National Collaborating Centre for Acute CareAcute Care

16 January 200416 January 2004

NCC-ACNCC-AC

One of seven Centres set up by NICE in One of seven Centres set up by NICE in April 2001April 2001

Based at the Royal College of Surgeons of Based at the Royal College of Surgeons of EnglandEngland

Staff team comprises systematic reviewers, Staff team comprises systematic reviewers, health economists, statisticians and health economists, statisticians and information scientistsinformation scientists

Commissioned by NICE to produce clinical Commissioned by NICE to produce clinical guidelines for the NHSguidelines for the NHS

Clinical guidelines are...Clinical guidelines are...

recommendations for the care of recommendations for the care of individuals by healthcare professionalsindividuals by healthcare professionals

based on the best available evidencebased on the best available evidence

advisory – they assist the practice of advisory – they assist the practice of healthcare professionals, but do not healthcare professionals, but do not replace their knowledge and skillsreplace their knowledge and skills

Clinical guidelines cover...Clinical guidelines cover...

management of diseases/conditionsmanagement of diseases/conditions

any aspect of management from any aspect of management from prevention & self-care through primary prevention & self-care through primary and secondary care to more specialised and secondary care to more specialised servicesservices

Guidelines should be:Guidelines should be:

ValidValid

ReproducibleReproducible

Cost-effectiveCost-effective

Representative/multidisciplinaryRepresentative/multidisciplinary

Clinically applicableClinically applicable

FlexibleFlexible

ClearClear

ReviewableReviewable

Amenable to clinical auditAmenable to clinical audit

Development ProcessDevelopment Process

1.1. Topic SelectionTopic Selection

2.2. ScopeScope

3.3. WorkplanWorkplan

4.4. Development of the guideline (GDG)Development of the guideline (GDG)

5.5. ValidationValidation

6.6. DisseminationDissemination

7.7. UpdateUpdate

1. Topic selection1. Topic selection

Topics selected by the Dept of Health and Topics selected by the Dept of Health and National Assembly for WalesNational Assembly for Wales

Criteria:Criteria:

– Potential to improve healthPotential to improve health

– Need to reduce variations in clinical Need to reduce variations in clinical practicepractice

– Link with Government priorities.Link with Government priorities.

Topics allocated to NCCs...Topics allocated to NCCs...

Seven National Collaborating CentresSeven National Collaborating Centres– NCC Acute CareNCC Acute Care

– NCC CancerNCC Cancer

– NCC Chronic CareNCC Chronic Care

– NCC Mental HealthNCC Mental Health

– NCC Nursing and Supportive CareNCC Nursing and Supportive Care

– NCC Primary CareNCC Primary Care

– NCC Women and Children’s HealthNCC Women and Children’s Health

Patient Involvement UnitPatient Involvement Unit

NICE delivers remit to the NICE delivers remit to the NCC…NCC…

"To prepare clinical guidelines for "To prepare clinical guidelines for the NHS in England and Wales for the NHS in England and Wales for the diagnosis and treatment of the diagnosis and treatment of lung cancer. This is to supplement lung cancer. This is to supplement the existing service guidance the existing service guidance published by DH in 1998 and this published by DH in 1998 and this commission replaces the earlier commission replaces the earlier commission to update that commission to update that guidance". guidance".

Another remit….Another remit….

““To prepare guidance for the NHS To prepare guidance for the NHS in England and Wales, on the in England and Wales, on the clinical and cost effectiveness of a clinical and cost effectiveness of a dental recall examination for all dental recall examination for all patients at an interval based on patients at an interval based on the risk from oral disease.” the risk from oral disease.”

2. Scope2. Scope

Prepared by the NCC and it outlines ...Prepared by the NCC and it outlines ...– Aspects of care to be coveredAspects of care to be covered

– Background epidemiologyBackground epidemiology

– Population coveredPopulation covered

– Healthcare settings coveredHealthcare settings covered

– Diagnostic procedures, treatments and Diagnostic procedures, treatments and interventions to be included or excluded.interventions to be included or excluded.

Must be a manageable size.Must be a manageable size.

Submit Draft Scope to NICESubmit Draft Scope to NICE

Consultation with stakeholders (4 wks)Consultation with stakeholders (4 wks)

Scope modifiedScope modified

Final scope (and comments) on websiteFinal scope (and comments) on website

Cannot normally be changed after thisCannot normally be changed after this . .

3. Workplan3. Workplan

NCC prepare a workplan setting out... NCC prepare a workplan setting out...

– GDG membershipGDG membership

– Development processDevelopment process

– TimescalesTimescales

– CostingsCostings

Agreed with NICE following negotiation.Agreed with NICE following negotiation.

The GDGThe GDG

Multidisciplinary participation is essential to Multidisciplinary participation is essential to ensure:ensure: Proper evaluation and interpretation of specialty-Proper evaluation and interpretation of specialty-

specific evidencespecific evidence

Relevance to the realities of everyday practiceRelevance to the realities of everyday practice

Ownership and cooperation of all stakeholderOwnership and cooperation of all stakeholder groupsgroups

Patient views and preferences are heardPatient views and preferences are heard

Role of GDGRole of GDG

Oversee, contribute to and agree ...Oversee, contribute to and agree ...

Clinical questionsClinical questions

Search strategySearch strategy

Consensus opinionConsensus opinion

Patient and carer involvementPatient and carer involvement

RecommendationsRecommendations

Final documents.Final documents.

4. Development4. Development

Define clinical questions (inform Define clinical questions (inform search)search)

Identify evidence (literature search)Identify evidence (literature search) Hierarchy of evidence:Hierarchy of evidence:

Systematic ReviewsSystematic Reviews

RCTsRCTs

Other well-designed studiesOther well-designed studies

Expert opinionExpert opinion

Assess & synthesise evidence.Assess & synthesise evidence.

Translate evidence into recommendationsTranslate evidence into recommendations

- - Graded A, B, C or Good practice point, Graded A, B, C or Good practice point, depending on strength of evidence depending on strength of evidence

Consensus opinion in important areas where there Consensus opinion in important areas where there is no evidenceis no evidence

- Formal consensus methods or GDG Formal consensus methods or GDG contributioncontribution

Prepare final guideline documentsPrepare final guideline documents- Full GuidelineFull Guideline- Algorithms where appropriate.Algorithms where appropriate.

5. Validation5. Validation

First Draft submitted to NICE - Full First Draft submitted to NICE - Full versionversion

4 weeks consultation – stakeholders4 weeks consultation – stakeholders Second draft prepared by NCC Second draft prepared by NCC 4 weeks consultation – stakeholders, 4 weeks consultation – stakeholders,

website, guidelines committee, NICEwebsite, guidelines committee, NICE Final draft prepared by NCCFinal draft prepared by NCC Ratified by NICE.Ratified by NICE.

6. Dissemination6. Dissemination

NCC publish full guidelineNCC publish full guideline

NICE publish short from and patient NICE publish short from and patient versionversion

Disseminated throughout the NHSDisseminated throughout the NHS

All versions available on NICE website.All versions available on NICE website.

7. Update7. Update

2-3 years depending on changes in the 2-3 years depending on changes in the available evidenceavailable evidence

Same or different development group.Same or different development group.

Dental recall: recall interval between Dental recall: recall interval between routine dental examinationsroutine dental examinations

Remit received from NICE in summer 2002Remit received from NICE in summer 2002 Scope drafted in early autumn and Scope drafted in early autumn and

stakeholder meeting held in November stakeholder meeting held in November 20022002

Guideline development group convened and Guideline development group convened and first meeting in January 2003first meeting in January 2003

Final meeting in January 2004Final meeting in January 2004 First draft submitted to NICE in February First draft submitted to NICE in February

Who is involved in the dental Who is involved in the dental recall guideline?recall guideline?

Systematic reviewing staff:Systematic reviewing staff:– NCC-ACNCC-AC– Cochrane Oral Health GroupCochrane Oral Health Group– International Centre for Evidence Based International Centre for Evidence Based

Periodontal HealthPeriodontal Health

Guideline Development GroupGuideline Development Group

Dentists and dental hygienists representing Dentists and dental hygienists representing NHS and mixed practicesNHS and mixed practices

PeriodontologistPeriodontologist ResearchersResearchers Patient representativesPatient representatives Groups represented include:Groups represented include:

– BDA, FDS, FGDP, Centre for Evidence Based BDA, FDS, FGDP, Centre for Evidence Based Dentistry, British Society of PeriodontologyDentistry, British Society of Periodontology

TimelinesTimelines

First draft out for stakeholder consultationFirst draft out for stakeholder consultation– 2424thth February to 23 February to 23rdrd March 2004 March 2004

Second draft our for consultationSecond draft our for consultation– 33rdrd May to 31 May to 31stst May 2004 May 2004

PublishedPublished– September 2004September 2004