NICE case studies
It was an unexpected pleasure to attend the NICE 2019 Conference in Manchester recently. My place at the conference was supported by the Royal College of Nursing (RCN) and I would like to thank them for offering me this opportunity.
I became interested many years ago in how we as a profession can contribute to the development of guidance and policies. This led to me having the opportunity to review draft documents relevant to my skills and expertise in both Chronic Kidney Disease and Heart Failure via the RCN who act as a consultee/stakeholder for the NICE work programmes.
The RCN encourages members with experience in the topic being addressed to review draft documents, and submit evidence if available. This can be a really positive experience contributing towards professional development, supporting revalidation, and enabling networking with a shared aim of leading improvements in patient care. Contributing in this way enables us as front line nurses to have an opportunity to influence guidance at a national level, and use our real life experience to shape future policies that we can then confidently apply in practice.
The conference exceeded all my expectations! If I’m honest I was slightly anxious about attending this conference - I felt that maybe I would be uncomfortable with the debates between the various organisations. However I found the speakers informative, the varied opinions and experiences interesting, and the overall atmosphere conducive to open discussion. Added to this was a strong representation of patients experience via patient stories and via the inclusion of patient advocates. It was also interesting to hear how evidence is gathered and how guidance developed.
This was of particular interest to me having recently completed a nursing research project looking at how Advanced Nurse Practitioners working with individuals with heart failure enquire, or not, about their patients mental health. This 3 phase institutional ethnographic study showed that one of the most important facilitators to enquiring about mental health was validation of our practice and shared experience and support from colleagues. This enabled us as a varied community team, often working in isolation, to better translate the relevant NICE guidance into practice.
It’s difficult to highlight only a few points from the wealth of information on the day, but my take home messages would be:
- A quote from Dr Phil Hammond that was referred to also by other presenters as so relevant to the Public Health messages that were incorporated in many of the talks; "Why pull people out of the river of disease when you can wander upstream and stop them falling/jumping in!”
- Multimorbidity was a constant theme in common in several of the presentations. Emily Lan (Lay member) gave a description of her experiences as a patient with complex needs, and an impassioned plea for patients to be treated as a whole person. Dr Paul Chrisp (NICE) discussed how using guidelines for individual conditions without considering the patient as a whole has the potential to lead to serious drug interactions. Discussion followed around the development of Guidelines considering Multimorbidity, and this is currently being considered.
- The guidelines can only ever be as good as the information available to the people writing them. We as nurses may well have perspectives based on experiences unique to our roles, and therefore if we want the guidelines to work for us we can get involved and share our experiences. This will help ensure the guidelines reflect both patients’ needs and our ability to translate the guidelines into practice.
“I work as a lecturer practitioner in mental health nursing at Cardiff University and Cardiff and Vale NHS Trust. Having worked in acute psychiatry and in the community, I specialised in cognitive behaviour therapy prior to being employed by Cardiff University.
As [a] member of the Mental Health Forum in the RCN I was asked to provide comments on the NICE technological appraisal for Computerised Cognitive Behavioural Therapy for Anxiety and Depression. This work was challenging not only for its technical content but also in ensuring that the role of nurses is properly reviewed. This work provided me with an insight into NICE work programmes and the stakeholder process. It complemented a number of other technological appraisals and clinical guidelines, and provided the basis for my involvement in implementation of NICE guidance.
This case study illustrates how the work of NICE has been channelled through my clinical academic role and resulted in real improvements in health care delivery. In order to adequately implement clinical guidelines published by NICE we needed the right number of people, doing the right thing at the right time. The publication of the NICE guidance on Core Interventions for Schizophrenia in 2002 highlighted the need for local improvements in service delivery and education. A work plan was developed which included the development of two degree programmes aimed at raising the number of mental health practitioners capable of delivering NICE guidance.
While aware that training alone is insufficient for successful implementation, the work plan therefore included the development of effective leaders, service redesign in inpatient mental health, and the development of local clinical governance groups to steer developments and monitor progress.
This work has begun to embed the NICE guidance in the routine work. In 2005 a multi-agency project to develop a clinical pathway for those who experience psychosis (schizophrenia and manic depression) was initiated. With increasing numbers of people in place to deliver the interventions outlined in the NICE guidance we are now beginning to have the right people in the right place at the right time. Future work will focus on compliance and the variance associated with the integrated care pathway.”
“I work as a Nurse Consultant, Paediatric Ambulatory Care at the Lancashire Teaching Hospital NHS Foundation Trust. In 2002, I worked on behalf of the RCN as a guideline development group member for the NICE guideline: Type 1 Diabetes in Children, Young People and Adults. I was lucky enough to be one of the two nurses asked to represent the RCN from the children and young people perspective of this guideline. This was developed by the National Collaborating Centre (NCC) for Women’s and Children’s Health, where meetings were held every couple of months.
The group was multidisciplinary, including two diabetes charities and NICE staff. The scope for the guideline shaped guideline development through to recommendations for clinical practice. NICE guidelines are not about service delivery models but recommend appropriate treatment and care of people with specific diseases and conditions.
Guideline development included finalising the scope; formulating the care pathway and guideline questions; breaking the questions down; systematically searching for evidence; developing recommendations for clinical practice. Most of the researching and writing was undertaken by the NCC. The document was made available for stakeholder comments at several stages. Feedback provided was addressed. This work took two years, with the two guideline subgroups meeting just once.
Every meeting was hard work, with lots of reading prior to the meeting. The meetings however were always really enjoyable and members of the group were treated as equals, with respect for each discipline. In October 2003, as a Territorial Army nurse, I was mobilised and sent to Iraq. Whilst there, NICE continued to send me all the papers for the meetings, and passed on my comments. This was so important to me to feel part of the outside world. I returned home in time for the launch of the final document in June 2004, at the Royal College of Paediatrics and Child Health. Press was invited and with the other nurse I gave interviews regarding the content of the guideline. We felt like celebrities, having our photos published in the Nursing Standard. I have since written articles about the guideline for several nursing journals, as well as presented at several conferences.
NICE guidance in this area is in widespread use, with some of the recommendations changing practice. It has been very rewarding to see the guidelines implemented across the country. NICE was certainly NICE by name and nature!"