1. NICE and Public Health: The First Two Years Mike Kelly Val Moore UKPHA Annual Conference 2007 Edinburgh

2. When we started At the beginning we had a clear model to build on Imperative to work across appraisals, guidelines and public health Build on the work of Cochrane, CRD, and evidence based medicine Build on the work of the Health Development Agency

3. Two types of public health guidance Programme guidance 18 months Programme Development Group (PDGs) Intervention guidance one year Public Health Interventions Advisory Committee (PHIAC)

4. Public health intervention guidance: recommendations on types of activity usually provided by local health organisations.

5. Public health programme guidance: broad strategic activities for the promotion of good health and the prevention of ill health. This guidance may focus on a topic (e.g. maternal and child health), a disease cluster (e.g. obesity), or on a particular setting (e.g. schools or workplaces).

6. Age, sex & hereditary factors Agriculture and food Production Education Work environment Housing Health care services Water & sanitation Unemployment Living & working conditions

7. Topic Selection Suggest a topic! Engagement with stakeholders Public Health Topic Selection Panel Ministerial referral

8. Interventions Promoting physical activity in primary care (March 06) Smoking cessation in primary care (March 06) Preventing teen conceptions and STIs (Feb 07) Physical activity in the workplace Substance misuse and vulnerable young people (March 07) Children and mental well being X2 Mental health and the workplace Mental health and older people Preventing the uptake of smoking in children Alcohol and children in school Reducing mortality in highly disadvantaged communities Supporting the smoking ban (April 07)

9. Programmes Maternal and child nutrition Smoking cessation services Behaviour change Physical activity and the environment Obesity (Dec 06) Community engagement Physical activity, play and sport in pre school and school aged children Health literacy in schools with reference to sex education Long term sickness incapacity

10. Key learning The distinction between programmes and interventions not in practice always easy to sustain. Scope drift – from stakeholders - from the advisory committees The key importance of scoping down

11. Key learning from the review process Limited national capacity Limited understanding of NICE – constructed as methodologically rigid More NICE than NICE Critiques of our methods – real and imagined Problems of taking a sequential approach – effectiveness – cost effectiveness - equity

12. Key learning about making recommendations Deriving the evidence statements is difficult in itself Too much detail and the advisory committee gets overwhelmed Too little detail and begins to operate at too high a level of generality/banality Tendency to huge amounts of information Must get the economics into the analysis from the beginning

13. Assessing Cost Effectiveness Probability of rejection Cost per QALY (£000) 20 3040 50 60 0 1

14. The reality of guidance development Absence of good trials Absence of good qualitative data Patchy and poor grey literature Very limited economic analysis and absence of cost data

15. The research doesnt exist The research doesnt say what you thought it said The research doesnt answer the question The research is of poor/dreadful quality methodologically There isnt a qualitative or grey literature to fill the gaps The findings are utterly equivocal

16. Formulation of primary research studies reflect the interest of researchers rather than the needs of the public or of guideline developers. Large gap between researchers and practitioners and policy makers

17. Absence of good process, implementation and content data How an intervention was done and what problems arose in doing it What was done – the content of the intervention so that it might be replicated How it might be implemented in non experimental settings Local infrastructures/context data How to make sense of non UK data

18. Inferential reasoning The evidence as a framework of plausible possibilities The evidence as a starting point for intervention not an imperative or a recipe The importance of inference and the importance of making those inferences explicit

19. Guidance products full guidance (web only) quick reference guide (QRG) evidence reviews, economic model, fieldwork report, minutes (web only) implementation support

20. Additional theoretical issues

21. The precise nature of the causal pathways not well understood so knowing where to intervene s sometimes very difficult. What kind of effects and effect sizes might reasonably be expected? What are the intervening and mediating variables? The ways in which interventions work in different segments of the population not well understood

22. Beyond the NHS Local government The education sector The private sector

23. Topic referred to NICE by Department of Health Scoping (6 - 8 weeks) Identify subject specialists/experts and co-optees for PHIAC Identify stakeholders & encourage registration Draft scope Stakeholder consultation on draft scope (4 weeks) Select project team Development (24 weeks) Validation (14 weeks) Sign off and publication (6 weeks) Final scope Identify fieldwork participants Develop synopsis of evidence Guidance Executive review and signoff Draft recommendations Develop technical reports Final Guidance Undertake fieldwork (4 weeks) Project Planning DH consultation Stakeholder consultation on evidence synopsis and invitation to submit evidence (4 weeks) PHIAC 2 nd Meeting Review fieldwork, submitted evidence and consultation comments, then draft guidance Stakeholder consultation on draft recommendations (4 weeks) Reviews of evidence completed by contractors/CC (16 weeks) Draft guidance 1 st PHIAC meeting to review evidence then draft recommendations Review stakeholder evidence

24. Topic referred to NICE by Department of Health Scoping (6 – 8 weeks) Invite community membership of PDG Develop draft scope Select project team Development (48 weeks) Validation (16 weeks) Develop final scope Identify fieldwork participants Approx 6 PDG meetings to consider reviews of evidence Form PDG in consultation with Chair Project Planning Stakeholder consultation on draft scope (4 weeks) Identify PDG Chair Scope consultation meeting PDG Drafting meeting to develop recommendations Sign off and Publicati on (6 weeks) PDG Review meeting to consider fieldwork, submitted evidence and consultation comments, then draft guidance Guidance Executive review and signoff DH Consultation Identify stakeholders & encourage registration Stakeholder consultation on draft recommendations (4 weeks) Produce fieldwork report Undertake fieldwork (6 weeks) Draft recommendations Reviews of evidence and economic appraisal Draft synopsis of evidence and economic appraisal PDG Activity Stakeholder consultation on evidence synopsis and invitation to submit evidence (4 weeks) Final Guidance Final draft guidance produced Review stakeholder evidence

25. Visit www.nice.org.ukwww.nice.org.uk

26. The NICE Implementation Strategy UKPHA - March 2007 And feedback from the first 200 days in the field

27. The right topics are the critical foundation for successful implementation! How NICE guidance is selected: You and the public Consultation workshops Topic selection panels

28. What topics do you think NICE should cover with its public health guidance in the future? What setting? What issue? Target audiences? Is there uncertainty about what works? Could it make a real difference to public health outcomes? Do you think resources are being wasted?

29. NICE implementation strategy Effective dissemination Supportive environment Implementation tools Shared learning Evaluation

31. How to put NICE guidance into practice – Key messages Core standards and the Healthcare Commission. Key principles such as board support and leadership, multi-disciplinary team, a systematic approach and dedicated resource Step by step process Advice for commissioners

32. Step by step process Check relevance and promote awareness Identify a lead Identify a group Do a baseline assessment Assess cost Develop an action plan Review and monitor

33. Slide Sets To assist with local awareness raising and dissemination www.nice.org.uk/slidesets

34. Implementation advice Developed through a nationally convened planning group And validated by users in the field Practical Advisory

35. NICE audit criteria e.g. from the 11 suggested criteria for obesity Public Health Documented healthy eating policies for LA and NHS staff and services Clinical care % identified adult patients with BMI>30, documented multi- component weight management plan

36. NICE Costing tools 1. National cost impact report 2. Spreadsheet template to help local users assess local impact Cost of optimum care less cost of current care = resource impact Resource impact can be either a cost (+) or saving (-)

37. Shared Learning site http://www.nice.org.uk/page.aspx?o=shared.learning 'Doing Well' (by people with depression) Greater Glasgow & ClydeDec-06'Doing Well' (by people with depression) Community Heart Failure Service Medway PCTCommunity Heart Failure Service Criteria for Management of NICE Guidance Sheffield PCTs We want to include implementation examples from non NHS audiences as well

38. The NICE field team patches (England)

39. What we offer.. Updates and advice to help the senior management implement NICE guidance Problem solving, by sharing examples of how organisations have worked together to implement guidance Advice on how to use the NICE support tools A chance to feedback to NICE on local issues, ideas and suggestions

40. The visit strategy (to end Feb 07) PlannedCompleted PCTs152116 SHAs10 Acute Trusts 172147 MH Trusts5951 (LAs15016) NHS Total393325 (83%)

41. Key themes from the NHS The compulsory-straight-away guidance is easier to implement than Clinical Guidelines or PH Guidance Knowledge of tools patchy - but when explained, welcomed Commissioning is a huge opportunity Huge demand for shared learning

42. Local Authorities – emerging findings Awareness of NICE is low Mechanisms for handling guidance are not common Format of guidance may need adapting Many services commissioned jointly and from voluntary groups and private sector

43. However there are real opportunities NICE Guidance fits with LA priorities e.g. dementia, child depression, sexual health, obesity, smoking cessation Health, and resource efficiency, are of increasing concern Potential mechanisms for implementation exist e.g. LAAs, OSC, Health Groups Audit Commission line of enquiry NICE generally welcome

44. What would help bring NICE guidance to the attention of non NHS audiences? Social care Childrens services Voluntary and community sector Professional groups Issue champions and leaders (entrepreneurs) Workplaces …………………

45. Sign up for IntoPractice the Implementers bulletin www.nice.org.uk Contact us implementation@nice.org.uk