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NICE guidance, dissemination, implementation and monitoring policy

Contents

  1. Introduction
  2. Purpose
  3. Scope
  4. Responsibilities, accountabilities and duties
  5. Procedure or implementation
  6. Training implications
  7. Monitoring arrangements
  8. Equality impact assessment screening
  9. Links to any other associated documents
  10. References
  11. Appendices

1 Introduction

The National Institute for Health and Care Excellence (NICE) is a non- departmental public body of the Department of Health in the United Kingdom, serving both the English NHS and the Welsh NHS. It was set up as the National Institute for Clinical Excellence in 1999, and on 1 April 2005 joined with the Health Development Agency to become the new National Institute for Health and Clinical Excellence (still abbreviated as NICE). Following the Health and Social Care Act 2012, NICE was renamed the National Institute for Health and Care Excellence on 1 April 2013 reflecting its new responsibilities for social care, and changed from a special health authority to a non-departmental public body.

NICE publishes guidelines in four areas. The use of health technologies within the NHS (such as the use of new and existing medicines, treatments and procedures), clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions), guidance for public sector workers on health promotion and ill-health avoidance, and guidance for social care services and users.

NICE quality standards, which are based on the best available guidance and evidence, can be used by commissioners and others to improve the standards of care.

All organisations must have an approved documented process for taking into account agreed best practice as defined in NICE clinical guidelines.

2 Purpose

The purpose of this policy is to set out the trust’s arrangements for implementing NICE Guidance.

2.1 Definitions or explanation of terms used

2.1.1 National Institute For Health and Care Excellence (NICE)

An independent organisation responsible for providing national guidance on the promotion of good health and social care and the prevention and treatment of ill health.

NICE produces guidance for healthcare professionals, patients, carers and the public to help make decisions about treatment and healthcare on the NICE website (opens in new window).

2.1.2 Care Quality Commission (CQC)

The Independent regulator of health and social care in England CQC (opens in new window).

2.1.3 NHS Litigation Authority (NHSLA)

The NHSLA (opens in new window) is a Special Health Authority responsible for handling negligence claims made against NHS bodies in England.

2.1.4 Technology appraisals

Recommendations on the use of new and existing medicines and treatments for example medicines, medical devices, diagnostic techniques, health promotion activity and surgical procedures.

The NHS is legally obliged to fund and resource medicines and treatments recommended by NICE technology appraisals.

2.1.5 Interventional procedures

Guidance which evaluates the safety and efficiency of such procedures where they are used for diagnosis or treatment. Interventional Procedures involve: making a cut or a hole to gain access to the inside of a patient’s body; or, gaining access to a body cavity (such as the digestive system, lungs, womb or bladder) without cutting into the body; or, using electromagnetic radiation (which includes x-rays, lasers, gamma-rays and ultraviolet light).

2.1.6 Clinical guidelines

Recommendations based on the best available evidence on the appropriate treatment and care of people with specific diseases and conditions. While clinical guidelines help health professionals in their work, they do not replace their knowledge and skills.

2.1.7 Safe staffing guidance

The guidance identifies organisational and managerial factors that are required to support safe staffing for nurses, and makes recommendations for monitoring and taking action if there are not enough nursing staff available to meet the nursing needs of the patients.

2.1.8 Public health guidance

Recommendations on the promotion of good health and the prevention of ill health. The guidance may focus on a particular topic (such as smoking), a particular population (such as school children), or a particular setting (such as the workplace).

2.1.9 NICE quality standards

NICE quality standards are a set of specific, concise statements that act as markers of high quality, cost effective patient care, covering the treatment and prevention of different diseases and conditions. These are shared through the trust database and the care group quality meetings.

2.1.10 NICE pathways

NICE Pathways visually represent all of NICE’s recommendations on a topic, and give access to the products that NICE has produced to support implementation of its guidance. They include up to date NICE guidance, quality standards and related information.

2.1.11 Information for patients, carers and the public

NICE produces versions of all its guidance for patients, carers and the public called ‘understanding NICE guidance’ which summarise in plain English, the recommendations NICE make to health and other professionals.

NICE has a page on its website that allows patients, carers and the public to search for the versions of guidance that are written for them. It can be found on the NICE website patients and public (opens in new window).

The trust’s information for service users and carers webpage has a permanent link to the above to promote access to NICE Information for patients, carers and the public.

2.2 What are the trusts’ obligation with regard to NICE guidance?

Health and social care professionals in England are expected to take NICE guidance fully into account when exercising clinical judgement.

The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, or carer.

If a decision is made that the treatment that NICE has recommended is not suitable for a patient, this should be recorded.

The NHS Constitution 2010 (The Department of Health (2010) states “You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you.” Recommended means recommended by a NICE technology appraisal.

Where NICE technology appraisals (TA’s) are concerned, “Commissioners and, or providers have a responsibility to provide the funding required to enable the guidance to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities”.

The National Institute for Health and Care Excellence (NICE) is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. They also provide guidance to help local authorities and other public organisations ensure services offered in each area improve the health and wellbeing of the local community. All NHS organisations in England and Wales are expected to take into account this guidance; this means wherever patients live they should get the same high quality care. NICE do not produce guidance on every health topic but are asked by the Department of Health to look at areas where there is confusion or uncertainty among healthcare professionals about the value of a drug, device or treatment. NICE also look at ways to promote and encourage good health in areas where there isn’t already clear, nationally-agreed guidance. NICE quality standards are based on the best available guidance and evidence and can be used by commissioners and others to improve the standards of care. (NHSLA Risk Management Standards 2013 to 2014).

3 Scope

This policy relates to all staff who undertake duties in relation to the implementation of NICE guidance.

This includes staff working directly in clinical services as well as those working in a range of corporate services, including for example, finance and contracting, performance and assurance, human resources and learning and development.

4 Responsibilities, accountabilities and duties

4.1 The board of directors

It is the responsibility of the board of directors to ensure that the trust consistently follows the principles of good governance applicable to NHS organisations.

This includes the development of policy and procedures for the dissemination, implementation and monitoring of NICE guidance.

This responsibility is delegated to the chief executive who will delegate implementation to a lead director.

A monthly dashboard report will be presented to the quality and safety sub committee and the head of nursing. The board of directors will be informed and assured that the system is working effectively through the minutes of the quality and safety sub committee.

4.2 Chief executive

The board of directors delegates the overall responsibility for effective risk management, meeting all statutory requirements and adhering to guidance issued, to the chief executive.

4.3 Executive director of nursing and AHPs

The executive director of nursing and AHPs is designated with lead responsibility for NICE guidance.

This lead role is undertaken in close liaison with the deputy director of safety and quality, responsible for NICE guidance dissemination, the head of patient safety, the medical director, the care group directors and the care group nurse directors.

The executive director of nursing and AHPs is responsible for:

  • gaining assurance that relevant NICE guidance is identified, disseminated, implemented and monitored
  • providing information on key risks and assurances to the board of directors
  • making sure that links are made to other relevant trust committees and groups as appropriate through other directors
  • discussing high risks identified on the relevant risk register
  • reporting on NICE guidance as part of the overall quality framework through the trust’s publicly reported quality account

4.4 Deputy director of safety and quality

The deputy director of safety and quality is responsible for assuring that the process for the dissemination and implementation of NICE is timely and effective.

4.5 Head of patient safety

The head of patient safety is the designated operational lead for NICE guidance. They are supported in this role by the designated trust wide NICE lead.

They are responsible for:

  • ensuring that via identified individuals there is an effective system for the receipt, dissemination and monitoring of the monthly summary of issued guidance from NICE and that there is a well maintained database of organisational responses to NICE guidance, co-ordinating and reporting on the dissemination, implementation and monitoring of NICE guidance via the care group quality meetings; including key risk areas and assurances on a quarterly, annual and by exception basis
  • making and documenting a decision about the relevance of new NICE guidance issued, where there is any doubt about relevance, seeking advice from the relevant care group nurse director(s)
  • forward planning in relation to NICE guidance, utilising the website resources provided by NICE as appropriate for example NICE forward planner and NICE email bulletins
  • formulating the trust compliance status via speciality (and where applicable care group) response, utilising the identified database and reporting to other trust committees and groups as appropriate
  • maintaining links to other relevant trust committees and groups as appropriate
  • reporting to commissioners as per required timescales
  • managing the alignment, implementation and reporting of the trust clinical audit programme in relation to the implementation and monitoring of NICE guidance, in line with the trust clinical audit policy
  • the head of patient safety will provide a regular NICE update to the quality committee or board

4.6 Trust wide NICE lead

The lead is responsible for:

  • managing the system for the receipt, dissemination and monitoring to the nominated NICE owners or leads from the monthly summary of issued guidance from NICE
  • maintaining effective evidence and archiving system(s) for the dissemination, implementation and monitoring of NICE guidance, including a record of all automatic email notifications from NICE and organisational responses to NICE guidance
  • assisting the head of patient safety with forward planning and trust compliance relevant to NICE guidance
  • administering and monitoring the trust’s NICE guidance reporting and recording system
  • raise any anomalies on and seek clarification on a decision with the relevant identified NICE lead and escalate any concerns
  • monitoring any NICE consultations registered by the trust and ensuring that feedback is received by NICE within the timescales allocated
  • producing a monthly care group update on NICE
  • the clinical effectiveness lead will be supported by the clinical effectiveness support officer to progress NICE and assure all of the aforementioned

4.7 Executive medical director or chief pharmacist

  • The executive medical director and chief pharmacist are responsible for taking a lead on the identification, dissemination, implementation and monitoring of NICE guidance on medicines.
  • This will be coordinated and reported through the medicines management committee in order that an integrated approach to the dissemination, implementation and monitoring of all NICE guidance is maintained.
  • They will assist the clinical effectiveness lead (trust wide NICE Lead) with forward planning in relation to NICE guidance on medicines.
  • They will identify priorities for the trust clinical audit programme in conjunction with the care group nurse directors and care groups.
  • The chief pharmacist is responsible for presenting POMH UK clinical audit results (NICE technology appraisals on medicines) to relevant forums as they become available.

4.8 Quality committee

The quality committee ensures that there is an appropriate process in place to monitor and ensure compliance with clinical standards and guidelines, including, but not limited to, NICE guidance. The safety and quality operational and assurance group (SQOAG) will provide assurance on the high standards of care delivered by the trust across the three domains of quality: clinical effectiveness, patient safety and patient experience. The SQOAG is authorised by the board of directors to act within its terms of reference and ensure all statutory elements of clinical governance are adhered to.

4.9 Care groups

The care group is responsible for the process of disseminating, implementing and monitoring NICE guidance relevant to the trust. compliance to NICE guidance is reported on a quarterly basis to the quality and committee. It will receive a monthly update on NICE guidance from the trust wide NICE lead. These reports will be reported up to the quality committee by the head of patient safety. These reports will be communicated down to local management levels via the lead members of the care groups. The head of patient safety is responsible for the continuous development of the policy for the dissemination, implementation and monitoring of NICE guidance. The care groups are delegated responsibility from the quality committee (QC) for the process of disseminating, implementing and monitoring NICE guidance. The care groups are multidisciplinary in nature with representation by diverse professions.

4.10 NICE (care group or service specialism) owners or leads

  • The sharing of NICE guidelines and quality standards with colleagues across the trust.
  • Receiving the relevance and level of compliance with NICE guidelines via consultation with their care group or specialism colleagues.
  • Sharing and completing baseline assessments and other supportive evidence for identified relevant or core guidance.
  • Providing the Clinical Effectiveness team with a response to all published guidance within 28 days of publishing to enable the reporting of compliance, relevance and risk to the related care group and SQOAG Therefore enabling the clinical effectiveness lead to be able to assure that a timely, complete, accurate and comprehensive report is available.
  • Ensuring that updates on compliance are provided to the Clinical Effectiveness team to allow for them to be recorded on the NICE portal once completed; for example, baseline assessments, action plans, related policy, protocols, standard operating procedures (SOP) etc.
  • Utilising local meetings and communication channels to disseminate and promote relevant NICE Guides to identified staff groups.
  • Attending quarterly NICE leads development or progress sessions.
  • Responding in a timely manner when review or comment relevant to NICE is requested.

4.11 Service leads or managers

With the support of identified NICE (care group or service specialism) owners or leads the service lead or manager will be:

  • responsible for health care governance systems and processes, help develop, implement and manage systems and processes for effective governance within (their) care group or service area
  • actively promote good practice, and ensure that all practice is delivered in accordance with NICE or other guidance on good practice
  • undertake baseline assessments relevant to applicable NICE guidance
  • ensure that action plans are SMART (specific, measurable, agreed, realistic and time based) and where risk is identified escalate and action as appropriate to maintain safety
  • ensure service compliance and evaluation take place as required and that clinical and non-clinical staff are involved routinely

4.12 Clinical staff or other relevant (non-clinical) staff

Clinical staff are expected to take account of NICE or locally commissioned guidance when exercising their clinical judgement in line with their role and duties. However NICE guidance does not override the individual responsibility of clinicians to make appropriate decisions regarding individual patients according to their clinical circumstances. NICE Guidance is identified as a core agenda item for supervision which staff are expected to discuss, as set out within the trust’s clinical and management supervision policy for clinical staff.

4.13 Trust wide responsibility

Trust wide services are responsible for taking account of best practice as set out by NICE in the context of the trust’s services.

This includes:

  • disseminating and reviewing NICE guidance through their trust structures
  • determining the level of relevance of the guidance
  • identifying a lead within their services for implementation of the guidance
  • facilitating engagement with NICE guidance within their services
  • maintaining effective records of NICE guidance implementation
  • implementing the process outlined in section 5
  • evidencing the undertaking of implementation reports to the relevant care groups
  • recording any risks identified, associated with NICE guidance on their risk register and implementing relevant action plans
  • participating in clinical audit of NICE guidance to monitor compliance and developing appropriate action plans based on the clinical audit results
  • identifying and planning for staff training needs
  • making sure that where the treatment that NICE has recommended is not suitable for a patient that this is recorded
  • reporting any decisions not to implement NICE guidance to the Quality Committee
  • contribute where applicable to any NICE consultations
  • maintaining communication with commissioners as required around service provision in line with NICE guidance

4.14 Other trust committees or groups

Medicines management committee (MMC), where guidance reviews and contributions to implementation plans for relevant NICE guidance (particularly NICE technology appraisals) are made.

Trust wide services, implement and monitor action plans and identify and manage risks though the risk register process.

5 Procedure or implementation

The core procedures for managing the dissemination, implementation and monitoring of NICE guidance are set out within the terms of Reference for the care group quality meetings.

5.1 Process for identifying relevant guidance

  • NICE has a rolling programme of guidance constantly in development and review and issues its guidance every month.
  • The trust wide NICE lead disseminates the issued guidance to the identified NICE owners or leads.
  • A decision about the relevance of guidance issued is taken by all trust services and the identified NICE owners or leads (care group or service specialism) report to the Clinical Effectiveness team to record on the NICE portal.
  • New or updated guidance, identified as being relevant to individual services is reported on via the quarterly dashboard and the quality committee report.

5.2 Process for dissemination or implementation

  • The guidance specific support tools produced by NICE, including slide sets, support and costing tools and quick reference guides, may be utilised within individual services as appropriate.
  • The trust wide NICE lead will cascade the monthly issued guidance (as they are issued) to trust wide services via the identified care group or service specialism owners or leads.
  • NICE owners or leads (care group or service specialism) will confirm by providing a response to the Clinical Effectiveness team 4 weeks of publishing. Indicating if NICE guidance is relevant within their services, and to what extent compliance is assured, the service specialism lead will draw on the opinion of appropriate clinical leads and staff to facilitate engagement.
  • The Clinical Effectiveness team will upload relevant information or evidence onto the NICE portal including completed baseline assessments.
  • Trust services will establish compliance levels with the recommendations contained in the guidance, including any risks or performance issues, and develop relevant action plans. These will be shared with the Clinical Effectiveness team to record on the NICE Portal. If guidance is deemed to be for information only.
  • Any identified risks or performance issues will be entered on the relevant risk register and included within the trust clinical audit programme as appropriate.

5.3 Process for conducting an organisational gap analysis

The template shown in appendix A may be used by the trust wide Services to undertake a gap analysis and to develop an action plan. There are also guidance specific support tools produced by NICE and directly linked to the guides, which may be utilised and therefore the trust gap analysis may not be required.

A decision may be taken that the gap analysis will be undertaken by an identified single representative on behalf of the whole organisation.

A gap analysis will involve the identification of relevant lead(s) by the trust services, who will assess NICE guidance in relation to current practice to determine what actions are needed to implement the recommendations within the guidance.

This process may involve variety of methods, such as individual or group discussions with staff, questionnaires, clinical audit, reviewing training content, use of performance data and so on.

Individual trust sector gap analyses and action plans will be integrated as appropriate for reporting purposes.

5.4 Process for developing action plans to address any shortfalls

Trust care groups or service specific teams will develop action plans following the undertaking of a baseline assessment (NICE specific) or gap analysis (appendix A) and report on these via the designated care group and service specialism meetings.

5.5 Process for ensuring that recommendations are acted upon throughout the organisation

The care group is responsible for ensuring that those recommendations are acted upon throughout the care group. The elements of the process are set out throughout this policy and are highlighted in the following sections:

  • section 4, responsibilities, accountabilities and duties
  • section 5, procedure or implementation
  • section 7, monitoring arrangements

Any action plans resulting from clinical audit which relate to NICE guidance will be monitored via the care groups where appropriate and uptake measured through routinely collected data for example, performance data, training records.

5.6 Process for documenting any decision not to implement NICE recommendations

Decisions not to implement NICE guidance will follow discussions within trust care groups or services and will be reported by the identified NICE leads to the Clinical Effectiveness team to record on the NICE Portal. Where not applicable trust wide this will be communicated to the care groups quality meeting then on to the quality committee via the dashboard.

Where a trust wide consultation process decides that a NICE guidance is wholly not applicable, leads will provide a rationale in respect of the decision not to implement the NICE guidance. This will be discussed and recorded in the minutes.

This information will also be reported onto the trust’s care group service specialism database.

6 Training implications

There are no specific training needs in relation to this policy, but the following staff will to be familiar with its contents:

  • all staff who in their course of their work undertake duties in relation to the implementation of NICE guidance
  • this includes staff working directly in clinical services as well as those working in a range of corporate services, including finance and contracting, performance and assurance, clinical audit, human resources and learning and development

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

  • local Induction
  • team meetings
  • one to one meetings or supervision
  • group supervision
  • practice development days and bulletins
  • continuing professional development (CPD) sessions

Discussed during other awareness raising and training including:

  • trust corporate induction (the section on policies)
  • subject specific training based on NICE Guidance for example falls, violence etc.

When changes are made to the policy, notification will be made via:

  • trust matters
  • other suitable means dependant on the nature of the changes

7 Monitoring arrangements

7.1 How the organisation identifies which NICE guidelines are relevant to its services

  • How: Via care groups and trust database, service specific meetings and discussion at care group meetings.
  • Who by: NICE owners, leads, identified service specific persons, or trust NICE lead.
  • Reported to: Care groups or medicines management committee.
  • Frequency: Monthly.

7.2 How a gap analysis is conducted to identify shortfalls

  • How:  Via care groups.
  • Who by: NICE owners, leads, or identified service specific persons.
  • Reported to: Care groups.
  • Frequency: Monthly.

7.3 How action plans are created to identify any shortfalls, including recording decisions not to implement NICE guidelines

  • How: Via care groups.
  • Who by: NICE owners, leads, or identified service specific persons.
  • Reported to: Care groups.
  • Frequency: Monthly.

7.4 POMH UK clinical audit results

  • How: Via the medicines management committee meeting and the care groups.
  • Who by: Chief pharmacist.
  • Reported to: Relevant trust forums, for example medicines management committee, medical audit meetings, professional network meetings, care group meetings, or specialist service meetings.
  • Frequency: As clinical audit results are published.

7.5 NICE Technology appraisals on identified medicines)

  • How: Via the medicines management committee meeting and the care groups.
  • Reported to: Relevant trust forums, for example medicines management committee, medical audit meetings, professional network meetings, care group meetings, or specialist service meetings.
  • Frequency: As clinical audit results are published.

8 Equality impact assessment screening

Download the NICE Guidance policy EIA.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any other associated documents

10 References

11 Appendices

11.1 Appendix A Template for organisational gap analysis and action plan

11.2 Appendix B Process for dissemination or implementation of NICE guidelines

  1. Clinical effectiveness lead notifies NICE clinical leads of NICE guidance, NICE consultations and links.
    • NG, NICE guidelines
    • CG, clinical guidance
    • QS, quality standards
    • ESUOM, evidence summary unlicensed and off label medicines
    • ESNM, evidence summary new medicines
    • TA, technology appraisal
    • IPG, interventional procedure guidance
    • MTG, medical technologies guidance
    • DG, diagnostics guidance
  2. NICE owners or leads, provide a response the Clinical Effectiveness team to update the NICE portal (within 4 weeks of NICE being published) and complete a baseline assessment for all core or relevant NICE guidelines and quality standards with action plans where required and other relevant evidence. Disseminate relevant guidance and standards to colleagues.
  3. Discussion and review, NICE owners or leads and the trust NICE lead discuss any considered and subsequently identified wholly not applicable guidelines and report to the relevant care groups accordingly. Following acceptance of this the clinical effectiveness lead may archive any trust-wide relevant guidelines. Clinical effectiveness lead will highlight any forthcoming consultation opportunities.
  4. Monitoring, the trust wide NICE lead will monitor trust overall compliance and assertively encourage compliance. NICE owners or leads to update Clinical Effectiveness team with outcomes of NICE guidance and quality standards when action plans are completed to allow the outcome to be recorded on the NICE portal with any on-going work relevant to the guidance.
  5. Reporting, NICE dashboard reported to care groups on a monthly basis.

11.3 Appendix C COVID-19 relevant NICE guidelines

11.3.1 Evidence summary (ES)

11.3.2 NICE guidelines (NG)

11.3.3 Medical technologies guidance (MTG)

11.3.4 Other information (opens in new window)

Document control

  • Version: 6.10.
  • Unique reference number: 321.
  • Approved by: Corporate policy assurance group.
  • Date approved: 29 January 2024.
  • Name of originator or author: Trust NICE lead or NICE leads (service specific).
  • Name of responsible individual: Executive director of nursing and allied health professionals.
  • Date issued: 5 February 2024.
  • Review date: 31 December 2023 (extension and amendment)
  • Target audience: All staff who in their course of their work undertake duties in relation to the implementation of NICE guidance. This includes staff working directly in clinical services as well as those working in a range of corporate services, including finance and contracting, performance and assurance, clinical audit, human resources and learning and development.

Page last reviewed: April 15, 2024
Next review due: April 15, 2025

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