Dr Paul Chrisp, Director of the NICE Centre for Guidelines, expands on NICE’s guideline strategy by answering some of the questions submitted during his keynote speech at Guidelines Live

Dr Paul Chrisp

Dr Paul Chrisp delivering the keynote presentation at Guidelines Live 2021

How will healthcare professionals be able to engage with the new‑format guidelines? 

NICE guideline recommendations will continue to be available through the NICE website. NICE is also exploring how to structure recommendations so that they are easier to find, understand, and access through other media and channels.

Will this be an improvement? We need a grasp of the overall summary quickly

Our vision is an improvement on the current way of presenting guidance on our website. It is more ambitious, based on user-centred design, and driven by structured content that can be published once, updated once, and delivered in multiple platforms embedded in users’ workflows.

‘Ear, nose, and throat’ is not included in the topic suites. Where will guidelines in this area appear? 

The list of topic suites is still being developed. This portfolio approach enables us to concentrate ongoing surveillance of emerging evidence on areas that have the greatest impact on population health and care, to produce living guideline recommendations in line with our strategy. 

Recommendations will be grouped into suites; when content from a suite needs to be updated, the whole suite will be evaluated and simplified by identifying related recommendations, rather than just updating sections of a single guideline. This allows a focus on key priorities for care pathways within a suite. Guidelines for other conditions will be updated by responding to significant changes in the evidence.

For topics not covered by NICE, how will you evaluate what is a ‘good’ guideline?

A NICE’s Accreditation Programme from 2009–2016 aimed to raise standards in guidance development and improve the quality of information. NICE recognises organisations that demonstrate high standards in producing health or social care guidance by reviewing them against criteria based on the Appraisal of Guidelines for Research and Evaluation II instrument. For topics not covered by NICE, it will determine whether an accredited organisation has produced a guideline and, if not, identify guidelines that NICE can accredit to address gaps.

Is there a trade‑off between rigour and speed when developing guidelines? 

There is a trade-off. Development time depends on the urgency of the referral to NICE, complexity of the topic, number of questions to be addressed, and likely volume of evidence. But it is also important to have a sufficiently robust process to meet the needs and priorities of guideline users. For example, speed was essential in the development of rapid guidelines for the management of COVID-19; these were produced in line with NICE principles, but at an accelerated pace. Because these are living guidelines, NICE can rapidly update them as evidence and data emerge. The response to a health and social care emergency imposes trade‑offs such as shortening, omitting, or accelerating the processes and methods used for developing standard guidelines. However, transparency of decision making and reporting is one of NICE’s core principles, underpinning all guidance and standards. It ensures that users can make judgements on the credibility and applicability of recommendations.

Will NICE be more specific on dosages/durations?

NICE guideline recommendations are based on the best available evidence. It can be specific about dosages and durations for particular conditions when needed, but this is best addressed by consulting the British National Formulary, commissioned by NICE on behalf of the NHS and accessible from the NICE website. 

Will the focus still be on guidelines and not ‘tramlines’, or will it be more didactic, with electronic noncompliance easier to detect? 

They will still be guidelines. But some recommendations will be more user-centred, better able to answer questions, and more specific in describing the actions required. Structured recommendations delivered through decision-support systems allow data on the degree of compliance to be captured. This can be used to better understand uptake, and whether an update is required. ‘Computable recommendations’ that generate data are at the heart of living guideline recommendations for a learning health and care system. However, care decisions remain a combination of clinical judgement, patients’ preferences and values, and evidence‑based recommendations.

Will there be a shift away from economic factors in NICE guidance?

Economic factors remain an important part of NICE guidance. When NICE was established, it was tasked with considering the costs and benefits of interventions and encouraging the most effective use of resources. The Health and Social Care Act 2012 restated this, and required a broad balance between the benefits and costs of providing health services or social care in England. The NHS Constitution commits NICE to providing ‘the best value for taxpayers’ money and the most effective, fair, and sustainable use of finite resources’. NICE strives to balance providing the greatest overall benefit for the largest number of people with fairness and respect for individual choice. NICE guidance aims to meet population needs by identifying care that is high quality and good value, providing the best outcomes for people using health and social care services within the budget available.

How far away is widespread integration of NICE guidelines into primary care systems using decision‑support software?

We are exploring the degree to which we move our guideline recommendations from a narrative to a structured format. NICE is engaging with suppliers of decision‑support systems to ascertain the degree of structuring and coding required to integrate NICE guideline recommendations into users’ workflows. Given that NICE has produced more than 25,000 recommendations, we need to prioritise the type of recommendations, areas, and structure.

Is there a risk of ‘pop-up fatigue’ with recommendations popping up all the time?

Pop-up fatigue is a well‑recognised feature of decision-support systems. We are exploring different formats for guideline recommendations that better answer our users’ questions. 

We need more guidance on how NICE guidelines should be delivered. Is there an evidence base for different delivery models, and should NICE look at this too? 

NICE guidelines always start with a scope, which outlines:

  • why there is a need for the guideline
  • the areas it will cover
  • what it intends to achieve.

NICE develops a guideline by reviewing the relevant evidence, based on review questions. These help to define literature searches, inform the planning and process of the evidence review, and act as a guide for the development of recommendations. Independent guideline committees prepare and consider a summary of the evidence. NICE committees also consider how recommendations will be used in practice. NICE has also produced guidelines on service delivery on a range of subjects, including major trauma, learning disabilities, and intermediate care.

How much push back should there be from GPs when NICE guidelines (particularly around 2-week wait referrals) have additional criteria?

We always listen to feedback from clinicians on how guidelines are used and on recommendations that have implementation challenges. Please contact NICE on any specific issues.

Share your views

If you have any comments on the forthcoming changes to NICE guidance, we want to hear from you. Email the Guidelines in Practice team at ginp@mgp.co.uk