Dr Mike Pearson, Director, CEEU, Royal College of Physicians
The Royal College of Physicians (RCP) has a major role in promoting standards within clinical medicine, including overseeing the academic standards of those entering the profession, and monitoring training, education and professional development. The College both promotes and supports its Fellows and Members in delivering best practice for patients and working effectively.
To this end, the RCP founded a research unit in 1979, which was the precursor to the current Clinical Effectiveness and Evaluation Unit (CEEU). One of its first studies examined deaths in young asthmatics, demonstrating that there were aspects of care that might have been improved in around 60% of cases.
The concept of improving medical care through audit was developed by Dr Anthony Hopkins. He led the unit during the 1990s, facilitating the development of many guidelines and audit tools, in collaboration with specialist medical societies and other bodies.
In 1998, following Dr Hopkins' premature death, the RCP reconsidered the role of its research unit, and the result of that review was a reformulated unit with a new name and brief – the CEEU.
The CEEU continues to:
- Encourage the production of clinical management guidelines
- Develop and perform audit studies to encourage implementation of best practice
- Develop methods for assessing the outcome of healthcare interventions.
To ensure the best use of limited resources, activity mirrors topics high on the government agenda. The main programmes of work follow the Calman–Hine cancer framework, and the National Service Frameworks (NSFs) for Coronary Heart Disease, Care of Older People and Diabetes.
The unit reorganised its working structures into specialty programmes led by an Associate Director – a senior clinician from the specialty released from his/her hospital to spend dedicated time in the unit.
These programme leaders know and understand the issues within the specialty, and communicate with other clinicians and professions and the DoH to ensure that the CEEU approach remains practical and relevant to all parties. They work with one or two permanent programme staff in the unit, supported by a management framework that includes quality IT and statistical support.
Relationship to NICE
The CEEU has worked with the National Institute for Clinical Excellence (NICE) since its inception, as part of the NICE audit and guideline programme.
NICE has recently decided to work through six NICE Collaborating Centres (NCCs). These will be multidisciplinary units with the capacity and expertise to evaluate evidence and synthesise high quality national guidelines.
An NCC is to be sited at the RCP and those elements of the CEEU programme currently funded by NICE will come under the NCC banner. Many staff will be shared between the NCC and CEEU. The NCC will have its own advisory board (with the majority being non-physicians) to oversee its activities and to monitor the quality of its work.
The CEEU will continue its programme-based approach and will be free to seek monies from other grant-giving agencies.
Relationship to other bodies
One of the keys to the success of our projects has been collaboration: all CEEU projects have multidisciplinary steering groups that include groups appropriate to the subject, e.g. specialist societies, professions allied to medicine, and nursing.
Important features include, wherever possible, input from both a patient organisation and NHS management – recognising that implementation must meet the needs of patients and be fitted into other management imperatives of the NHS. None of our initiatives is of any value unless there are means to put it into action.
Our most recent success has been the National Guidelines for Stroke (led by an intercollegiate stroke group), based not only on the medical evidence but also on the views of patients and carers. The main document has been very well received and won the BMA book prize for the best non-commercial book of 2000, and the accompanying patient/carer leaflet was highly commended in its class.
The CEEU has been associated with many guidelines over the past decade, but too many have been poorly implemented. The CEEU is keen to support the production of documents that provide practical advice for everyday practice, and then to evaluate whether the recommendations are actually used and what effect they have.
We are working with the various specialist societies to build up a comprehensive library of guidelines relevant to the medical specialties – and plan a kite-marking process later in 2001.
Two national sentinel audits in the field of care of older people, in stroke and in evidence-based prescribing for older people, have recently been completed and have shown the power of national comparative audit data.The large numbers studied led to good confidence intervals, and hence a greater acceptance of the validity of the results.
The benchmark techniques of comparing one hospital's performance against the national picture without recourse to league tables has been widely accepted by both professionals and management. We have many reports of changes in practice being implemented based on the results of the data. Between the two stroke audits the quality of care improved significantly, although much more remains to be done.
Minimum data sets
In 1999 the CEEU recognised the need for data to support the emerging cancer framework. It used our experience from a multicentre lung cancer audit project to set up a multidisciplinary steering group (including all the major players) to set down the data necessary to evaluate the care of lung cancer patients.
Lung cancer is a particular challenge because patients receive care from several disciplines on different NHS sites. The core data set was produced within 6 months and is the base for the NHS Information Agency (NHSIA) cancer data sets initiative.
The CEEU team has been part of the latter exercise and is now hoping to be commissioned to test the data set and implement it across the UK, aided by the continuing support and direction provided by the lung cancer steering group.
This experience helped the unit address the needs of the emerging NSF in Coronary Heart Disease. A multidisciplinary steering group was able to produce rapidly a core data set of the variables needed to measure whether the targets set by the NSF for myocardial infarction were being met.
NICE has since commissioned the CEEU to take this on: first, with a survey of the current national picture of facilities for myocardial infarction, and, second, an ambitious project to collect data on every myocardial infarction across the country (see below).
Process measures can provide much useful information about the quality of care being provided, but ultimately for patients it is the outcome of care that really matters. In medicine there are few well-defined outcome measures, and the CEEU has been working on outcomes of asthma, of chronic obstructive pulmonary disease and of stroke, with the last two projects supported by the Academy of Royal Medical Colleges.
New methods of data collection
We have moved on from our paper-based record system of 3 years ago to various new systems: optical character recognition (stroke audit) and collection of local data directly onto a disk (evidence-based prescribing for older people).
The Myocardial Infarction National Audit Project (MINAP) has linked with the Central Cardiac Audit Database (CCAD) to develop national data collection by intranet technology, with sophisticated security to ensure confidentiality. The project is currently recruiting its first wave of one third of English hospitals, and is perhaps the first national IT project to seek permission to speed up planned implementation.
The data will be centrally analysed, interpreted by the multidisciplinary steering group, and later this year automated reports will be available to individual units within days of data submission. The completeness of data, the medical interpretation and the rapid turnaround add new dimensions for audit that will have relevance beyond cardiology.
The MINAP data system at CCAD links to the NHSIA. The CEEU is working with the NHSIA to link to other records for the same patient, e.g. the Office of National Statistics, to obtain accurate death rates at set intervals after an infarct. The opportunity to link to primary care will be examined, especially in the next NSF to be addressed – diabetes.
This may be an important model for other common chronic conditions that require effective collaboration between primary and secondary care if best patient outcomes are to be achieved.
For further information on the work of the CEEU, visit the website at http://www.rcplondon.ac.uk/college/ceeu_home.htm (Figure 1).
|Figure 1: Home page of the Clinical Effectiveness and Evaluation Unit|
clinical effectiveness and evaluation unit, RCP
|Set up||Founded 1979, established (in present form) 1998|
|Objectives||To produce quality guidelines that are useful in everyday clinical practice, and to devise ways in which to measure outcomes and hence demonstrate that implementation of that guidance does have a beneficial effect on patient care|
|Funding||From a variety of sources including NICE, the DoH, the Academy of Royal Medical Colleges, charities and industry|
|Key personnel||Director:||Dr Mike Pearson|
|Manager:||Ms Jane Ingham|
|Coronary Heart Disease:||Dr J Birkhead, Mr A Georgiou, Mrs L Walker & Miss L Knight|
|Care of the Elderly:||Dr J Potter & Mr R Grant|
|Stroke:||Dr A Rudd & Ms P Irwin|
|Lung Cancer:||Dr M Peake|
|Respiratory:||Dr M Roberts & Mr Steven Barnes|
|Diabetes:||Dr Nick Vaughan|
|Guidelines:||Ms Melissa Denerley|
|Contact details||Address:||CEEU, Royal College of Physicians, 11 St Andrews Place, Regent's Park, London NW1 4LE|
|Tel:||020 7935 1174, ext.349|
|Fax:||020 7487 3988|