The National Institute for Clinical Excellence (NICE) has established six National Collaborating Centres to develop clinical guidelines and provide audit advice for the National Health Service.
Each collaborating centre is hosted by a royal college (see Figure 1, below) and is a partnership of professional organisations, patient groups and academic units with expertise in guideline and audit methodology.
The collaborating centres were set up in an attempt to rationalise clinical effectiveness programmes previously funded by the Department of Health and to provide the basis for a national guideline development programme.
|Figure 1: The six national collaborating centres and where they are based|
Structure of the NCC-PC
The National Collaborating Centre for Primary Care (NCC-PC) is based at the Royal College of General Practitioners (RCGP). However, it is best described as a virtual centre as it involves multiple partnerships with a range of organisations. These are represented on the board, which also includes a representative from NICE as an observer (see Figure 2, below). Such a broad representation is necessary to ensure a true primary care and public health perspective.
|Figure 2: Board membership of the NCC-PC|
Guideline development will be carried out by 'provider' partners based at the School of Health and Related Research (ScHARR), University of Sheffield, and the Clinical Governance R&D Unit, Department of General Practice, University of Leicester.
The virtual centre has been established with a small headquarters based at the RCGP, with a chairman, a manager and administrative support. The past few months have been concerned with setting up the board and ensuring that processes are established for the governance of the board, by establishing terms of reference.
Three formal board meetings have already been held. Relationships are being defined, including the range of accountabilities involved.
The guidelines produced will apply to all settings in the NHS. For example, the guideline on epilepsy will apply to both primary and secondary healthcare.
Guidelines will be developed according to a set method defined by NICE in its manual The Guideline Development Process – Information for National Collaborating Centres and Guideline Development Groups,1 which can be downloaded from the NICE website (www.nice.org.uk).
A new, important component of the work will be an assessment of the cost-effectiveness of guideline recommendations. All guidelines must also include patient/carer and healthcare professional perspectives to supplement the systematic review of the evidence.
The process has to be robust and transparent, and it includes the following stages:
- Agreeing the scope, i.e. what will the guideline cover?
- Establishing a guideline development group to manage the work
- Searching, appraising and synthesising research evidence
- Incorporating expert opinion
- Developing key recommendations for the NHS including audit criteria
- Consulting on the provisional guideline
- Publishing and disseminating the guideline to medical professionals in the NHS.
Patients and professional organisations whose members may be affected by a guideline can contribute to the initial scope, formation of the guideline development group and submission of evidence. They are also consulted on the provisional guideline before the final document is published. This is the 'stakeholder' process; full details can be found on the NICE website.
Development of the following guidelines is being led by the NCC-PC:
- Type 2 diabetes
- Generalised anxiety disorder and panic disorder
- Assessment of familial risk of breast cancer
- National post-MI audit tool
- Educational resource pack for referrals.
In addition the NCC-PC is expected to contribute to guidelines on type 1 diabetes and depression.
Examples of topics being developed by other collaborating centres include: head injury, preoperative tests, heart failure, multiple sclerosis, type 1 diabetes, community infection control, depression, eating disorders, schizophrenia, infertility, and caesarean section.
The topics should be seen in the context of the overall range of diseases for which NICE intends to produce clinical guidelines. There are 33 guideline topics; the full range can be seen on the NICE website. A further list will be issued by the Department of Health later this year.
To support the collaborating centres, NICE has also established the National Guideline Support Unit at the University of Newcastle and National Guidelines and Audit Patient Involvement Unit at the College of Health in London. The centres are expected to work closely with each other and with relevant stakeholders.
There is an extensive and detailed quality assurance process. It is important to state that the final guideline is signed off by NICE and not by the collaborating centre or host professional organisation.
To do this, NICE has established a Guidelines Advisory Committee to advise on the commission of guideline development work and audit advice, and to monitor its quality. The committee includes representatives from patient and carer organisations, doctors and nurses, guideline developers, health economists, and NHS managers.
How will the NCC-PC improve patient care?
There is research evidence to show that systematically developed guidelines, if effectively disseminated and implemented, can improve patient care.
The idea behind the collaborating centres is to produce authoritative and credible guidance to be issued by NICE for use in the NHS. This will define a common standard for healthcare professionals and for patients. People will know what to expect, particularly in chronic disease management.
There will be a scheme for updating clinical guidelines, as information is now available on how this should be best done. Readers will be aware, however, of the crucial importance of dissemination and implementation. Currently this is neither the remit of the collaborating centres nor NICE and will depend on local processes such as clinical governance.
Collaborating centres are evolving organisations that will need time to mature. Success will depend on adequate resourcing and support, and developing mature partnerships between the different stakeholders involved in guideline development.
This ambitious guideline development programme will apply only in England and Wales, as Scotland will have its own arrangements. Primary care organisations will need to be aware of the guideline development programme as it will have significant training, commissioning, clinical governance and service implications.
Whether the collaborating centres will help to promote best practice and improve patient care will depend on several things. Investment in dissemination and implementation strategies at local levels is essential, as is making resources available for service, workforce and prescribing developments. There are also some very real barriers to getting evidence into practice, which have to be overcome, such as the limited time available within the consultation, and the shortage of doctors and nurses.
In essence, the guideline development programme will need to become embedded in wider NHS policies and become part of the significant developments in commissioning, such as clinical networks and integrated care pathways.
|The National Collaborating Centre for Primary Care|
|Set up||December 2001|
|Objectives||To develop clinical guidelines and audit advice for NICE, particularly for primary healthcare|
|Funding||NICE. Funding is provided for infrastructure and on a project variable basis for individual guideline development groups|
|Key personnel||Chairman of the NCC-PC Board:||Dr Mayur Lakhani|
|Vice-Chairman:||Mr David Pruce, Royal Pharmaceutical Society of Great Britain|
|Directors of Guideline Provider Units:||Professor Richard Baker, Professor Allen Hutchinson|
|Contact details||Address:||RCGP, 14 Princes Gate, Hyde Park, London SW7 1PU|
|Tel:||020 7581 3232|
|Fax:||020 77225 3047|
|Websites:||www.nice.org.uk and www.rcgp.org.uk|
- The views expressed in this article are those of the author and not necessarily those of NICE.
- See also 'GPs must be involved in developing NHS guidelines' in this issue.
- National Institute for Clinical Excellence. The Guideline Development Process Series No. 3 – Information for National Collaborating Centres and Guideline Development Groups. London: 2001. Available from www.nice.org.uk