The National Collaborating Centre - Chronic Conditions (NCC-CC) is one of six centres established by NICE from which to commission high quality clinical guidelines (see Figure 1 below). Each centre is a professionally led group with the expertise and experience to develop clinical guidelines.
Figure 1: The six national collaborating centres and two support units and where they are based
The British Thoracic Society asthma guidelines, produced in 1990 by a consortium that included the Royal College of Physicians, were the first national guidelines for a major condition in the UK. Since then, many guidelines have been produced for many different conditions, mostly as a result of the enthusiasm of the national professional specialist societies.
At the same time there has been a huge increase in the number of published studies, and methods for systematically evaluating the ever-increasing literature have been developed, most notably by the Cochrane Collaboration. The Scottish Intercollegiate Guideline Network (SIGN) has demonstrated that it is practical to apply these techniques to the development of guidelines.
Those involved in evaluating guidelines for appropriateness became concerned that many of the guidelines already produced had not been based on systematic assessment of the evidence and thus might not represent the best advice for clinical practice.
Structure of the NCC-CC
Although the NCC-CC is based at the Royal College of Physicians, it is not a department of the College.
The NCC-CC uses a system of governance that reflects the Centreês multidisciplinary ethos. A board of partners, representatives of organisations with a stake in the management of chronic conditions, oversees the work plan of the centre and the progress of the individual commissions (see Figure 2, below).
Figure 2: Partners of the NCC-CC
The ethos of the centre is truly collaborative, drawing on the expertise of all healthcare professions as well as patients and carers in equal measure. We work alongside the other NCCs to produce coherent, useful and effective guidelines and audit advice of a consistently high standard for the NHS.
The NCC-CC has used the expertise of the Royal College of Physiciansê Clinical Effectiveness and Evaluation Unit (CEEU) (see Guidelines in Practice Vol 4, February 2001).
The CEEU is still working on multiple audit and other projects but the two unitsê work plans will complement each other rather than overlap. In this way the NCC-CC is benefiting from, and building on, the experience of major national projects that have been based at the CEEU. These include the National Clinical Guidelines for Stroke, the Myocardial Infarction National Audit Project, national audits of lung cancer, stroke and prescribing for older people, and outcome indicators for continence care, stroke, chronic obstructive pulmonary disease and fractured proximal femur.
Continuity and a spirit of collaboration have been achieved through joint management.
Each NCC has been permitted to develop its own approach within the broad principles set by NICE:
- Involvement of all stakeholders via a transparent and open process.
- Use of multiprofessional development groups, members of which are nominated by their stakeholder parent organisation.
- Systematic review of the evidence base and evaluation to give graded recommendations.
- Inclusion of health economic evaluation.
All members of the guideline development groups have an equal voice in the discussions.
Importantly, each group has two representatives from patient/carer organisations, and our initial experience leads us to expect that their input will have a very positive effect on the resultant guideline.
NICE has set up a Patient Involvement Unit to support the NCCs in fully incorporating the viewpoint of both patient and carer (see Guidelines in Practice Vol 4, December 2001).
The guideline development groups are supported by a team from the NCC-CC, composed of group leader, project manager, systematic reviewer, information scientist, health economist and clinical expert.
This team undertakes the literature search and the evaluation of evidence in a systematic and explicit manner. The team will be supported by the National Guidelines Support and Research Unit set up by NICE to advise the collaborating centres on methodological issues and ensure a consistent approach.
This is a more efficient use of NHS resources than diverting busy clinicians from their clinical workload, and has the advantage of a consistent approach to literature searches and evidence evaluation.
Each guideline is intended to be as evidence-based and as transparent as possible as to how the recommendations were arrived at. However, there are inevitably gaps between the mountains of evidence and, if a guideline is to be of practical value for the busy clinician, consensus techniques must be used to fill in those gaps.
Formal consensus methods will allow everyone to understand how decisions have been reached. We intend recommendations to be as definite and unequivocal as possible, and our groups are advised to avoid •sitting on the fenceê.
Each recommendation will carry with it in the publication an indication of the strength (or otherwise) of evidence supporting it, so that a reader will be able to judge whether or not to accept or adapt each recommendation in different clinical situations. As a US definition stated 10 years ago, •Guidelines should make explicit recommendations with a definite intent to influence what clinicians do.ê1
Topics for clinical guidelines are chosen and referred to NICE by the Department of Health and the National Assembly for Wales. Once a topic has been referred, the process of commissioning and defining the scope of each commission is undertaken by the Centre in conjunction with NICE. This procedure takes 3-4 months.
The hard work of producing the guidelines takes 12-15 months, after which there is a two-stage consultation period overseen by NICE. This ensures that all stakeholders have an opportunity to contribute to the development of final guidance. Further details are available on the NICE website: www.nice.nhs.uk.
Each comment will be considered, the guideline development group will then respond, and the responses will be published on the NICE website.
It is important to emphasise that the final decision on the wording of a guideline recommendation rests with the guideline development group and not with NICE.
NICE retains the final option to recommend, or not to recommend, the document for use in England and Wales.
Each guideline commission will appear as a full and detailed guideline, a short-form version of the recommendations aimed at the busy clinician, and a version for patients and carers. The latter two will appear as NICE documents to be promulgated across both countries.
NICE has commissioned four broad guidelines from the NCC-CC since its inception in April 2001 (see Box 1 below). Each has a very comprehensive scope and there is a huge amount of evidence to be evaluated.
Box 1: Guidelines commissioned from NCC-CC by NICE
There is a learning process from one commission to the next, and so the starting dates of the guidelines in the Centreês work programme have been staggered. The task is very challenging but we are learning how to work more efficiently without sacrificing the commitment to achieve an evidence-based, high quality end product.
Some of the more detailed aspects of guideline processes are available in a set of documents on the guideline development process, which can be downloaded from the NICE website.
The NATIONAL COLLABORATING CENTRE - CHRONIC CONDITIONS
|Launched||Clinical Excellence 2001, December 2001|
|Objectives||To produce clinical guidelines and audit advice for the NHS as commissioned by NICE|
|Key personnel||Director: Dr Mike Pearson Manager: Ms Jane Ingham Administrator: Mr Rob Grant|
Address: NCC-CC, Royal College of Physicians 11 St Andrews Place, London NW1 4LE
- Field MJ, Lohr KN, eds. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press, 1990.