Select Committee on Health Minutes of Evidence

Memorandum by Bandolier (NC 107)


      The issue is this: when a person interacts with the NHS, how can the NHS deliver a service that:

    1.  Reflects the best use of important, valid evidence.

    2.  Is delivered safely.

    3  Is delivered efficiently and without undue waste.

  Moreover, the delivery of the service has to assure that lacunae of poor practice, or even dangerous practice, do not occur.

  These are great questions, because they are central to the problems of the NHS in recent years. Solutions may need to be radical, but can also be sensible and acceptable to the great majority of NHS staff. The impact of evidence-based medicine over the last 10 years has demonstrated that we do things that don't work and are harmful, and that we fail to do things that are beneficial and safe. The impact of waste is considerable. For instance, hospital acquired infection consumes the resources of over 20 400-bed hospitals, and adverse drug reactions another 15. At least half of this is preventable.


  The problems are that the system hinders implementation of good practice, that artificial budgetary parameters prevent joined-up practice, and that individuals who deliver good practice are not valued. It is worth examining examples to understand, at least in part, the problems.

The system

  Academic medicine values impact factors. These measure the prestige of journals that publish scientific papers. HEFCE reviews of university departments makes great play of the number of scientific papers published and the prestige of journals in which publish them. The thrust is for new science. Trying to get a paper on effective service delivery published in a high impact factor journal is almost (though not quite) impossible. In the USA we have seen some really important papers, but from one or two institutions like Harvard's department of Public Health and Policy.

  The result is understandable—that NHS staff wanting to develop their careers academically do "scientific" research. Academic medicine is too much divorced from service delivery and improvement. Those that do not, do no little or no research. There is little culture of quality improvement. The Commission for Health Improvement is a welcome improvement, but at the moment it is more of a stick rather than a carrot.

  Another problem is that the individual professions have their own paths to advancement. This includes the usual "paper chase" of additional qualifications and continual education. Yet service is delivered by multi-diciplinary teams; there is no mechanism for team training or building to improve service delivery.

  NICE has been criticised: it is not national, it isn't an institute, it has little to do with clinical medicine, and it is unlikely to be excellent. How could it live up to the name within it's limited budget and scope? The UK as a whole has too few people actively engaged in the kind of research that is needed for NICE to succeed. "Evidence" is too often regarded as a discipline where everything is known, whereas the truth is that though we have a good beginning there are many areas where we just don't know enough.


  Evidence is poorly collected. Most papers on evidence use methods and terms of little value to people delivering service. Most of the outputs from evidence, including the Cochrane Collaboration, are in a form (odds ratios, for instance) that most people just do not understand. Much of the evidence-base is just wrong. In some areas, like diagnosis, we have yet to even make a start on producing useful evidence. Much health economics is not evidence-based, wrong, or just plain useless because it is not understood. Operational research, vital to a huge organisation like the NHS, is a new concept to most in the NHS, despite being an important discipline since the late 1930s.

  The bottom line is that the NHS does not provide tools for people to do a better job, nor encourage systems that allow them to do so. Despite this, almost everyone in the NHS wants to do a better job and is frustrated to a greater or lesser degree that it seems so hard.


  What the NHS needs to do is to embrace quality improvement in its widest context. This will be no mean feat, because the NHS is enormously complex, and the potential for mistakes, or just not getting it absolutely right, is huge. What we need are the following:

    1.  To provide top-down rules for basic standards of care in key areas. NSFs do this very well.

    2.  To provide the right tools to allow individuals to improve the NHS.

    3.  To exploit the fundamental good will of NHS employees.

    4.  To create a culture of quality improvement.

  It is the last three that are not being dealt with currently.

  Quality must at the top of the NHS agenda, as is now recognised. That is not to say that quantity is not important, but we waste so much in the NHS through lack of quality that a quality agenda should automatically deliver more quantity in any case.

  People will be motivated to provide better quality services when they know and trust the evidence, when they know what the clinical and economic consequences will be for their organisation and the NHS, and when they are given help in making a new service work or an existing one work better.

  The prime mover should be an enlarged, strengthened and independent NICE. It has to be enlarged because there is a big job to do. It must be strengthened because it does not command the respect it must command. It must be independent because quality has to be seen to be the most important aspect and to take quality out of the political agenda. The whole of new NICE has to emphasise "people, products, processes". An outline of the proposed system is shown in the Figure.

  1.  Proposals should have a price attached, and for the proposals outlined below a projected budget is given. NICE needs a budget of about £100 million a year. Not all of this need be new money and there will be clear initiatives already extant that could become part of an enlarged NICE.

  2.  The new NICE should set out to be:

    —  National—truly encompassing all of England & Wales.

    —  An Institute—it should become the NHS's University, providing relevant training and education for people in the NHS.

    —  Relevant to clinical practice—it need to examine issues the NHS needs to solve now, and that includes issues relevant both to parts of the NHS and to its users.

    —  Excellent—setting standards for evidence, management, economics, diagnosis and service delivery.

  3.  The new NICE will set out to deliver best evidence, in quantity, and to commission research where needed. It will do this by setting up a number of units:

    —  Evidence institute. This will be a single centre to produce the evidence needed by the NHS. This could be reviewing new information or existing information. It will employ people with knowledge of clinical trials, EBM, mathematical modelling, health economics and operational research. The aim would be not only to provide a bigger, better version of what NICE is supposed to be now, but it will also respond to issues that arise in the NHS and where evidence is needed now for better practice. Information from the evidence institute should be made available to all (public and professionals) on the Internet.

  The institute will be a major training supplier for the NHS. PCOs and Trusts will be expected to second individuals for periods between 3 and 12 months for EBM training to take back the skills to their employer. Research would be commissioned outside the evidence institute only exceptionally; if it were commissioned it would be directed to units known to be able to respond fast and well.

  Diagnostic institute. Diagnosis includes clinical diagnosis, laboratory tests and imaging. Much more needs to be done to help professionals, especially in primary care, to make faster and more accurate diagnosis using a variety of methods. In this context diagnosis also means effective rules for referral. Our knowledge is so thin that this needs a separate initiative, linked with at least one major teaching hospital.

  Quality and service delivery institute. The UK desperately needs a unit like the Health Policy and Management Department at Havard. We need UK-based thinking, recognising UK problems, and coming up with UK solutions. The new NICE will encourage the use of system re-engineering, EFQM, and similar initiatives. It will more effectively promote systems research and development within the NHS to provide NHS solutions for NHS problems.

  Patients and consumers institute. The new NICE will be expected to obtain patient and consumer input and integrate it into its work. This should not just be discussion with advocacy groups, self-selected. It should involve new research into outcomes. Many outcomes used in clinical trials are chosen without regard to patient of service requirements. This makes defining whether a treatment is effective or cost effective difficult.

  4.  The new NICE will need to engage NHS employees locally in their communities. Each PCO and Trust will therefore have a NICE ambassador. The ambassadors will communicate the objectives and products of NICE in their institution, but will be conduits to NICE about NHS quality issues that need responses now. NICE ambassadors should have annual budgets of £50,000 to spend on facilitating projects in their institution, or for training, or other relevant items.

  These ambassadors will not only network with NICE at the centre, but will also form local networks at county or strategic health authority level. This will help coordinate actions between PCOs and Trusts for joined up local quality improvement. They will coordinate local training and initiatives.

  At some intermediate level there should also be NICE Academies further to promote coordination and communication. The present NHS Regions may be too large for this, which may be better done at a sub-Regional level. The new NICE Academies should have annual budgets of about £1 million to spend on facilitating projects, for training, or other relevant business.

  PCOs represent the future. But they will need resourcing to do this properly. A significant part of the enlarged NICE budget will be spent on promoting evidence, quality and delivery at the PCG level. This should include financial and career incentives for ambassadors.

  5.  Each PCO or Trust Chief Executive will have to demonstrate each year that their organisation has undertaken a number of initiatives in quality improvement or control. Some may be simple, others complicated, but together they must show a continual improvement in quality for the institution. Chief executives may be expected to designate quality improvement officers, who could also serve as ambassadors for their institution, but the responsibility for delivery resides with the CE.

  6.  Recognition and reward are key elements presently missing from the delivery of better services. The new NICE will institute a system of local and national awards for quality and service delivery. These will be available for projects, teams and individuals. In the new NHS these will be as important as further degrees, qualifications and scientific publications in individual advancement.

  7.  Commissioning projects will be the joint responsibility of the new NICE, in association with its ambassadors, and with research units. This will ensure that research is relevant to the NHS. Other inputs would be from the DoH, Welsh Assembly, NHSE, and NHS litigation sources, but the final decision should rest with the new NICE.

  8.  Information delivery will need to have an element of push from the new NICE. Keeping the NHS informed is vital. A policy must be developed that will deliver knowledge, education, the quality message, and the message that if you are not in you are out. This need not be heavy, and shouldn't be glossy.


  There are several other things that are needed, one essential and the other desirable.

  A.  The essential thing is electronic communication. All the new NICE material will be available to everyone on the Internet or PCO or Trust Intranets, and in detail so that professionals and public can see and appreciate the evidence on which decisions are based. It could be an important part of the NeLH. Putting material on the Internet is easy and cheap, and involves no special skills, and it should be the responsibility of NICE.

  There is no need to invent new systems for information. We do, however, need to ensure that new developments in electronic information handling can be disseminated. The main problem is the lack of useful information, not delivery systems.

  B.  Industry must be brought into the project. UK healthcare industries are way ahead of their European or American counterparts in their knowledge management, but are often controlled from countries outside the UK where the evidence imperative is less well understood. There is an absolute need that healthcare industries be actively engaged in evidence development and understanding. It will help the NHS, but it will also confer commercial advantage on companies embracing evidence quality. It is not at all unlikely that joint research projects would take place.

  C.  Because many technologies will be pharmaceutical, regulatory authorities in the UK, European Union, and the USA will be relevant to NICE. Clinical trials done for regulatory reasons and using methods demanded by regulators may be inadequate for clinical practice decisions. This may have to be remedied.


  The comments in this paper concentrate on what NICE could be rather than on what it is and does now.

  What NICE is doing now is important, as is how well it accomplished that task. But NICE as presently constituted is likely to fail to make any lasting impression on the NHS, and will be a source of friction with healthcare industries. That is not a criticism of the staff of NICE, but a recognition that it could not succeed. There is too much to do, the problems are too complex, and the requisite expertise in the UK limited.

  Is NICE necessary? Absolutely, but the scale of the task requires consideration of NICE in a different context, not one of rattling off advice that too many will disagree with, but taking the longer view. The NHS deserves consideration of how to do the best for the health of the UK, in terms of technologies and service delivery. That is a big task. It will require time, resources, inspired leadership and the patient building up of a cadre of gifted experts working together across several disciplines.

December 2001

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