Evidence-based guidelines contributing toward health system’s priorities

A well-functioning health system functions in harmony with trained and motivated health workers, a reliable supply of technologies and medicines, a well-maintained infrastructure, strong financing and planning, and evidence-based policies. Evidence-based guidelines in this regard can contribute and provide support to reduce health inequalities and address health systems priorities. This article is based on one of the sessions by The National Institute for Health and Care Excellence UK in the conference proceeding of the 2nd annual conference of Indian Health Outcomes, Public Health, and Economics Research Center and highlights the importance of evidence-based guidelines and updating recommendations as soon as a new body of evidence becomes available.

According to the World Health Organization, the health system comprises all organizations, institutions, resources, and people whose primary purpose is to improve health.^[1] Evidence-based policies are one of the fundamental elements of a well-functioning health system.^[2] Moreover, medical science is evolving, and a dynamic field that calls for rational and evidence-based decision-making to ensure the best quality of care is provided to patients. Thus, making guidelines an essential component of clinical practice.^[3]

The National Institute for Health and Care Excellence (NICE) produces clinical recommendations for the treatment of patients with specific health conditions. NICE is an executive non-departmental public body sponsored by the Department of Health and Social Care, UK and^[4] provides guidance and advice to improve health and social care by:

1. Producing evidence-based guidance and advice for health, public health, and social care practitioners

2. Developing quality standards and performance metrics for those providing and commissioning health, social care, and public health services

3. Providing a range of information services for commissioners, practitioners and managers across health and social care.^[4]

NICE has come a long way since 1999; noting the global changes in the health systems and pressure, evolving technologies, and growth in innovation, NICE is using data to form guidance, track and update the guidelines, and ensure that these guidelines are understood as easily by patients as by clinicians. Considering health system challenges, after stakeholder consultations in April 2021, NICE launched its 5-year strategy, which maps the long-term trends and challenges in healthcare. Key elements that emerged from this consultation were:

1. Topic selected have to be aligned with the system’s needs

2. Content of the guideline needs to be more up to date

3. information needs to be more accessible to frontline workers

4. Targeted work towards reducing health inequalities.

To cater to these, NICE is transforming three critical elements of their operation [Figure 1], that is, (A) actively drawing cutting-edge improvements in care, (B) translating these improvements to practical and useable advice, and (C) being active in the health system by adopting the best possible care. To achieve these, NICE is improving the usefulness and usability of guidelines by developing digital living guidelines; making it more straightforward for our recommendations to be shared and embedded in external clinical decision support tools that clinicians are using; and making these recommendations accessible for health-care professionals, so it results in better care for patients.

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Figure 1:

Transforming three key areas of operation. (Taken from nice International and IHOPE conference proceeding held on September 28, 2022). IHOPE: Indian Health Outcomes, Public Health, and Economics Research Center.

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In the process of developing guidelines, if the surveillance team of NICE determines that new evidence may impact the present recommendation in the guideline, the decision regarding updating that particular guideline is taken. This development process of updating the individual recommendations as soon as a new body of evidence becomes available is called a “living guideline.”^[5] As was also seen in the COVID-19 pandemic, as soon as new evidence was available, guidelines were updated for health workers to provide the best quality care to the patients. This process of updating guidelines results in improved quality and safety. Along with this, NICE updated its content strategy by designing structured website content for improved usability, extensive user testing to understand what is needed in content structure and delivery, and finally, using content management tools to implement and test content.

Four strategic aims for the implementation of these guidelines are:

1. Embedding implementation upstream: This ensures that implementation activities are delivered across the full cycle of guidance development and supports the digital living guideline model.

2. Strengthening external collaboration: Helps maximize opportunities for implementation by aligning with partner’s regulation, monitoring, and improvement frameworks.

3. Developing implementation campaigns for system priorities: Ensures that implementation activities are of value and reflect the priorities and needs of the system. For instance, delivering campaigns on system priority areas, including health inequalities, supporting integrated care systems or helping post covid system recovery. In this context, NICE is reviewing the value of implementation products currently produced and delivered for guidance.

4. Increasing the use of data for uptake and impact: Understanding the use of data for uptake and impact informs the development and implementation of the guidance, allowing to delivery of an approach that measures the impact of the digital living guideline, that is, how clinicians are using these; working with system partners and then deciding which target area to focus next.

For instance, in one of the latest guidelines on depression, NICE not only supported the role of clinicians but also emphasized the role of the patient’s choice. The guideline was produced with the help of clinicians, practitioners, and people with lived experience of depression. This is the first of the guidelines by NICE that provides the choice of treatment options, allowing patients to have evidenced based guidelines and tools to have a rightful conversation with clinicians to pick the one that’s suitable for them.

Another example of alignment with health system priorities is reducing health inequalities is NICE work on tackling health inequalities. NICE has a comprehensive library of guidance aligned to health inequalities frameworks and has published extensively on approaches to reduce health inequalities through community engagement and shared decision-making. So, this year, NICE is helping with a national approach (led by NHS England and NHS improvement) to reduce health inequalities as per the 5-year strategy of NICE. To do this, NICE has mapped all the areas that will help in reducing health inequalities and contribute to the implementation tools to reflect best practices in reducing health inequalities.

The guideline production method is a rigorous and robust process, and it is important that the recommendations are very latest and reflect the best clinical evidence. However, clinicians have shared with NICE during consultations that, at times, NICE can be slow and unresponsive when faced with new evidence and to deal with this new approach of digital living guidelines has been adopted by NICE. This approach aims to address these concerns and ensures alignment with the system’s needs. By getting the right information, to the right people, at the right time, living guidelines will support clinicians and patients to make a shared decision about care based on the most recent up-to-date evidence. However, NICE cannot be at the forefront of guidelines development without international collaboration, and to contribute to the global health community, NICE supports other countries to help improve their nation’s health and well-being. Collaboration with the Indian Health Outcomes, Public Health, and Economics Research Center (IHOPE) is one such project in which IHOPE is developing guidelines on ophthalmological conditions, and NICE is supporting it by sharing their learnings and experiences.