Implementation of NICE Recommendations

1.0April 2009 to October 2009

1.1 Response to NICE Recommendations

During the period, a total of 45NICE recommendations were received, these consisted of:

  • 8 Clinical Guidelines
  • 22 Interventional procedures
  • 15 Technology appraisals

Appendix 1 details the position at the end of October 2009:

  • 29 are not applicable to UHMBT
  • 1 has been audited and is shown to be compliant, a futureclinical audit is planned to confirm continuing compliance
  • 13 are believed to be compliant, clinical audit is planned (or being planned) to confirm compliance
  • 2 are believed to be compliant, have shared Trust/PCT implementation, and arrangements for clinical audit to confirm compliance are being agreed with the PCTs

1.2 NHS Litigation Authority

An NHSLA assessment at Level 2 for the General Standard took place during October 2009. Evidence was provided that demonstrated compliance with standard 5.8 (NICE Guidance) and standard 5.9 (National Service Frameworks, National Confidential Enquiries and other High Level Enquiries). Normally, passing these standards at Level 2 in an organisation with Level 2 status indicates automatic compliance with Standards for Better Health, criteria C3 and C5a.

1.3 Clinical Governance

Following an external review of Pharmacy Services, a recommendation was made to increase their involvement in the implementation of NICE recommendations. This has resulted in the imminent establishment of a Medicines Management Sub-Committee. The terms of reference have been drafted and are due to be presented to the next Clinical Quality and Safety Committee for approval. The terms of reference of all Sub-Committees have therefore been reviewed and responsibility for implementation of NICE recommendations will be split as follows:

  • Medicines Management Sub-Committee – responsible for all non-cancer drug recommendations
  • Cancer Quality Group – responsible for all cancer drug recommendations
  • Clinical Audit and Effectiveness Sub-Committee – responsible for all other recommendations

1.4 North Lancashire PCT

Meetings have recently taken place with staff from NHS North Lancashire NICE Impact Group and the North West NICE Implementation Consultant. A process for managing NICE implementation has been agreed and Trust Policies will be amended to reflect this (see Appendix 2).

2.0April 2008 to March 2009

The Care Quality Commission (CQC) undertook an in depth review of Standards for Better Health criteria C3 and C5a. Their conclusion was that sufficient evidence could not be provided to assure that the criteria had been met throughout the whole year.

The shortcomings have been addressed in an action plan (Appendix 2). The action plan also includes issues arising from sections 1.3 and 1.4 (above).

In the evidence presented to the CQC, the issues were:

  • There were a number of minor omissions in completing proforma
  • A number of clinical assessments were not documented sufficiently
  • Prior to the establishment of the current clinical governance framework in January 2009, the committee structures did not clearly demonstrate a process for NICE implementation. Although the CQC found that this was in place from January 2009.
  • There was no evidence of the Trust Board receiving adequate assurance for the criteria throughout the year.

Completion of the action plan (Appendix 2) will be monitored by the Medical Director and the Clinical Quality and Safety Committee.

3.0Recommendations

The Board is asked to note the contents of this paper and to approve the Action Plan (Appendix 2)

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