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Evidence Based Guidance for Public
Health and the role of NICE Purpose, Process and Issues
Antony Morgan
Associate Director
Centre for Public Health Excellence
What is NICE?
The National Institute for Health
and Clinical Excellence (NICE) is
the independent organisation
responsible for providing national
guidance on the promotion of good
health and the prevention and
treatment of ill health.
• Public health – guidance on the promotion of
good health and the prevention of ill health –
for those working in the NHS, local authorities
and the wider public and voluntary sector.
• Health technologies – guidance on the use
of new and existing medicines, treatments
and procedures within the NHS.
• Clinical practice – guidance on the
appropriate treatment and care of people with
specific diseases and conditions within the
NHS.
Programme guidance: key stages
•
•
•
•
Scoping
Development
Validation
Publication
• Committees (PHIAC, Programme
Development Groups)
• Stakeholders
• Timeframes
Scopes aim to specify
• The intervention
• The outcome the assumed mechanism/mediator/link between
intervention and outcome
• The research questions
• Approach to dealing with equity
• Current policy and practice context
• Conceptual model of how it works
Development: reviewing the
evidence
• Extensive use of reviews and primary
research
– Rapid reviews
– assess quality and strength of evidence
– assess applicability
• Economic appraisal
– economic evaluations and modelling
Key questions
• What is effective?
• What is ineffective?
• What is harmful or dangerous?
Work
environment
Water &
sanitation
Education
Health
care
Agriculture
and food
Production
Age, sex &
hereditary
factors
services
Housing
Finding, collating and synthesising
evidence
• Broad spectrum of possibilities.
• Quality of the research, not privileging types of or
hierarchies of evidence
Areas of enquiry:
Our reviews aim to address the following areas – looking
explicitly at evidence on variation and inequalities - in
answering questions about effect and effectiveness:
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•
•
•
•
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Intervention: aims & objectives, delivery mode, intervener
Target group characteristics & views
Setting & context
Intensity/duration
Cost
Implementation & feasibility
Drafting recommendations
• Advisory committees draft the
guidance
This is prepared on the basis of the
best available evidence
Drafting the recommendations
• Recommendations
–
–
–
–
–
strength and applicability of evidence
cost effectiveness
impact, including on inequalities in health
risks, benefits
implementability
Generating and synthesising evidence
- issues so far……….
Searching for evidence
• The need for comprehensive assessment for available evidence
versus ‘forensic searching’ for most appropriate evidence.
• Lack of emphasis on ‘how things work’.
• Lack of match between our research questions and strategies
for finding most appropriate studies.
On inequalities - a limited evidence base
• Evidence about what works to reduce inequalities
very limited
• About 0.4% of published scientific papers discuss
interventions which might reduce inequalities
• About the same percentage of funded research
concerned with interventions
• Rich in description, weak on solution.
And why?
• Gaps in the initial formulation of primary research
studies.
• Gap between evidence and practice
• Failure to distinguish between determinants of health
and determinants of inequalities in health
The classification system
• The conceptual and operational apparatus for capturing different
dimensions of inequalities is underdeveloped.
• The precise nature of the causal pathways and the different
dimensions of inequality is under-investigated
• The health interaction between different aspects of inequalities
not highly developed.
• The ways in which interventions work in different segments of
the population not well understood
We need to move towards better conceptual
frameworks for ….
• Helping to identify the causal models which operate
from the social to the biological
• Need to distinguish proximal, intermediate and distal
causes
• Need to establish necessary and sufficient conditions
• Need to establish biological and social plausibility
How can the review process help
• Getting the questions right
• Achieving methodological diversity
• Maintaining the need for quality
Getting the questions right – understanding the
problem – primary research
•
Placing questions in policy context - distinction
between health disadvantages, health gaps and
health gradients
•
Make explicit models used to explain inequities in
health and help us to understand the mechanisms by
which health inequities are generated.
•
Make better use of life course approach for
understanding relationship between different
interventions
Getting the questions right – review
stage
• Distinguishing between impact, process and experience
• Distinguishing between audience, high level policy makers or
local providers of services.
Achieving methodological diversity
• Internal to systematic review process
– Starting further down the chain - more focus on the how things
work rather than what works?
– Synthesising qualitative and quantitative
– Synthesising impact, process and experience
• External to systematic review process
– Different forms of knowledge – Whitehead’s ‘Evidence Jigsaw’.
– Dealing with issues of transferability and plausibility of proposed
actions
– Dealing with tacit knowledge of stakeholders – professionals and
the public
Maintaining the need for quality assessment
• Transparency, systematicity, relevance
• New tools for assessing strength of evidence
Also:
• Importance of the outcomes – burden of ill health
• Equity versus health impact
• Risks of not taking action
How much should and can the
review process help in
addressing these issues?
www.nice.org.uk