1 Introduction and background

1.1 About this guide

September 2015: The 'Into practice guide' has been updated to include more links to quality improvement resources and up-to-date measurement tools, including national outcomes frameworks. The guide also clarifies the status of NICE technology appraisals in health and local authority settings and provides advice on implementing the recommendations.

Aim of this guide

This guide provides practical advice on how to use National Institute for Health and Care Excellence (NICE) guidance and related quality standards to achieve high quality care. The guide includes helpful tips, links to resources developed by NICE and others, and examples of how people have used NICE guidance and related quality standards to improve the quality of health and social care.

As more local authorities and social care organisations start to use NICE guidance and related quality standards, we will gather more case studies and examples relevant to that sector, and update this guide to reflect and share their experiences.

Who this guide is for

This guide is for commissioners and providers of health and social care. It is aimed at anyone who has a responsibility for commissioning or delivering high quality care and health improvement based on the best available evidence. It is for people involved in commissioning, planning, delivering and scrutinising care services. It is also aimed at anyone who is leading on implementing a specific piece of guidance, or using a quality standard to improve quality across a team or service.

In health, these people may include:

  • NICE leads and clinical governance staff

  • board members and lead clinicians (for example, medical directors, clinical directors and directors of nursing)

  • clinicians who have a clinical governance responsibility as a major part of their role (for example, nominated directorate clinical governance leads)

  • clinical teams working together to ensure a piece of NICE guidance is implemented into everyday practice, or a quality standard is used to drive improvements in care

  • commissioners of NHS services, such as clinical commissioning groups (CCGs).

In public health and social care, these people may include:

  • public health staff involved in supporting evidence-based practice in local authorities and CCGs

  • social care commissioning staff

  • teams involved in the provision of social care

  • local authority health-improvement leads

  • heads of service and service managers

  • Health and wellbeing board and scrutiny committee members.

How to use this guide

This guide is made up of helpful tips, links to resources and examples of how other people have used NICE guidance and related quality standards to improve the quality of health and social care. It isn't intended to categorically state or place limitations on how NICE guidance and quality standards should be used and it may be that you already have effective systems within your organisation, which we would like to hear about.

The guide has been formatted so that you can access advice and resources on specific aspects of guideline implementation and quality improvement. Or you may consider using it as a way to benchmark the effectiveness of your local processes.

1.2 Models for change

The content of this guide is based on our work with NHS organisations and local authorities across the country, and the published literature.

There is no single model for effective implementation of NICE guidance; different organisations will implement NICE guidance in different ways. However, this guide is based on some common principles from the published literature about the factors that may help to foster an environment that is conducive to change (such as strong leadership and a focus on improving care) and help identify the barriers to changing established practice that may impede progress in all organisations, whatever the culture.

Every organisation or team will have its preferred approach or way of working to improve the services they offer, and our suggestions for implementing NICE guidance are designed to be flexible and fit into your local improvement model and structures. Some organisations may wish to follow our advice in its entirety, but others may wish to just adapt what we suggest or incorporate parts of it into local improvement models.

If you wish to explore some commonly used models of service improvement and the theoretical basis underpinning them, please refer to this C4EO resource.

1.3 About NICE

NICE provides national guidance and advice to improve health and social care. We provide independent, authoritative and evidence-based guidance to ensure safe, effective care that is good quality and value for money. We develop our guidance and other products by working with experts from the NHS, social care, local authorities and others in the public, private and voluntary sectors, including members of the public. NICE guidance is for the NHS, local authorities, social care providers, charities and anyone with a responsibility for commissioning or providing healthcare, public health or social care services.

NICE also produces quality standards, which are a concise set of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. The statements, along with the guidance on which they are based, should contribute to the improvements outlined in the outcomes frameworks published by the Department of Health: the NHS Outcomes Framework, the Adult Social Care Outcomes Framework and the Public Health Outcomes Framework. The statements are intended to be used with frameworks and regulations already in place to provide practical support to drive up the quality of care.

Our guidance and standards are produced openly and transparently – see further see information about how we produce guidance and develop quality standards.

NICE also provides NICE Evidence Services, an online portal that gives access to high-quality evidence and examples of best practice for health and social care. The service helps people from the NHS, public health and social care sectors to make better decisions about services they commission and provide.

1.4 Benefits of implementing NICE guidance

Putting NICE guidance into practice and using NICE quality standards to improve quality benefits everyone – people who use health and social care services and their carers, the public, NHS organisations, local authorities, health professionals, public health and social care professionals, and policy makers.

Health and social care organisations can use NICE guidance and related quality standards to help them meet their legal requirements. In the NHS the guidance and standards can help organisations meet the requirements set out in the NHS Constitution and the Health and Social Care Act 2012 (section 8). NICE has prepared a statement defining what needs to be in place for services to be compliant with the recommendations made in NICE technology appraisal guidance.

Sharing information about how services compare with NICE's recommendations demonstrates a culture of candour. Using NICE guidance and related quality standards can also help NHS and local authorities to meet regulatory requirements from organisations such as the Care Quality Commission. In local authorities, NICE guidance and quality standards will complement and reinforce Department for Education National Minimum Standards and Ofsted requirements. They can also help organisations respond to council scrutiny as well as inform the work of scrutiny committees. Further information about how NICE guidance and quality standards fit into the existing regulatory framework in social care can be found on the NICE website.

Using NICE guidance may help cut costs, while at the same time maintaining and improving services. Commissioners may also use NICE quality standards to ensure that they are commissioning high-quality care or services locally through the contracting process, as well as to improve the performance of providers.

In an increasingly diversified and competitive environment, health and social care providers need to be able to quickly and easily demonstrate how their organisation is performing and their focus on increasing quality. They also need to be open and transparent with commissioners and service users about how safe and clinically and cost effective their services are. One way of doing this is to use relevant NICE guidance and quality standards to show where high-quality care is being provided and highlight areas for improvement.

People working with local communities have a crucial role in tackling health inequalities and promoting people's health and wellbeing. NICE guidance and related quality standards provide evidence-based advice and information to feed into local planning cycles and take forward priorities identified in joint health and wellbeing strategies. NICE's local government briefings make it easier to find out which public health actions are most effective and provide the best value for money. A range of resources for local government is available.

Registered residential or home care providers can use NICE quality standards for care homes alongside other recognised quality benchmarks to contribute to their provider quality profile. This briefing provides more information about what local authorities and partner organisations can achieve by helping to improve the health and wellbeing of older people in care homes.

Health and social care professionals want to deliver the best possible care they can. Continuing professional development is an important part of professional life, and many staff are subject to registration or revalidation. For example, the Good Medical Practice Framework for appraisal and revalidation suggests that doctors take part in systematic quality improvement activities. Implementing NICE guidance and using related quality standards can reassure all health and social care staff about the quality of their own practice, as well as that of the services they offer.

Having a robust structure for implementing NICE guidance and using quality standards will also help with putting into practice evidence-based guidance from other sources, and developing a culture of continuous quality improvement.

1.5 What your organisation needs to have in place

High-level support and clear leadership

Top-level commitment to evidence-based practice and continuous quality improvement is essential to implementing NICE guidance and using NICE quality standards.

Ultimate responsibility for leading a culture of evidence-based practice rests with the chief executive, but this is often delegated to others, such as board members (for example, medical directors or chief nurses, directors of public health, elected member committees or senior officers in local authorities).

Directors and senior stakeholders should receive regular internal reports on the local use of NICE and other evidence-based guidance, including audit reports, highlighting areas where the organisation does not provide its services in line with evidence-based recommendations or there are weaknesses identified in service provision. They should consider whether this identifies any risks for service users, and these should be recorded if significant. Reports outlining the extent to which services are currently in line with relevant quality standards can be used to identify priorities for quality improvement.

Tips and resources

Evidence shows that in health successful implementation plans have:

  • a person on the board, such as a medical director or chief nurse, who drives the implementation agenda forward, and

  • a clear implementation policy approved at the highest level.

In local authorities, people who could play a key role in using NICE guidance include:

  • executive leaders, including directors of adult and children's services and directors of public health

  • political leaders, including chairs of overview and scrutiny committees and elected council members leading on children's services and adult social care.

A nominated lead for the organisation

Identifying a person to coordinate local activities around NICE guidance and related quality standards as they are published is vital for effective implementation. The most practical way of achieving this is to incorporate these responsibilities into those of an existing post (for example, in health, a clinical-effectiveness coordinator, clinical governance manager, chief pharmacist or head of prescribing and pharmacy). In a local authority, a public health lead, policy manager, senior knowledge officer or local strategic partnership manager responsible for quality assurance could take responsibility for coordinating the use of NICE guidance and related quality standards.

The responsibilities of this person could include:

  • monitoring guidance and quality standards as they are published and ensuring they are assessed for relevance to the organisation's services

  • coordinating an organisational response to NICE consultations

  • disseminating guidance and related quality standards to key people and identifying nominated leads to implement the guidance or coordinate quality improvement activities

  • horizon scanning and guiding forward planning, including preparing briefings on the potential impact (such as financial) of implementing the guidance

  • ensuring an effective documented process for monitoring and providing feedback is in place and adhered to

  • producing regular senior-level reports

  • ensuring significant deviations from NICE recommendations are recorded in the organisation's risk register

  • arranging educational events.

Key attributes that a nominated lead will need to have (and which may be included in a job description) are:

  • a thorough knowledge of relevant policy drivers

  • a thorough knowledge of service delivery in the organisation

  • ability to analyse, challenge and improve current practices

  • a record of achievement in managing projects and change

  • strong interpersonal and leadership skills

  • credibility.

Tips and resources

See a shared learning example of a NICE lead driving education and development around NICE guidance: how to make NICE and information literacy part of your clinical practice.

A multidisciplinary forum

Strategic decisions on the use of NICE guidance and related quality standards should be made in a multidisciplinary forum. To be most effective, this forum should be a decision-making body that reports to the highest-level group in the organisation. It could be an existing forum (or team) that already serves other functions in the organisation. The group should be chaired by a senior person in the organisation who has strong leadership skills and credibility and can act as a champion for implementing NICE guidance and using related quality standards.

The forum should:

  • ensure that effective forward planning and engagement occurs

  • assess the relevance of NICE guidance and related quality standards for the organisation as they are published

  • ensure guidance and related quality standards are disseminated to the appropriate people

  • identify named leads for each piece of guidance and related quality standard

  • ensure that the organisation knows its current position regarding all relevant guidance and related quality standards

  • record any deviation from NICE guidance recommendations, and ensure that strategies for achieving it in the future are agreed if appropriate

  • identify areas for quality improvement and incorporate them into future quality improvement programmes and strategies

  • ensure delivery against local action plans

  • review local audit action plans and results as necessary

  • check that appropriate financial arrangements are in place.

It is important to consider ways of coordinating work across organisations, especially where guidance and related quality standards cross the primary and secondary care interface, or apply across health and social care. Collaboration reduces duplication of effort and ensures a coordinated, standardised response to each piece of guidance across health and social care services locally. This will help to ensure integrated care.

Tips and resources

The multidisciplinary forum should have decision-making powers and report to the chief executive or senior managers of the organisation. Examples of groups that can take a lead on NICE guidance include governance committees, quality committees and, in local authorities, a subgroup of the Health and Wellbeing Board. The group can also include people from other organisations in your local area if appropriate.

In smaller provider organisations where only 1 or 2 pieces of guidance and related quality standards are relevant, decisions could be made during senior management team meetings.

It may be helpful for the group to receive presentations from named leads for a specific piece of guidance on their progress against action plans.

See shared learning examples of:

A local policy

Organisations should have a clear policy for implementing NICE guidance and using related NICE quality standards, which is endorsed at the highest level of the organisation.

1.6 What your organisation needs to do

Raise local awareness

Raise local awareness of NICE guidance and related quality standards that are in development or newly published.

Encourage signing up to NICE news to receive the monthly bulletin, showing guidance and related quality standards that NICE has published each month. You can disseminate the newsletter or develop your own.

For those working in primary care, sign up to receive the Update for primary care newsletter tailored for general practice.

Refer people to the relevant NICE Pathways, our simple-to-use interactive tools that bring together all NICE products on a topic.

To look ahead and see what guidance and quality standards are due to be published in the near future you can use the forward planner, which has a list of all current guidance and quality standards as well as those in development.

Tips and resources

See shared learning examples of:

Plan ahead – NICE guidance and quality standards in development

Take part in developing NICE guidance and related quality standards

People in your organisation can help to shape the recommendations that NICE makes in several ways:

Find out more about stakeholder registration and other ways to get involved, including joining a NICE committee or working group.

Tips and resources

Read about a lay member's experience of being part of a NICE guideline development group.

Consider the financial and service planning impact

The financial implications of implementing NICE guidance need to be an integral part of an organisation's financial and business plans. Once you have seen the draft guidance, you could consider starting some preparatory work, looking at local services and processes. This can be particularly helpful in supporting the timely implementation of NICE technology appraisal guidance.

The estimates of costs for implementing NICE guidance outlined on our forward planner should be included in the financial plans of NHS organisations. If the activity is within tariff, then the tariff will normally include the costs of implementing NICE guidance and commissioners will expect providers to deliver accordingly without additional funding. For activity that is outside the tariff, organisations should specify the process for negotiating funding between commissioners and providers.

When reviewing the costs and potential savings of implementing NICE guidance, you could check the 'Do not do' recommendations in the savings and productivity collection. This has recommendations from NICE guidance about practices that should be stopped completely or should not be used routinely. This information could be used locally to review practice, or as standards for audit.

You could also search the savings and productivity collection for examples of how other health and social care staff are improving quality and saving money. The collection includes a tool that allows potential savings to be calculated for your organisation.

In a local authority, any bids for resources or resource re-alignment should be expressed in light of the organisation's statutory duty to promote people's wellbeing and its need to comply with legislation and statutory guidance, and the resulting benefits for local people and the economy. When a local authority is a relevant health body, the local authority must make funding available to allow it to meet the statutory requirement to fund NICE technology appraisal guidance (section 8c of The National Institute for Health and Care Excellence (Constitution and Functions) and the Health and Social Care Information Centre (Functions) Regulations 2013).

As commissioners, local authorities have a responsibility both to secure specific services when required and, increasingly, to shape the wider market for the benefit of everyone who uses services, including self-funders. Ensuring that the available services are 'good enough' or better is an essential element of market-shaping. By identifying evidence-based good practice and aspirational improvements in service, NICE guidance and related quality standards provide ready-made and externally verified standards for commissioners to use. Even when local authorities are not directly responsible for the purchasing of services, their market-shaping role allows them to engage with all local providers and to promote the quality agenda.

NICE public health guidance and local government briefings demonstrate the cost effectiveness of preventing ill health and provide support to the local government sector to make the best use of limited resources. The return on investment tools have been designed to support investment decisions by commissioners and policy makers in local authorities and the NHS.

See further information about all of NICE's cost saving resources.

Tips and resources

The costs of implementing forthcoming NICE guidance should be raised with the finance department, and during discussions with local commissioners. You can get an indication of what is needed from the forward planner or the draft guidance.

Ensure there are good links between NICE implementation leads, service planning leads and finance departments.

See a shared learning example of financial planning and cost saving (home haemodialysis).

Assess the relevance of published NICE guidance and quality standards

When NICE guidance or quality standards are published, discuss their relevance at your organisation's multidisciplinary forum. Record any actions, including whether there are likely to be any deviations from the published guidance in the way the organisation implements it.

You may want to check the guidance against the clinical procedures register in an NHS trust, or with any local committees. You may also want to consider whether or not it will have an impact on other organisations you work with.

You should record the relevance on a local database or register.

Tips and resources

The NHS report on innovation, health and wealth suggests introducing a systematic approach to ensure rapid and consistent implementation of NICE guidance throughout the NHS, to reduce variation and ensure access to clinically and cost-effective technologies and medicines. The report suggests that local processes should not seek to duplicate NICE assessments or challenge an appraisal recommendation. All NICE technology appraisal recommendations should be automatically incorporated into local formularies. NICE has prepared a statement defining what needs to be in place for services to be compliant with the recommendations made in NICE technology appraisals.

NICE has produced guidance on developing and updating local formularies, describing the systems and processes needed to ensure NHS organisations develop and update local formularies in accordance with statutory requirements.

See further information on when and where to apply NICE guidance.

If guidance or quality standard is not relevant, agree and record a decision

If the high-level group decides that the NICE guidance or quality standard is not applicable to the services provided or commissioned, record the decision in formal minutes and on a local database or register.

It is good practice to review this decision if services change or your organisation takes on new services.

Identify a named lead for relevant guidance and quality standards

Identify a senior lead for each piece of NICE guidance or quality standard, who can make people aware of its content and lead change if needed. The lead is likely to be a prominent figure who will champion the guidance and inspire others. To ensure everyone knows about relevant NICE guidance and related quality standards, you could:

  • use your intranet and other internal communication mechanisms

  • include information about guidance and quality standards in induction training for all staff

  • liaise with your education and training lead to make use of educational forums

  • link with existing networks across a region; this might include strategic clinical networks, drug and therapeutic committees, local strategic partnerships, and public health networks

  • develop local newsletters, or use NICE newsletters, leaflets, prescribing updates or information packs for different audiences.

NICE produces and links to a range of learning resources and interactive educational tools that are intended to assess and improve users' knowledge of specific pieces of NICE guidance. NICE has also commissioned and worked in partnership with others to produce online educational tools. These can be used as part of a local drive to help support the implementation of a specific piece of guidance, or they can be used more broadly as part of an organisational approach to learning and continuing professional development.

All NICE implementation support tools can be found in into practice.

Tips and resources

It is easier to implement a specific piece of NICE guidance or use a quality standard to drive improvement if everyone in the organisation understands the benefits of evidence-based practice, the broad aims of NICE and how they can play a part. Consider a NICE presentation as part of your other work to promote evidence-based practice, introducing people to what NICE could mean for them.

See shared learning examples of:

To support local authorities in using some specific pieces of NICE guidance, NICE has produced tools for local government and social care.

To help residential care home providers, NICE has produced implementation tools and resources; for example, a care plan template for delirium and an e-learning resource for a nutritional screening tool. The local government briefing on care homes summarises NICE's key recommendations for local authorities and partner organisations on the health and care of older people in care homes. It also highlights relevant quality standards.

NICE Evidence Search is a web-based portal that gives access to high-quality authoritative evidence and good practice. This can help people from across the NHS, public health and social care sectors to make better, evidence-based decisions.