NICER Guidance: fostering an organisational culture of evidence-based decision making

Our aim was to foster an organisational culture of evidence-based decision making throughout the Public Health Suffolk Directorate and wider County Council through the routine use of NICE Guidelines (NGs), Quality Standards (QSs) and Technology Appraisals (TAs) Our objectives were to ensure that the concept and practice of evidence-based decision making was widely understood and adopted in our commissioning and de-commissioning decisions, project start-up business cases and individual funding request evaluations. To facilitate this, we needed to design and embed a systematic process for the routine review of NICE publications within the Directorate. Specific objectives could be summarised as:

-Securing senior buy-in for the concept and the establishment of a multispecialty project team (called the NICER Guidance Group) to look at the issue in detail and pioneer the work.
-Design, document and embed a systematic process for the identification, analysis and implementation of newly released NGs, QSs and TAs.
-Identify key roles and responsibilities to facilitate and champion the newly designed processes in practice.
-Ensure relevant NGs & QSs are routinely used by commissioners and contracting colleagues to inform service specification and quality monitoring of commissioned PH services.

The context surrounding this project was the re-organisation of the NHS and transition of public health responsibilities from PCTs to local authorities in April 2013. This re-organisations led to the deconstruction of established processes for reviewing NICE publications that had been established within Suffolk PCT. Moreover, in the Suffolk context, it also led to some local authority staff and teams being absorbed into the newly created Public Health Directorate within the County Council. It was within the context of a newly established Public Health Directorate with many new staff that the need for establishing evidence-informed decision making in our practice and culture was identified. The benefits of this were ensuring commissioning, de-commissioning and pathway re-design decisions were grounded in the latest evidence and NICE recommendations, in- turn ensuring maximum health gain from every pound of public money spent on our services and interventions. Furthermore, practicing in an evidence-based way is a core public health value. At an individual level, embedding the review of NICE guidance in the Directorate has encouraged the use of evidence provided by NICE into the consciousness of all staff within the Directorate, not just the NICER team.

As NICE begin to offer more publications relevant to social care, additional benefits identified are to share our learning and established system with social care directorates and colleagues within the County Council.

Our first (and perhaps most important step) was to secure senior buy-in and support from members of the Directorate Senior Management Team (SMT). This was achieved through the presentation of a business case at SMT (see attached documentation) which was sponsored by one of the senior Public Health Consultants within the Directorate. This gave us the necessary mandate for establishing a project team to analyse how best to approach the issue and pioneer the work. Importantly, it also secured the buy-in of Assistant Directorates to give their teams and staff permission to participate in the work. One of the biggest problems encountered related to individuals' capacity to undertake the additional work created by the new process and the priority given to it. Initially, several commissioning managers cited their lack of time and capacity as a reason not to engage in the process. This was overcome by the Director of Public Health Suffolk and the SMT gently reinforcing the importance of the work with their staff and encouraging individuals in their teams to give themselves permission to prioritise the work and participate in the process. Simple management tools and techniques, such as mapping the process on paper and surrounding each step with clear quality standards, such as timescales and accountable champions has really helped to get the process implemented in practice. Furthermore, developing simple pro-forma to help carry out a baseline assessment of current service delivery against the recommendations was another useful tool that assists commissioners and makes the processes that little bit easier for them. Several adjustments of the process map and pro-forma were required as we tested and then modified the process following feedback of those involved.

As agreed with the Public Health Suffolk SMT, six month and one year progress reports were produced and fedback to SMT for their review and comment. As part of the one year progress report, the group undertook a staff survey to see how the introduction of the NICER Group and new business process was working for staff. The survey was circulated to 15 public health project and commissioning managers involved in the process and asked six simple questions:
1. What has worked well about the current process and approach?
2. What has worked less well about the current process and approach?
3. How could the current process and approach be improved?
4. Has the process helped you keep up-to-date with the latest NICE Public Health Guidance, Quality Standards and Local Government Briefings?
5. Has the process helped you to identify any gaps or areas of non-compliance in commissioning or service delivery in your area of expertise?
6. Is there anything else about the NICER work that you'd like to add?
We received responses from 10 managers, giving a (66%) response rate. A flavour of the feedback we received from commissioning managers included: "It makes you think about your individual programme - sometimes in areas you may not have considered or given much thought. I have felt fully supported from XXXX in terms of guidance around what to do etc". and "Rather than NICE Guidance being added to the reading pile, it makes you review what & how is happening in Suffolk & identify areas for improvement". When asked what has worked less well, a flavour of the comments received included: "It is difficult to review the services I commission against guidance that has a broad remit e.g. domestic abuse or behaviour change" and... "A more condensed format. A certain timeframe in which NICER guidance is disseminated to the team - perhaps every three months so we are all aware when it's coming, allowing us to set aside specific time to complete". In response to this feedback and in an attempt to mitigate the issues highlighted, we now push out a forward agenda of all NICE publications being released in the forthcoming quarter. This then allows commissioners to build in time to their agendas for the review of NGs relevant to their service area. When a NG is released that cuts across several service areas, we have found that bringing together a mini task group to formulate a coordinated response is a more efficient approach.

Secure senior buy-in and support from the outset is a must. Without this mandate, encouraging busy people to engage with the process will bedevil implementation and progress. Further to this, having a senior operational leader (in our case in the form of a Public Health Consultant) to help manage the change process and champion the work was also important to projects' aims and objectives. Try to define a project team that covers the work area/domains you're seeking to work with and influence change within. These people are essential to pioneering the work, championing the change, and realising the benefits of the new process. Make it systematic. Document your process for reviewing and analysing NICE publications by using a process map or pathway. Surround each step in the process with clear quality standards i.e. expected time-frames and accountable champions. This is a key document when communicating what you're trying to achieve to stakeholders within your directorate or teams. Test and modify. It's important to Listen to staff feedback and adjust your process and paperwork accordingly. Keeping documentation live, simple, concise and easy for commissioners to complete has worked well for us.