Balancing National Guidance with Local Priorities

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Balancing National Guidance with Local Priorities

• Professor Peter Littlejohns
• Clinical and Public Health Director

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Presentation

• General context
• Benefits and limitations of national guidance
• Challenges and solutions

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Making health policy is challenging ..
Clinical capacity and ambition
Health system objectives and resources
Users expectations
Health Policy
Growth in health technology
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Role of NICE

• Identifies good practice using the best
• available evidence
• Helps resolve uncertainty for
• the public, patients and
• professionals
• Helps reduce variation in the availability
• and quality of practice and care
• Guidance not a reimbursement decision
• Since April 2005 has a public health remit

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Putting the N in NHS

• People who use the NHS have a reasonable
  expectation of consistent access and quality
• Currently no democratic mandate for determining
  local policy accountability to the people is
  still through Parliament
• NSFs, NICE guidance and national standards
  together create a framework which both focuses
  investment and helps raise standards

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So, some important questions ..

• How explicit should the NHS be about what it
  provides (and how quickly) and what it
  doesnt?
• What should be covered by national policy and
  what should be left to local discretion?
• How should the decision be made?
• Should national policy (and priorities) have the
  first claim on available resources?
• Who should have a say in determining local
  priorities?

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National guidance benefits and limitations

• Consistent approach to best practice
• Broad professional support
• Credible engagement with patient and public
  organisations
• Robust guidance through well-researched process
  and methods
• Resources to do the job properly

• Limitations on local professional ownership
• Implementation success dependent partly on local
  agenda
• Drives resource consumption without local budget
  accountability
• Development timelines may delay local service
  development

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NICE undertook 2 studies on National versus local
Prioritisation

• A questionnaire was sent to all DPHs in England
  asking about the influence of NICE on local
  prioritisation in 2000. (Views of Directors of
  Public Health about NICE Appraisal Guidance
  results of a postal survey. Davies E, Littlejohns
  P. Journal of Public Health Medicine
  200224319-325)
• A questionnaire was sent to all DsPH of PCTs in
  England in the spring of 2003. The questionnaire
  asked about local priority setting the
  development of the Local Delivery Plan (LDP)
  influences on national priority setting
  influences on local priority setting
  displacement of local priorities by national work
  programmes and details of any foregone
  priorities ( formed NICE submission to the
  Wanless 11 report and MFPHM submission)

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Priority setting in PCTs and formulation of the
Local Delivery Plan (LDP)
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Methods used to identify local priorities in PCTs
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The relative influence on local priority setting
of the different national work programmes
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Challenges and solutions

• Getting local support for national guidance
• Balancing funding for local initiatives and
  implementing national guidance
• Under-developed methods and process at local
  level
• Sharing expertise to ensure good quality local
  and national guidance

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Solutions (1)

• Shared ownership of the national agenda
• National guidance should deal with generally
  shared and agreed - priorities (major causes of
  morbidity and preventable mortality investment
  and disinvestment decions)
• Some local discretion on the sequencing of
  national guidance in relation to local priorities

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Solutions (2)

• Both local and national guidance/initiatives
  should have full resource impact assessment
• A degree of funding protection for local
  initiatives
• Possibly a national resource (?at NICE) to
  support evaluation of local priorities