Antony Morgan

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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

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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.

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• 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.

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Programme guidance key stages

• Scoping
• Development
• Validation
• Publication
• Committees (PHIAC, Programme Development Groups)
• Stakeholders
• Timeframes

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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

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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

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Key questions

• What is effective?
• What is ineffective?
• What is harmful or dangerous?

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General socio-economic, cultural and
environmental conditions
Living working conditions
Work environment
Unemployment
Social and community networks
Water sanitation
Individual Lifestlye Factors
Age, sex hereditary factors
Education
Health care services
Agriculture and food Production
Housing
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Finding, collating and synthesising evidence

• Broad spectrum of possibilities.
• Quality of the research, not privileging types of
  or hierarchies of evidence

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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
• Intervention aims objectives, delivery mode,
  intervener
• Target group characteristics views
• Setting context
• Intensity/duration
• Cost
• Implementation feasibility

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Drafting recommendations

• Advisory committees draft the guidance
• This is prepared on the basis of the best
  available evidence

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Drafting the recommendations

• Recommendations
• strength and applicability of evidence
• cost effectiveness
• impact, including on inequalities in health
• risks, benefits
• implementability

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Generating and synthesising evidence - issues so
far.
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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.

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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.

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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

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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

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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

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How can the review process help

• Getting the questions right
• Achieving methodological diversity
• Maintaining the need for quality

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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

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Getting the questions right review stage

• Distinguishing between impact, process and
  experience
• Distinguishing between audience, high level
  policy makers or local providers of services.

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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 Whiteheads
  Evidence Jigsaw.
• Dealing with issues of transferability and
  plausibility of proposed actions
• Dealing with tacit knowledge of stakeholders
  professionals and the public

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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

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• How much should and can the review process help
  in addressing these issues?

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