By Amanda Hunter (Staff Writer)
In December 2014, I experienced my own geeky pre-Christmas anticipation as I eagerly awaited the publication of the new NICE guidance on antenatal and postnatal mental health [1]. For those of you who aren’t afflicted with my UK maternity care and clinical guidance obsession, the National Institute for Health and Care Excellence (NICE) publishes recommendations that influence UK healthcare practice and policy, amongst other things. These recommendations focus on the “best available evidence” for care (p.86) [2] - arguably an important component of good practice when providing care and recommendations to patients [3, 4].
On the publication date, I merrily downloaded the document but couldn’t help feeling disappointed as I noticed some of its limitations and discrepancies. I felt that some of my concerns might have been eased by additional commentary in sections where the guidance appeared to be inconsistent or incomplete.
In this post, I will consider how including concise comments in NICE guidance might aid practitioners by better contextualizing recommendations. I use the example of Section 1.8.2 of the NICE Antenatal and postnatal mental health guideline, which recommends:
For a woman with a history of severe depression who initially presents with mild depression in pregnancy or the postnatal period, consider a TCA, SSRI or (S)NRI. (p.34) [1]
The subsequent recommendation (1.8.3) suggests:
For a woman with moderate or severe depression in pregnancy or the postnatal period, consider the following options:
- a high-intensity psychological intervention (for example, CBT)
- a TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:
- she has expressed a preference for medication or
- she declines psychological interventions or
- her symptoms have not responded to psychological interventions
- a high-intensity psychological intervention in combination with medication if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and there is no response, or a limited response, to a high-intensity psychological intervention or medication alone. (pp.34-35) [1]
In this suggested intervention list for perinatal depression, women with mild depression and a history of severe depression are only to be offered a pharmacological treatment, based on the available evidence and recommendation alone. In contrast, women with moderate or severe depression should be offered information about the risks of medication and the option of psychological interventions. Significantly, there is no recommendation to support women with mild depression and a history of severe depression by offering information about medication risks or alternative options – even if this would be beneficial.
Rather than advocate that NICE include commentary about such discrepancies, one could argue that healthcare practitioners should have the clinical skills to interpret these recommendations and facilitate informed patient choice in clinical practice [3]. Indeed, some practitioners have the confidence and experience to use the guidelines as guidance rather than a set of rules (though, notably, it has been recommended that all departures from guidance recommendations should be documented and justified) [3,5]. For other healthcare staff, factors such as staffing issues, time constraints, lack of experience, lack of autonomy and fear may affect how they use and implement guidance in practice [3,6,7]. In some cases, these challenges may cause practitioners to follow NICE guidance as if they were a set of rules rather than recommendations [7]. The pressure to comply with NICE guidelines may also increase if the government were to enforce stricter adherence to these recommendations, as was suggested in Labour’s election campaign [8].
One might question why clinicians should be allowed to deviate from evidence-based recommendations. However, some practitioners and patient groups have raised concerns around implementing particular pieces of NICE guidance. Such criticisms have highlighted the lack of clarity, safety issues, insufficient available information, insufficient use of ‘experts’ in guidance development, overemphasis on cost-effectiveness and workload burdens linked with some guidance [8,9,10]. Some guidelines may also be limited by a paucity of evidence or resources. For example, limited resources meant that the recently updated NICE intrapartum [i.e. occurring during childbirth or during delivery] care guideline was incomplete and that some of its guidance is still outdated [11].
The provision of commentary in NICE guidance might dispel some of these concerns by highlighting the potential for flexibility in guidance adherence, particularly when evidence is conflicting or missing. Similarly, promoting awareness of potential gaps in recommendations and evidence might also stimulate additional research aimed at improving patient care and healthcare outcomes that are not identified in the guidance’s research recommendations.
Despite the potential benefits of increasing transparency around recommendations, justifiable concerns might be voiced regarding the introduction of biased commentary into NICE guidance. That said, we must also contemplate how judgements are made about what evidence is to be included or excluded in recommendations. Beliefs about what medical knowledge or evidence is deemed to be legitimate and valuable may be taken for granted, even when the outcomes linked to using certain medical interventions may not be the same in all instances [12]. These accepted beliefs would then also have the potential to affect and bias how NICE reviewers critique and evaluate research for inclusion.
NICE guidance has the potential to be a valuable clinical tool for healthcare professionals who are responsible for providing treatment and information to patients. However, it may be important for those care providers to understand the basic context of NICE’s recommendations when working in a busy clinical setting prevents them from reading the full guidance. Providing concise commentary alongside NICE recommendations may help healthcare workers to better interpret this advice in these contexts, which, in turn, ensures that patients receive the best available information and evidence to inform their choices about care and treatment. Commentary in NICE guidance might also support some practitioners to move away from strict adherence to these guidelines and better support the patients whose needs and wishes do not match recommendations.
Any views or opinions presented in this blog post are solely those of the author.
1. NICE. (2014). Antenatal and postnatal mental health: clinical management and service guidance. NICE Clinical Guidelines 192. National Institute for Health and Care Excellence. Available at guidance.nice.org.uk/cg192 (accessed 29 March 2015).
2. NICE. (2014). Developing NICE guidelines: the manual. National Institute for Health and Care Excellence. Available at http://www.nice.org.uk/article/pmg20 (accessed 29 March 2015).
3. Williams, V. (2014). Woman-led care. AIMS Journal 26(1): 5.
4. Nursing and Midwifery Council. (2015). The Code: Professional standards of practice and behaviour for nurses and midwives. London: Nursing and Midwifery Council. Available at http://www.nmc-uk.org/Documents/NMC-Publications/revised-new-NMC-Code.pdf (accessed 29 March 2015).
5. Wragge Lawrence Graham & Co LLP. (2014). When NICE guidance is more than just guidance - The duty on CCGs following R (Elizabeth Rose) v Thanet Clinical Commissioning Group. Wragge Lawrence Graham & Co LLP, Insights, 17 April. Available at http://www.wragge-law.com/insights/when-nice-guidance-is-more-than-just-guidance-the/ (accessed 29 March 2015).
6. Merrick, S. (2014). Lip service and red tape. AIMS Journal 26(1): 11-12.
7. Edwards, N. (2014). Midwife Julia Duthie’s case. AIMS Journal 26(2): 9-13.
8. Price, C. (2015). Labour to 'toughen rules' on following NICE guidelines as part of 'wide-ranging review'. Pulse, 27 February. Available at http://www.pulsetoday.co.uk/political/political-news/labour-to-toughen-rules-on-following-nice-guidelines-as-part-of-wide-ranging-review/20009297.article#.VRhAQLd0zIU (accessed 29 March 2015).
9. Stephenson, J. (2015). Some midwives 'confused' by new NICE guidelines on safe staffing levels. NursingTimes.net, 11 March. Available at http://www.nursingtimes.net/nursing-practice/specialisms/midwifery-and-neonatal-nursing-/some-midwives-confused-by-new-nice-guidelines-on-safe-staffing-levels/5083195.article (accessed 29 March 2015).
10. House of Commons Health Committee. (2008). National Institute for Health and Clinical Excellence: First Report of Session 2007–08. Volume 1. London: The Stationery Office Limited. Available at http://www.publications.parliament.uk/pa/cm200708/cmselect/cmhealth/27/27.pdf (accessed 29 March 2015).
11. The Royal College of Midwives. (2014). Comment on NICE guidance around birth. The Royal College of Midwives, News, 3 December. Available at https://www.rcm.org.uk/news-views-and-analysis/news/comment-on-nice-guidance-around-birth (accessed 29 March 2015).
12. Lock, M., Nguyen, V.-K. (2010). An Anthropology of Biomedicine. Chichester: Wiley-Blackwell.
[1] Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs) are medications used in treatment for depression.
[2] Cognitive behavioural therapy (CBT) is a type of talking therapy.