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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 May 19; 334(7602): 1054–1055.
PMCID: PMC1871750

Commentary: NICE—setting clinical standards

Gillian Leng, implementation director, Michael Rawlins, chairman, and Mercia Page, director, centre for clinical practice

The clinical guidelines programme of the National Institute for Health and Clinical Excellence (NICE) is arguably the largest in the world and is unique in considering both cost effectiveness as well as clinical effectiveness. This article by Hill and Treasure is the first in a series to be published in the BMJ: each article will give a short account of key features of newly published NICE guidelines. The articles will particularly focus on areas where changes in current practice are recommended.

NICE guidelines are produced by an independent guideline development group. Its members include relevant clinicians, experts in areas such as systematic reviews and health economics, as well as at least two patients or carers. The development process is based on an internationally agreed methodology (box),1 2 and NICE has now published almost 50 clinical guidelines. In a recent survey, NICE's guideline on schizophrenia achieved a higher total score (and by a wide margin) on all internationally agreed elements of guideline development1 than any of the 26 other international guidelines on the same topic.3

There is no point, though, in developing clinical guidelines if they have no significant impact on patient care. Passive dissemination has only a limited effect, and barriers to implementation exist at several levels.4 Difficulties include a perceived lack of resources, clinicians' concerns about the undermining of their autonomy, ingrained practices, and general disagreement with the content.

NICE's implementation support programme aims to erode these concerns in three broad ways. Firstly, it provides practical help for organisations and individuals to overcome some of the initial barriers. These include templates to facilitate calculation of the likely costs and savings of putting a guideline into practice, interactive guides for commissioners based on guideline recommendations, a database of examples of effective implementation, as well as a small team of consultants to provide hands-on advice and support (

Secondly, the programme seeks to generate “leverage” to encourage implementation by working with other organisations. These include the Healthcare Commission (an independent regulatory body that assesses organisations in England against the standards set in NICE guidelines) and organisations responsible for undergraduate and postgraduate education. The use of financial incentives is encouraged through the quality and outcomes framework, a mechanism for payment in primary care against a set of measurable indicators.

Thirdly, NICE believes it is particularly important to monitor progress and to identify and tackle the problem of barriers to change. It does this by referring to data on drug use, national audits, and published surveys and through feedback from the NICE implementation consultants. A recent example from a national audit showed that 85% of patients with lung cancer are now being seen by a multidisciplinary team, as recommended in the NICE guideline.5 All these findings are available on the NICE website (

As research evidence and medical knowledge continue to expand, the use of guidelines will increasingly become essential to inform day to day practice. Organisations such as NICE will therefore have a key responsibility for ensuring that their guidelines are up to date, in an accessible format, and available from a variety of sources.

Key stages in developing a NICE guideline2

  • Scoping—Defining the parameters of the guideline after consultation with relevant stakeholder groups
  • Setting clinical questions—Framed to cover the most important aspects of the scope
  • Reviewing—A systematic review of the relevant evidence is done; included studies range from randomised controlled trials to case series
  • Assessing cost effectiveness—Either by reviewing published analyses or, for selected questions, by undertaking new economic analyses
  • Developing recommendations—The evidence is evaluated by an independent development group specially constituted for each guideline
  • Consultation—Draft recommendations are subject to consultation with relevant stakeholder groups and external experts
  • Publication—NICE guidelines are available in various forms: a quick reference guide; a lay version for patients and carers; a version known as the “NICE guideline” that summarises the recommendations; and a full guideline containing the methodology and evidence reviews


Contributors: GL and MP had the idea for the article. GL and MR did the literature search and wrote the article. MP revised the article. GL is the guarantor.

Competing interests: None declared.


1. AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Quality and Safety in Healthcare 2003;12:18-23.
2. National Institute for Health and Clinical Excellence. The guidelines manual London: NICE, 2006.
3. Gaebel W, Weinmann S, Sartorius N, Rutz W, McIntyre JS. Schizophrenia practice guidelines: international survey and comparison. Br J Psych 2005;187:248-55.
4. Grol R, Wensing M, Eccles M, eds. Improving patient care. The implementation of change in clinical practice Oxford: Elsevier, 2004.
5. National Clinical Audit Support Programme. National lung cancer audit report 2006

Articles from The BMJ are provided here courtesy of BMJ Publishing Group