The Royal College of Midwives (RCM) is the professional organisation and trade union representing 95% of all practising midwives in the United Kingdom. Virtually all practising midwives work within the NHS, and the RCM is recognised in every Trust that provides a midwifery service.

  The RCM welcomes the opportunity to respond to the Health Committee inquiry into aspects of the work of the National Institute for Health and Clinical Excellence. This response represents the views of midwifery members and RCM staff.

  The RCM fully supports the aims of NICE guidance to ensure consistent improvements in people's health and equal access to healthcare. The principle of one independent organisation taking responsibility for reviewing the current evidence and research and developing universal recommendations can represent optimal use of resources. However, as the topic selection is determined at government level, guideline development is increasingly seen as acting in accordance with political drivers.

1.   Why NICE's decisions are increasingly been challenged?

  1.1  Under the auspices of NICE guidelines clinicians, and other healthcare, have matured and are challenging the care which is solely based on research evidence may not be most effective way to provide healthcare.

  1.2  Members have voiced a lack of confidence in some of the recommendations and feel they are biased towards cost reduction as opposed to clinical and cost effectiveness. An example of this is evident in the implementation of the antenatal visiting schedule as organisations have interpreted this literally and blanket apply recommendations therefore reducing individualised woman-centred care. Within the current climate of cost constraint, the NICE guidelines may be used adversely to providing quality care. There is evidence of the consequences of this namely in staff and service reduction, as it is use negatively when calculating the manpower or service resources. In cases where recommendations would support a reduction of either staff or services they are readily adopted. Interestingly if the recommendations require extra resources they are ignored, therefore, wide open for manipulative interpretation. As stated earlier they are not primarily used for improvement in clinical practice and decision-making.

  1.3  The guidelines may have set out to address best clinical care however are let down by the complexities in the determinants in providing this care. In addition the narrow evidence base considered in the development of NICE guidelines ie using RCTs as the "gold standard", to the exclusion of other types of equally valid evidence, is concerning. This results in disillusioned clinicians when planning the total care as the best practices in the other determinants are not supported.

  1.4  There is also concern that the slow implementation of NICE guidelines can be associated with no requirement for impact or outcome evaluation to ensure the harm and benefit ratio of its outcome.

  1.5  The evidence on which the recommendations are based are also challenged as not being appropriate to the context of UK healthcare. Equally, by addressing topics in isolation, the whole impact on care and practice can be overlooked. As an example antenatal abdominal palpation in pregnancy to screen fetal growth was not recommended. However the impact of stopping this practice will result in:

(a)  Clinicians not developing the skills or competency needed for abdominal palpation, important clinical skills in the management of labour, if not practiced antenatally.

(b)  The social and educational opportunities in the interaction with the woman has been overlooked as an outcome.

2.   Weather public confidence in the Institute is waning, and if so why?

  2.1  The RCM would challenge whether the Institute's aims of consistent improvements in health and equal access to healthcare have materialised as anecdotal information suggests that there is selective implementation of the guidelines often driven by financial or political imperatives.

  2.2  There is a lack of robust evidence to suggest that the public are aware or knowledgeable about NICE guidelines; for example amongst maternity service users, especially the socially excluded.

  2.3  High profile media on the economic consideration of many treatment therapies highlights the difficulty of universal application when faced with an individual situation and also the wide variations in access that remain.

  2.4  The public's expectations of having choice, continuity and control promoted by government is not the reality many are experiencing.

3.   Nice's evaluation process, and whether any particular groups are disadvantaged by the process

  3.1  NICE experiences the same challenges of engaging with and involvement of many social groups and these challenges may result that the guidelines will never truly be representative of all sections of the population.

  3.2  The process is dependant on individuals having access to the internet and e-mail which excludes members of the public and some health care professionals.

  3.3  Implementation of Public Health guidance requires engagement with a wider group of stakeholders. In addition to the National Health Service, schools, local government, National government, voluntary services and the public should be actively encouraged by NICE to become involved in the consultation and share responsibility for implementation.

4.   The speed of publishing guidance

  4.1  The RCM acknowledges the in-depth work involved in guidelines production and the importance of thorough literature review and consultation. Though acknowledging that NICE has recognised this, the RCM will want to be assured that the guideline is still contemporary when finally completed. However what is more concerning is the slow implementation and service commissioner's commitment to implementation.

5.   The appeal system

  5.1  The RCM have no experience of the appeal system and therefore cannot respond to this question.

6.   Comparison with work of the Scottish Intercollegiate Guidelines Network (SIGN)

  6.1  The SIGN process for guidelines development appear to be a more straight forward process however this might be reflective of the smaller population, smaller community of healthcare professionals and less bureaucracy.

7.   The implementation of NICE guidance, both technology appraisals and clinical guidelines (which guidance is acted on, which is not and the reasons for this

  7.1  As there is no national audit of implementation the RCM is unable to provide a specific response. However financial commitment, local political drivers, inter-professional rivalry, lack of knowledge and understanding and lack of a whole systems approach to implementation appear to be contributory factors. Anecdote suggests that guidance recommendation which appears to offer direct cost savings, eg NHS not providing certain drug therapies, are more likely to be acted on.

  7.2  Due to an often narrow clinical scope approach, some clinicians fail to comply or implement recommendations as a result of conflict with their own personal opinion, values, beliefs and experience, clinicians feel professional expertise has not been considered in the evaluation of the evidence.

Royal College of Midwives

March 2007