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CANDOUR - Issue 4 - June 1999

The newsletter of the ASA/ JCALC Clinical Effectiveness Committee and the ASA Clinical Effectiveness Project

In this issue :

‘Faster Access to Modern Treatment’: How NICE Appraisal will work

‘Clinical Governance: Quality in the new NHS’

‘The NHS Performance Assessment Framework’

Journal of Pre-hospital Immediate Care


Issue 3 CANDOUR INDEX Issue 5


Quality in the new NHS and the ASA Clinical Effectiveness Project.

Over the past couple of months several documents and discussion papers have been published by the NHS. Stuart Nicholls will outline here his thoughts on their implications for UK ambulance services and in particular the ASA Clinical Effectiveness Project.

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‘Faster Access to Modern Treatment’: How NICE Appraisal will work

– an NHSE discussion paper (January 1999)

Many of you will have seen the above document outlining how the National Institute for Clinical Excellence (NICE) will promote faster access to clinical and cost effective patient care and assist in reducing variation in treatments and outcomes across the country.

A letter from the NHSE asking for comments, sent to the Ambulance Service Association Director, was passed to the ASA Clinical Effectiveness Project Manager. Comments were collated on behalf of the Ambulance Service Association by Stuart Nicholls (ASA Clinical Effectiveness Project Manager) and Paul McCormick (Chief Executive of Northern Ireland Ambulance Service, and Chair ASA/JCALC Clinical Effectiveness Committee).

This is their response to the discussion paper :

"We welcome the objectives of NICE especially it’s role in acting to ‘develop a variety of clinical guidance "products"’ (p2) and in providing guidance on new and existing treatments for specific conditions and individual treatments and products.

Within the ambulance service there is great variation in the adoption, definition, interpretation and application of existing guidelines. This is not conducive to equitable and quality patient care. It is therefore imperative that NICE appraisal does ‘result in the issue of guidance on whether the treatment can be recommended for routine use’ (p2).

A recent ASA survey (Evidence for Change II – a survey of clinical audit within the UK ambulance services – yet to be published) pointed to a desire from UK ambulance services to have national guidelines of best practice which were clinically and cost effective.

Obviously the ambulance services themselves are producing individual audit projects and research, but it is done individually and often results in duplication and small sample sizes which are inadequate to provide real evidence of best practice. The survey highlighted the need for a body such as NICE to review pre-hospital guidelines, protocols and procedures with a view to distributing a definitive set which are evidence based, clinically and cost effective. NICE’s role in appraising new and existing treatments would complement this.

It would also be pertinent to include pre-hospital guidelines in any guidelines produced for in-hospital treatment upon which it may have an effect. This would serve to produce a more seamless pathway of care for the patient and allow for a more complete audit trail upon which outcomes of patient care could more readily and accurately be measured.

Traditionally ambulance service guidelines have been steered locally (through advisory panels) by clinicians with wide-ranging skills and ostensibly their remit has been paramedic training standards. We would therefore support any framework which through ‘NICE will offer clinicians more support than they have ever had before in making complex decisions about individual patient care.’(p2) and that is also backed ‘through clinical governance arrangements to ensure variations in care for patients which cannot be justified by genuine local differences are not allowed to persist’.(p3)

Given that ambulance services are ‘prescribed’ which medicines, devices, treatments and to a lesser extent products, they are allowed to practice with, we feel that much of the work relevant to ambulance services would fall in the area where no obvious sponsoring company exists (p6, p9). We believe that the Department of Health should not just ‘consider whether any research be commissioned through the NHS R&D programme’ but actively promote research in the pre-hospital treatments dealt with by ambulance services as there is a distinct lack of knowledge available upon which to base any evidence. Indeed, we feel that any appraisal of pre-hospital treatments would ‘fail’ due to the lack of research evidence available for comparisons to be made. There is a strong requirement for new and existing pre-hospital treatments to be appraised through NHS R&D research programmes.

We believe a more explicit process should be put in place whereby ambulance services can provide the evidence at grass roots level of variations in patient care; a body such a NICE liasing with the ambulance service ‘treatment commissioners’ – the Joint Royal Colleges Ambulance Liaison Committee - can provide the appraisal skills required and together produce accurate guidelines which reflect clinically effective practice. By having both the clinical input and the input from grass roots any national guidelines would more readily be adopted, rather than being adapted in many different forms as is the current system through local advisory panels.

The ASA/JCALC Joint Clinical Effectiveness Committee and the ASA National Clinical Effectiveness Project are already addressing these issues. We would very much like to work along side the NICE appraisal scheme, and it’s R&D programme, to ensure the evidence and guidance produced is relevant and has the support of the clinicians and, more importantly the ambulance staff involved whilst remaining in the best interests of the patients."

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‘Clinical Governance: Quality in the new NHS’

Guidance on implementation (March 1999)

Following the publication of A First Class Service in the new NHS, and drawing on responses to that document, the NHSE has issued more detailed guidance on the implementation of clinical governance in 1999/2000 and beyond.

Work is underway within the ASA to produce its’ own guidance specific to UK ambulance services which will soon be forthcoming. The key points of clinical governance are outlined here with specific reference to the ASA Clinical Effectiveness Project.

Clinical governance itself is a framework within which local organisations can work to improve and assure the quality of clinical services for patients. The detail of clinical governance arrangements will differ between bodies and types of organisations, although obviously there are common steps to be taken as it applies to all sectors of the NHS.

The focus of clinical governance is team work, partnership and communication, to ensure that standards of clinical care are continually improved, whilst reducing variations in outcomes of, access to, service as well as ensuring that clinical decisions are based on the most up-to-date evidence of what is known to be effective. These are very much part of the objectives of the ASA Clinical Effectiveness Project.

By focusing on the key aspects of clinical audit and clinical effectiveness, the ASA Project aims to promote collaboration and communication and assist in the facilitation of clinical governance issues. The objective is to create an open and participative culture in which education, research and the sharing of good practice are valued and expected.

The ASA are aiming to achieve this through improved communication (for example this newsletter and the ASA website) and through the development of a structure of Regional Clinical Audit Groups. Proposals are currently under discussion upon the exact structure of these groups as a result of the support of UK ambulance services expressed through the Evidence for Change Survey II, where 90% of services encouraged this form of collaboration.

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‘The NHS Performance Assessment Framework’ (March 1999)

Again this is a document targeting collaboration to improve clinical services through a framework for

  • assessing performance, covering quality and efficiency
  • encouraging benchmarking between similar NHS organisations
  • underpinning national and local performance and accountability arrangements

This framework can be summarised in the following diagrams which outline the NHS Quality Framework and how this sits with clinical audit as a tool within clinical governance for setting standards, measuring and monitoring performance, and delivering change.

Figure 1 A simple illustration of the key elements of the NHS quality strategy (from A First Class Service).

Figure 2. Clinical Audit Cycle in context of Performance Assessment Framework

In the new climate of collaboration there are many areas within the High Level Indicator Set which ambulance service provision can impact either directly or indirectly. Through collaborative quality improvement programmes all organisations within the NHS can work together to improve performance locally within these indicator sets i.e. ambulance services working with other local health service providers in areas such as deaths from circulatory diseases & accidents, acute/ chronic care management, emergency admission rates, and avoidable deaths.

Again these measures lend themselves to benchmarking and sharing of good practice. It is also hoped that the ambulance services can develop common and shared performance indicator sets of their own and not rely on ORCON standards as the measure of performance. This should be a natural progression as local Health Improvement Programmes are developed and monitored and the results of all this work are published in annual reports under clinical governance. The outcome for the patient and the quality of care provided are the true measures of a high performance ambulance service.

Indeed standards for pre-hospital care are being set as the National Service Framework for Coronary Heart Disease is implemented. Standards will be set for policies and interventions to promote health and reduce inequalities; raise the quality of clinical care and reduce variations in access to, and the quality of services. These will be based on the best available evidence of clinical and cost-effectiveness, and will therefore evolve as quality of services is continually measured and assessed. A benchmarking approach will be used stating a minimum standard acceptable, good practice and better practice.

Again, the ASA Clinical Effectiveness Project and the proposed Regional Clinical Audit Group structure will act to facilitate collaboration and benchmarking to allow the sharing of best practice and the accumulation of a sound evidence base from which appropriate pre-hospital standards can be set. It would obviously be very useful if all UK ambulance services were collecting the same information, measured in an identical manner so that direct comparisons can be made and best practice shared.


Please send in your comments and thoughts on these NHS publications. We would especially be interested in any initiatives already underway which address the issues raised here.

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Journal of Pre-hospital Immediate Care

Following a recent readership survey, it was apparent that many readers would like to have more articles originating from ambulance services within the Journal. This is of course entirely appropriate, especially given the large amount of clinical audit work being undertaken by UK ambulance services.

The Journal of Pre-hospital Immediate Care is therefore proposing to have a section of the Journal devoted to ambulance service audit. This section will comprise of a brief summary of an audit and the proposed action to be taken as a result. Each summary would be approximately 200-300 words. The Journal is aware that many audits highlight problems with services and, therefore, sometimes people are reluctant to publish these. It is therefore proposed that all audit summaries would be published together with an acknowledgement at the end of all the contributors. In this way individual audits could not be ascribed to a particular individual or ambulance service.

The Journal hope you will be able to submit something to this new section. If you do not already receive the Journal and would like a copy for inspection please use the contact details below. Similarly, should you wish to contribute to the Journal please request a copy of the Guidance for Authors for the Journal.


Dr Matthew Cooke

Editor - Journal of Pre-hospital Immediate Care

BMA House, Tavistock Square, London, WC1H 9JR

Tel. 0171 383 6795, Fax. 0171 383 6668

Email: [email protected]

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