Nice guidance for the management of low back pain?
2010
This paper considers the status of NICE guidelines in general and challenges clinicians to consider how they are responding to the back pain guidelines in practice.
How are you responding to the Nice guidance for the management of low back pain?
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Sources of funding: Conflicts of interest: None Dr Lisa Roberts: |
Nicky Wilson: Address for correspondence: |
In November 2005, the Department of Health requested that the National Institute for Health and Clinical Excellence (NICE) develop 'a clinical guideline on the acute management of patients with chronic low back pain, to include indications for referral and pathways of care.'1 The guideline, addressing persistent or recurrent, non-specific low back pain that has lasted for more than six weeks but for less than a year, was published in May 20092 and summarises the care and treatment that people in England and Wales can expect from the National Health Service, to help them manage their pain.3
This paper considers the status of NICE guidelines in general and challenges clinicians to consider how they are responding to the back pain guidelines in practice.
The status of NICE guidelines
NICE has become internationally known as one of the most productive developers of clinical guidelines in the world4 The guidelines produced have established a reputation as one of the most rigorous, evidence-based recommendations on therapy5 and are developed by 'independent clinical and patient experts who give up their time and expertise over two years to produce robust, evidence-based guidance.'6
According to Michael Rawlins, Chairman of NICE, the guideline developers' only aim is to help to improve the care and treatment of people with specific conditions by highlighting gold standard approaches based on the available evidence.6 When minimal evidence is available, recommendations are based on the Guideline Development Group's experience and opinion of what constitutes good practice.7
The final documents do not differentiate between obligatory and optional standards for clinical care as NICE considers this undesirable.8
In summary, NICE guidelines provide evidence for clinicians, although controversy remains as to their actual status.
Currently, NICE clinical guidelines are not legally mandatory in England and Wales, unlike technology appraisals (where if a new treatment is approved, Primary Care Trusts are legally required to make funds available if the patient fits the profile).9
Nevertheless, NICE advice cannot be ignored. In its response to the Bristol Royal Infirmary Report, NICE advocates that health professionals should take its guidance fully into account when exercising their clinical judgement, but it does not override their responsibility for making appropriate decisions for individual patients.8
More recently however, the status of NICE recommendations and guidance appears to be changing. According to Praities, general practitioners have been challenged to prove they follow NICE guidelines or face the possibility of suspension, prosecution or the closure of their practice10 and claims have been made that guidance from NICE would become legally enforceable from 2009/10, with doctors facing tough annual checks on their adherence10 In secondary care, hospitals will also be expected to prove they are complying with national guidelines on clinical effectiveness as part of the Care Quality Commission's registration process11 (from April 2010 for NHS Trusts).
Challenges and questions
In addition to challenging the status of NICE guidelines, clinicians also question aspects of the development process. NICE has previously been criticised for a lack of transparency in the way it makes its decisions,12 its apparent failure to support innovation12 and its failure 'to communicate its role and dilemmas effectively. '12 Furthermore, its methods of consultation were criticised when it was alleged that NICE does not take patients' views into account when rationing health care interventions13 or that the process is dominated by advocacy groups14. This claim has been strongly rejected, as three lay members are recruited though open advertising, for an appraisal committee.15 Specific to the back pain guidelines, methodologically, NICE has been reproached for not considering evidence from cohort studies and clinical case series.16
As well as being challenged by clinicians, researchers and patients, NICE guidelines have been under review legally. The guidelines on chronic fatigue syndrome were legally challenged by two patients alleging that experts who had helped formulate the guidelines were biased against certain types of treatment17.
The judge rejected this challenge at the High Court in London, concluding that there was a proper and effective system in place to ensure that, as far as possible, there was no conflict of interest and duty among members of the guideline development group.17
It is evident that NICE, now 10 years old, remains controversial, constantly in the public eye and is still considered by some, to be a national treasure.18 Whilst it has brought the process of health care rationing out into the open,13 it remains deeply unpopular with the pharmaceutical industry, who take issue with its 'arbitrary threshold' for deciding which medications are cost effective and can be funded by the NHS, however the organisation is growing in popularity with governments around the world18. What is clear is that opinion remains divided and the publication of new guidelines provokes much debate among professionals, health care commissioners and service-users.
Health care professionals' responses to the NICE back pain guidelines
The response to the publication of the back pain guidelines has been varied, with some professional organisations supporting the guidance19-22 whilst others have expressed dissatisfaction at some of the recommendations.23-24 A particular source of controversy is that injections into the lumbar spine are not supported, whilst other conservative forms of management (acupuncture and spinal manipulation) are recommended.
Such is the strength of feeling by some clinicians, the British Pain Society, the largest multidisciplinary professional pain organisation within the UK, forced its president from office after he refused to denounce the NICE guidance,16 although this campaign was highly criticised6
The NICE back pain guidelines have certainly generated debate among individuals, professional bodies and specialist societies and this looks set to continue, Therefore it is important for clinicians to consider their own response and engage in this debate,
Your response to the NICE back pain guidelines
When any health care professional reads an academic paper or set of guidelines, they need to ask themselves, 'Should I change my practice based on what I have just read?' Having made this decision, the challenge remains how to implement these changes and monitor the effect on clinical outcomes,
It has long been recognised that there is no single, effective way to ensure that standards and guidelines are used in clinical practice,25 Therefore, how are you going to monitor whether the NICE back pain guidelines have affected your practice? How robust is your clinical effectiveness strategy?
For example, do you currently monitor outcomes from care episodes, serviceeuser experiences and measure whether you are using evidence-based treatment strategies? If so, it should be straightforward to measure these factors after publication of the guidelines using the audit tools that are available on the NICE website26-28 and compare them with pre-guideline data to identify changes in practice. If you do not collect such data routinely, these guidelines may serve as a wake-up call, as health care commissioners and service-users in the public and private sectors are likely to require you to provide evidence that you use evidence-based practice in future. (Such evidence can be provided either through service evaluations, i.e. defining current care without reference to any standards, or audits that review care against explicit criteria or standards.)
Conclusion
The NICE back pain guidelines are stimulating wide-spread debate among health professionals, not least because there is an expectation that providers will comply with the recommendations 'unless they can show a good reason to vary from them'10 The status of guidelines appears to be changing, with the suggestion that 'failure to implement NICE guidance could bring severe sanctions'10 and so there has never been a more important time for clinicians to engage with this debate.
Specific to the management of back pain, with finite resources and relatively small effect sizes for treatments, it is inevitable that there will be perceived winners and losers in the competitive clinical arena. Care needs to be taken in interpreting guidelines, however, that absence of evidence for an effect in a population is not construed as evidence for the absence of any effect.29
Putting aside any differences in opinion about the content, there is consensus among health care professionals that these back pain guidelines cannot be ignored. Therefore, having read the guidelines and this paper, how are you going to change your practice based on what you have just read?
References.
(1) NICE. Special Health Authority Twelfth Wave Work Programme: Low back pain. www.nice.org.uk/nicemedia/pdf/Low_ Back_Pain_remit.pdf (Accessed 17.10.09).
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(19) British Chiropractic Association (2009) British Chiropractic Association comment on NICE guidelines regarding non-specific low back pain. http://www.chiropractic-uk.co.uk/gfx/uploads/textbox/Press%20releases/0236132-NICE_GuidelinesFV.pdf (Accessed 26.09.09).
(20) Chartered Society of Physiotherapy (2009) CSP welcomes new NICE guideline for low back pain. www.csp.org.uk/director/press/pressreleases.cfm?item_id=7D3DOEOCOF585900C060CSB604F90245 (Accessed 26.09.09).
(21) General Osteopathic Council (2009). GOsC welcomes new evidence-based guidance on treatment of back pain. www.osteopathy.org.uk/uploads/gosc%20welcomes%20nice%20guideline%20on%20Iow%20back%20pain.pdf (Accessed 26.09.09).
(22) British Medical Acupuncture Society. The Point. 2009;27:1. http://www.medical-acupuncture.co.uk/point-2009-summer.pdf
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