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Parkinson’s disease

About

What is covered

This interactive flowchart covers the diagnosis and management of Parkinson's disease in adults in primary and secondary care.

Updates

Updates to this interactive flowchart

27 February 2018 Unilateral MRI-guided focused ultrasound thalamotomy for moderate to severe tremor in Parkinson's disease (NICE interventional procedures guidance 606) added to deep brain stimulation and other options.
8 February 2018 Parkinson's disease (NICE quality standard 164) added.
18 July 2017 Recommendations updated in line with the publication of NICE guideline NG71 on Parkinson's disease in adults, which updates and replaces NICE guideline CG35.
15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing Parkinson's disease in adults in primary and secondary care in an interactive flowchart

What is covered

This interactive flowchart covers the diagnosis and management of Parkinson's disease in adults in primary and secondary care.

Updates

Updates to this interactive flowchart

27 February 2018 Unilateral MRI-guided focused ultrasound thalamotomy for moderate to severe tremor in Parkinson's disease (NICE interventional procedures guidance 606) added to deep brain stimulation and other options.
8 February 2018 Parkinson's disease (NICE quality standard 164) added.
18 July 2017 Recommendations updated in line with the publication of NICE guideline NG71 on Parkinson's disease in adults, which updates and replaces NICE guideline CG35.
15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Parkinson's disease in adults (2017) NICE guideline NG71
Subthalamotomy for Parkinson's disease (2004) NICE interventional procedures guidance 65
Deep brain stimulation for Parkinson's disease (2003) NICE interventional procedures guidance 19
Parkinson's disease (2018) NICE quality standard 164
Hypersalivation: oral glycopyrronium bromide (2013) NICE evidence summary ESUOM15

Quality standards

Quality statements

Point of contact with specialist services

This quality statement is taken from the Parkinson's disease quality standard. The quality standard defines clinical best practice for Parkinson's disease and should be read in full.

Quality statement

Adults with Parkinson’s disease have a point of contact with specialist services.

Rationale

A point of contact with specialist services will facilitate continuity of care and ensure that adults with Parkinson’s disease have ongoing access to information, advice, care and support when they need it. This will support self-management and informed decision-making and will help to ensure that individual needs are proactively reviewed and managed. The point of contact could be a Parkinson’s disease nurse specialist.

Quality measures

Structure
Evidence of local arrangements to ensure that specialist services can provide a point of contact for adults with Parkinson’s disease.
Data source: Local data collection, for example, service protocols. The UK Parkinson’s Excellence Network UK Parkinson’s Audit identifies whether patients in elderly care and neurology services can access a Parkinson’s disease nurse specialist.
Process
Proportion of adults with Parkinson’s disease who have a point of contact with specialist services.
Numerator – the number in the denominator who have a point of contact with specialist services.
Denominator – the number of adults with Parkinson’s disease.
Data source: Local data collection, for example, audit of electronic patient health records.
Outcome
a) Satisfaction of adults with Parkinson’s disease with ease of access to specialist services.
Data source: Local data collection, for example, patient survey.
b) Satisfaction of adults with Parkinson’s disease that they have the support and knowledge they need to self-manage their condition.
Data source: Local data collection, for example, patient survey.

What the quality statement means for different audiences

Service providers (such as hospital elderly care services, neurology services and NHS community providers) ensure that adults with Parkinson’s disease have ongoing access to a point of contact with specialist services. Providers should ensure that, where possible, the point of contact for adults with Parkinson’s disease is a healthcare professional who they already know, and that response times are clear.
Healthcare professionals (such as Parkinson’s disease nurse specialists, community matrons and allied health professionals) provide ongoing support and information about clinical and social matters to adults with Parkinson’s disease within agreed response times. Support should include clinical monitoring and medicines adjustment, and home visits when appropriate.
Commissioners (such as clinical commissioning groups) commission services that ensure that adults with Parkinson’s disease have ongoing access to a point of contact with specialist services, with clear response times.
Adults with Parkinson’s disease have a point of contact with specialist services, such as a nurse specialising in caring for people with Parkinson’s disease, who they can contact between their reviews. If they do make contact, they should know how long it will take for someone to get back to them.

Source guidance

Parkinson’s disease in adults (2017) NICE guideline NG71, recommendation 1.1.6

Definitions of terms used in this quality statement

A point of contact with specialist services
A point of contact with specialist services that adults with Parkinson’s disease can access between scheduled reviews. This could be a Parkinson’s disease nurse specialist. The point of contact should provide access to:
  • clinical monitoring and medicines adjustment
  • ongoing support, including home visits when appropriate
  • information about clinical and social matters of concern to people with Parkinson’s disease and their family and carers (as appropriate).
[Adapted from NICE’s guideline on Parkinson’s disease in adults, recommendations 1.1.6 and 1.7.1]

Information about impulse control disorders

This quality statement is taken from the Parkinson's disease quality standard. The quality standard defines clinical best practice for Parkinson's disease and should be read in full.

Quality statement

Adults with Parkinson’s disease taking dopaminergic therapy are given information about the risk of developing impulse control disorders, when starting treatment and at least annually.

Rationale

Dopaminergic therapy, especially with dopamine agonists, is associated with a risk of developing impulse control disorders. It is important to discuss this risk and provide information to adults with Parkinson’s disease, and their family members and carers, when starting treatment and at least annually. This will help them to recognise the symptoms and know where to get help if these develop.

Quality measures

Structure
a) Evidence that written information about the risk of developing impulse control disorders with dopaminergic therapy is available.
Data source: Local data collection, for example, information leaflets.
b) Evidence of local processes to ensure that adults with Parkinson’s disease taking dopaminergic therapy have a discussion with a healthcare professional about the risk of developing impulse control disorders when starting treatment and at least annually.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of adults with Parkinson’s disease starting dopaminergic therapy who are given written information about the risk of developing impulse control disorders.
Numerator – the number in the denominator who are given written information about the risk of developing impulse control disorders.
Denominator – the number of adults with Parkinson’s disease starting dopaminergic therapy.
Data source: Local data collection, for example, audit of electronic patient health records. The UK Parkinson’s Excellence Network UK Parkinson’s Audit includes evidence of a conversation with the patient/carer and/or provision of written information regarding potential adverse effects for any new medicines.
b) Proportion of adults with Parkinson’s disease starting dopaminergic therapy who have a record of a discussion about the risk of developing impulse control disorders.
Numerator – the number in the denominator who have a record of a discussion about the risk of developing impulse control disorders.
Denominator – the number of adults with Parkinson’s disease starting dopaminergic therapy.
Data source: Local data collection, for example, audit of electronic patient health records. The UK Parkinson’s Excellence Network UK Parkinson’s Audit includes evidence of a conversation with the patient/carer and/or provision of written information regarding potential adverse effects for any new medicines.
c) Proportion of adults with Parkinson’s disease taking dopaminergic therapy who have a record of a discussion within the past 12 months about the risk of developing impulse control disorders.
Numerator – the number in the denominator who have a record of a discussion within the past 12 months about the risk of developing impulse control disorders.
Denominator – the number of adults with Parkinson’s disease taking dopaminergic therapy.
Data source: Local data collection, for example, audit of electronic patient health records. The UK Parkinson’s Excellence Network UK Parkinson’s Audit includes evidence of the extent of monitoring for compulsive behaviour in people taking dopaminergic drugs.
Outcome
a) Awareness of the risk of developing impulse control disorders among adults taking dopaminergic therapy for Parkinson’s disease.
Data source: Local data collection, for example, patient survey.
b) Awareness of the risk of developing impulse control disorders among family members and carers of adults taking dopaminergic therapy for Parkinson’s disease.
Data source: Local data collection, for example, survey of carers.

What the quality statement means for different audiences

Service providers (such as hospital elderly care services, neurology services and general practices) ensure that healthcare professionals are aware of the need to provide oral and written information about the risk of developing impulse control disorders to adults with Parkinson’s disease when starting dopaminergic therapy (not just dopamine agonists) and to discuss this with them at least annually. Providers ensure that processes are in place to provide this information and include family members and carers in the discussion, if appropriate, so that they are aware of the symptoms and know where to get help if these develop.
Healthcare professionals (such as neurologists, elderly care consultants, Parkinson’s disease nurse specialists, GPs, allied health professionals and pharmacists) provide oral and written information about the risk of developing impulse control disorders to adults with Parkinson’s disease when starting dopaminergic therapy (not just dopamine agonists) and discuss this with them at least annually. They also provide information for family members and carers if appropriate.
Commissioners (such as clinical commissioning groups) commission services that ensure adults with Parkinson’s disease are given oral and written information about the risk of developing impulse control disorders when starting dopaminergic therapy and have a discussion about impulse control disorders at least annually.
Adults with Parkinson’s disease, and their family members and carers (if appropriate) are given written and verbal information about the risk of developing impulse control disorders (impulsive behaviour) when they start taking medicine for Parkinson’s disease. They have a discussion with their healthcare professional about this at least once a year.

Source guidance

Parkinson’s disease in adults (2017) NICE guideline NG71, recommendation 1.3.8, 1.4.3 and 1.4.4

Definitions of terms used in this quality statement

Information about the risk of developing impulse control disorders
Oral and written information should be given about:
  • the different types of impulse control disorders (for example, compulsive gambling, hypersexuality, binge eating and obsessive shopping)
  • the increased risk of impulse control disorders developing with dopamine agonists
  • the risk that impulse control disorders may be concealed by the person affected
  • who to contact if impulse control disorders develop
  • the possibility that if problematic impulse control disorders develop, dopamine agonist therapy will be reviewed and may be reduced or stopped.
[NICE’s guideline on Parkinson’s disease in adults, recommendation 1.4.3]

Referral to physiotherapy, occupational therapy or speech and language therapy

This quality statement is taken from the Parkinson's disease quality standard. The quality standard defines clinical best practice for Parkinson's disease and should be read in full.

Quality statement

Adults with Parkinson’s disease are referred to physiotherapy, occupational therapy or speech and language therapy if they have problems with balance, motor function, activities of daily living, communication, swallowing or saliva.

Rationale

Adults with Parkinson’s disease may experience a wide range of symptoms. Physiotherapy, occupational therapy and speech and language therapy can help people to manage their symptoms, maintain their independence and avoid hospital admission. After a referral to therapy services, it is important to ensure that therapists are included as part of the person’s multidisciplinary team.

Quality measures

Structure
a) Evidence that physiotherapy, occupational therapy, and speech and language therapy specific for Parkinson’s disease are available locally.
Data source: Local data collection, for example, service specifications.
b) Evidence of local processes to identify adults with Parkinson’s disease and problems with balance, motor function, activities of daily living, communication, swallowing or saliva.
Data source: Local data collection, for example, service protocol. The UK Parkinson’s Excellence Network UK Parkinson’s Audit identifies whether reviews include a formal assessment tool or checklist for activities of daily living and the Parkinson’s non-motor symptoms questionnaire or other form of checklist to screen for non-motor symptoms.
Process
a) Proportion of adults with Parkinson’s disease and balance or motor function problems identified within the past 12 months who are referred for physiotherapy specific for Parkinson’s disease.
Numerator – the number in the denominator who are referred for physiotherapy specific for Parkinson’s disease.
Denominator – the number of adults with Parkinson’s disease and balance or motor function problems identified within the past 12 months.
Data source: Local data collection, for example, audit of electronic patient health records. The UK Parkinson’s Excellence Network UK Parkinson’s Audit includes evidence of a physiotherapy referral.
b) Proportion of adults with Parkinson’s disease and difficulties with activities of daily living identified within the past 12 months who are referred for occupational therapy specific for Parkinson’s disease.
Numerator – the number in the denominator who are referred for occupational therapy specific for Parkinson’s disease.
Denominator – the number of adults with Parkinson’s disease and difficulties with activities of daily living identified within the past 12 months.
Data source: Local data collection, for example, audit of electronic patient health records. The UK Parkinson’s Excellence Network UK Parkinson’s Audit includes evidence of an occupational therapy referral.
c) Proportion of adults with Parkinson’s disease and problems with communication, swallowing or saliva identified within the past 12 months who are referred for speech and language therapy specific for Parkinson’s disease.
Numerator – the number in the denominator who are referred for speech and language therapy.
Denominator – the number of adults with Parkinson’s disease and problems with communication, swallowing or saliva identified within the past 12 months.
Data source: Local data collection, for example, audit of electronic patient health records. The UK Parkinson’s Excellence Network UK Parkinson’s Audit includes evidence of speech and language therapy referrals for communication and swallowing.
Outcome
a) Health-related quality of life for adults with Parkinson’s disease.
Data source: Local data collection, for example, patient survey.
b) Hospital admission rate for falls among adults with Parkinson’s disease.
Data source: Local data collection, for example, audit of electronic patient health records.
c) Hospital admission rate for aspiration pneumonia among adults with Parkinson’s disease.
Data source: Local data collection, for example, audit of electronic patient health records.

What the quality statement means for different audiences

Service providers (such as hospital elderly care services, neurology services, general practices and NHS community providers) ensure that adults with Parkinson’s disease have regular assessments of balance, motor function, activities of daily living, communication, swallowing and saliva. If problems are identified they are referred for physiotherapy, occupational therapy or speech and language therapy specific for Parkinson’s disease.
Healthcare professionals (such as neurologists, elderly care consultants, Parkinson’s disease nurse specialists and GPs) are aware of local referral pathways to physiotherapy, occupational therapy and speech and language therapy for adults with Parkinson’s disease. Healthcare professionals carry out regular assessments of balance, motor function, activities of daily living, communication, swallowing and saliva for adults with Parkinson’s disease and refer them for physiotherapy, occupational therapy or speech and language therapy specific for Parkinson’s disease if problems are identified.
Commissioners (such as clinical commissioning groups) commission physiotherapy, occupational therapy, and speech and language therapy specific for adults with Parkinson’s disease and ensure that referral pathways are in place.
Adults with Parkinson’s disease are referred to a physiotherapist for specialist treatment if they have problems with movement or balance. They are referred to an occupational therapist if they have difficulties with everyday activities such as dressing, cooking and working, and to a speech and language therapist if they have speech problems or problems with swallowing or drooling.

Source guidance

Parkinson’s disease in adults (2017) NICE guideline NG71, recommendations 1.7.3, 1.7.6 and 1.7.8

Definitions of terms used in this quality statement

Activities of daily living
Includes personal care, dressing and bathing, housework, shopping, food preparation, eating and drinking, and ability to continue with current work and usual activities.
[NICE’s guideline on motor neurone disease, recommendation 1.9.1]
Physiotherapy, occupational therapy and speech and language therapy specific for Parkinson’s disease
Adults with Parkinson’s disease should have contact with a physiotherapist, occupational therapist or speech and language therapist with experience of Parkinson’s disease to ensure disease-specific care is given.
[NICE’s guideline on Parkinson’s disease in adults, recommendations 1.7.2, 1.7.5 and 1.7.7 and full guideline]

Levodopa in hospital or a care home

This quality statement is taken from the Parkinson's disease quality standard. The quality standard defines clinical best practice for Parkinson's disease and should be read in full.

Quality statement

Adults with Parkinson’s disease who are in hospital or a care home take levodopa within 30 minutes of their individually prescribed administration time.

Rationale

Serious complications can develop if levodopa is not taken on time. These include acute akinesia and, if delays are significant, neuroleptic malignant syndrome. These complications can lead to increased care needs and increased length of stay in hospital or a care home.

Quality measures

Structure
a) Evidence of local processes to accurately document administration times for levodopa for adults with Parkinson’s disease on admission to hospital or a care home to reflect timings before admission.
Data source: Local data collection, for example, service protocol.
b) Evidence of local processes to identify missed, early or late administration of levodopa for adults with Parkinson’s disease in hospital or a care home.
Data source: Local data collection, for example, service protocol.
Process
a) Proportion of prescribed doses of levodopa for adults with Parkinson’s disease in hospital or a care home that were missed.
Numerator – the number in the denominator that were missed.
Denominator – the number of prescribed doses of levodopa for adults with Parkinson’s disease in hospital or a care home.
Data source: Local data collection, for example, audit of medicines administration records.
b) Proportion of doses of levodopa for adults with Parkinson’s disease in hospital or a care home that were given more than 30 minutes before the individually prescribed administration time.
Numerator – the number in the denominator that were given more than 30 minutes before the individually prescribed administration time.
Denominator – the number of doses of levodopa for adults with Parkinson’s disease in hospital or a care home.
Data source: Local data collection, for example, audit of medicines administration records.
c) Proportion of doses of levodopa for adults with Parkinson’s disease in hospital or a care home that were given more than 30 minutes after the individually prescribed administration time.
Numerator – the number in the denominator that were given more than 30 minutes after the individually prescribed administration time.
Denominator – the number of doses of levodopa for adults with Parkinson’s disease in hospital or a care home.
Data source: Local data collection, for example, audit of medicines administration records.
Outcome
a) Patient safety incidents related to medicines for adults with Parkinson’s disease in hospital or a care home.
Data source: Local data collection, for example, local records of patient safety incidents.
b) Length of hospital stay for adults with Parkinson’s disease.
Data source: Local data collection. National data can be collected from NHS Digital’s Hospital Episode Statistics.

What the quality statement means for different audiences

Service providers (hospitals and care homes) ensure that adults with Parkinson’s disease are identified on admission so that their requirements for levodopa can be accurately identified and monitored to reflect timings before admission. This should include an assessment of self-medication. Providers should ensure that staff are trained to understand the importance of taking levodopa at the appropriate times, and to report any medicines-related patient safety incidents.
Health and social care practitioners (such as doctors, nurses, pharmacists, and care home managers and staff) ensure that adults with Parkinson’s disease have an accurate medicines chart that reflects timings for levodopa before admission. Practitioners should support adults with Parkinson’s disease to take levodopa on time, which may include self-medication. Practitioners should report any medicines-related patient safety incidents for adults with Parkinson’s disease.
Commissioners (such as clinical commissioning groups and local authorities) commission services that ensure timings of administration for levodopa are accurately identified and monitored for adults with Parkinson’s disease. There are examples where commissioners have used local CQUINs to ensure that levodopa is given on time and not missed for adults with Parkinson’s disease.
Adults with Parkinson’s disease who are admitted to hospital or a care home know that they need to take their levodopa medicine on time and are supported to do so. This will ensure that they do not develop complications that can happen when this medicine is not taken at the right time.

Source guidance

Parkinson’s disease in adults (2017) NICE guideline NG71, recommendations 1.3.2 and 1.3.4 [the timeframe of 30 minutes is based on consensus of expert opinion]

Definitions of terms used in this quality statement

Individually prescribed administration time
The time that the person routinely takes their levodopa medicine. This should be in line with timings before admission and their individual prescription. Timings should only be adjusted after discussion with a specialist in managing Parkinson's disease.
[NICE’s guideline on Parkinson’s disease in adults, recommendation 1.3.2 and expert opinion]

Access to Clozapine for treating hallucinations and delusions

This quality statement is taken from the Parkinson's disease quality standard. The quality standard defines clinical best practice for Parkinson's disease and should be read in full.

Quality statement

Services for adults with Parkinson’s disease provide access to clozapine and patient monitoring for treating hallucinations and delusions.

Rationale

Medicines for Parkinson’s disease can cause hallucinations and delusions. If these symptoms of psychosis are not controlled adequately, they can lead to permanent admissions to care homes. It is therefore important that specialist services ensure adults with Parkinson’s disease can access clozapine and the required patient monitoring if needed. As specialist Parkinson’s services may not be able to provide this directly, they should agree with other local services how access will be provided and ensure that the specific needs of adults with Parkinson’s disease (such as the need for a lower dose) are understood and met.

Quality measures

Structure
Evidence of local pathways to provide access to clozapine and patient monitoring for treating hallucinations and delusions in adults with Parkinson’s disease.
Data source: Local data collection, for example, service protocol and referral pathways.
Outcome
a) Prescribing rates of lower dose clozapine for adults with Parkinson’s.
Data source: Local data collection, for example, Clozaril Patient Monitoring Service.
b) Satisfaction with the management of hallucinations and delusions among adults with Parkinson’s disease.
Data source: Local data collection, for example, patient survey.
c) Permanent admissions to care homes for adults with Parkinson’s disease and hallucinations or delusions.
Data source: Local data collection, for example, audit of patient health records.

What the quality statement means for different audiences

Service providers (such as hospital elderly care services and neurology services) ensure that adults with Parkinson’s disease can access clozapine and patient monitoring for treating hallucinations and delusions. This may mean joint arrangements with mental health services are needed. Providers ensure that healthcare professionals are aware that adults with Parkinson’s disease need lower doses of clozapine than adults without Parkinson’s disease.
Healthcare professionals (such as neurologists, elderly care consultants and Parkinson’s disease nurse specialists) follow local processes to provide access to clozapine and patient monitoring for adults with Parkinson’s disease and hallucinations or delusions if needed. If this means a referral to another service, healthcare professionals ensure that the need for a lower dose of clozapine in adults with Parkinson’s disease is understood.
Commissioners (such as clinical commissioning groups) commission a clozapine service for adults with Parkinson’s disease and hallucinations or delusions that includes monitoring. Commissioners should encourage joint working between services to ensure that the specific needs of adults with Parkinson’s disease are understood and met.
Adults with Parkinson’s disease and hallucinations or delusions can have treatment with clozapine if they need to. If they start clozapine, they will need to be registered with a monitoring scheme to have regular blood tests.

Source guidance

Parkinson’s disease in adults (2017) NICE guideline NG71, recommendation 1.5.17

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

catechol-O-methyl transferase
monoamine oxidase B

Paths in this pathway

Pathway created: March 2014 Last updated: February 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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