The first day started with the dissemination meeting of a project supported by the UK Prosperity Fund. The project, led by CNHDRC, focused on utilising UK expertise to support the development of standardised methods to generate evidence-based care pathways for chronic disease in China. The division director of CNHDRC, Prof Kun Zhao, outlines the aim of developing a standardized approach to developing and updating clinical guidelines in China, with a practical application to existing care pathways and guidelines in hypertension and diabetes, currently in use in Xiamen and Qingdao.

The meeting continued with an overview by experts from Xiamen and Qingdao on the ongoing efforts to improve the management of patients with chronic diseases. At the end of the meeting Prof Mike Roberts from UCL Partners shared some experiences on transforming health care towards evidence-based practices and current thinking on new integrated care models in the UK. He emphasized the importance of establishing standardised guidelines to provide high quality and equitable care for the whole Chinese population.

During the afternoon of the 17th, a leadership training workshop was delivered. At the beginning of the workshop, participants were familiarized by the theory on how to implement change and introduce new guidelines into clinical practice.  Later on, effective team leadership strategies in implementing change were discussed.  The training was attended by senior officials from Xiamen Health Bureau and Qingdao Health Bureau, representatives from tertiary and secondary hospitals, nurses, local administrative officials as well as clinicians. The knowledge gained from the workshop is expected to help local stakeholders build effective clinical teams to implement the new guidelines in an efficient manner.

The following week, a workshop was held over two days on ‘Health Policy Evaluation and Technology Assessment Knowledge Sharing’. This workshop was organised in order to help support the momentum generated by the newly launched China Health Policy and Technology Assessment Network, with CNHDRC in the role of focal point of the network (the iDSI China HTA hub).  The workshop was opened by Hongwei Yang, the deputy Director General of CNHDRC, Prof Kun Zhao and Dr Kalipso Chalkidou, Director of the GHD. The aims, objectives and structure of the nascent China HTA network were introduced. In addition, the workshop explored a number of topics considered highly relevant for HTA development in China. These include the role of the iDSI Reference Case and how it may be adapted for a Chinese context; evaluating non-budgetary constraints; health system strengthening; measuring HTA impact; economic evaluation and public health; adapting HTAs; and HTA and medical devices.  For each thematic area there were presentations from UK-based academics and Chinese researchers, as well as experts from the Thai HTA agency, HITAP. HITAP colleagues shared their experiences of how HTA was used to inform UHC policy in Thailand. The workshop concluded with reflections on the working plan for the China network as an iDSI HTA hub, and exploring new collaborations and next steps.

In terms of next steps, it was highlighted that a key objective should be to increase the number of members of the China Health Policy and Technology Assessment Network and on standardising the methodology used in developing clinical guidelines, especially for chronic diseases in China.

1- Dissemination Meeting on Developing Evidence-based Care Pathways for Chronic Disease in China
February 17th – Morning

National Developments showcase & providing means for utilising UK expertise

Following successful launch of this UK supported Prosperity Fund project on July 28th 2016, the dissemination meeting had the key aim of communicating progress in establishing a standardised approach to clinical guidelines development, and in applying them to update existing care pathways in China. The topic areas selected for the pilot were on priority chronic disease areas namely hypertension and diabetes that were currently in use in Xiamen and Qingdao cities.

A representative on the behalf of CNHDRC Director General- Ms Wei Fu gave an opening speech where he provided an overview of the burden of chronic diseases in China. He described China’s aging population as a critical high priority issue, highlighting the estimated 220 million people aged above 60 in China, added to by about 8 million people per year. He emphasized the significance of establishing a ‘tiered healthcare system’ in China utilizing UK NHS expertise and experience to support the local development of standardised care pathways. He concluded by inviting the audience of about 50 in number consisting of senior officials from Xiamen Health and Qingdao Health authorities, representatives from tertiary and secondary hospitals, nurses, local administrative officials and clinicians- to share the results of the preliminary version of the guidelines handbook, and encouraged feedback and discussion among attendees.

Ashwini Kirchner, Head of Health and Social Care at the British Embassy in Beijing highlighted the importance of bilateral commitment between the UK and China, to learn from one another. She stated that healthcare is a key point of interest between the two countries. Kirchner highlighted the aims of Prosperity Fund Project in providing cutting edge policy in an area where the UK can offer expertise, and to give way for a real impact on the ground.

Kun Zhao, Division Director in CNHDRC, described the status quo and progress of Chinese guidelines development. She compared UK and Chinese guidelines, and provided recommendations for realizing the project aims. She linked the importance of robust guidelines development with the considerable uncertainty around the effectiveness of most of new technologies in China, and the absence of economic and equity perspective in setting hospital treatment standards in different regions in China.

The preliminary version of the Chinese guidelines handbook received strong positive feedback from the audience. Changqin Liu, Vice President of the first affiliated hospital of Xiamen University noted the professionalism underpinning the handbook and described it as a first of its kind to be developed in China.

“This guidelines handbook is very comprehensive…It is first time where we can align with UK Clinical Guidelines principles….I learned a lot”
Fusong Liu- Cardiology department Director of The Third People’s hospital of Qingdao.

Professor Mike Roberts of UCL Partners concluded the meeting by giving a brief presentation on new models of care in the UK, such as ‘Integrated Care Pioneers’ and ‘Vanguard sites’. His presentation can be found here.

2- Leadership & Change Management training
February 17th – Afternoon

Leading Change: New guidelines, new approach..

The afternoon session was dedicated to a training workshop that builds on the introduction of the new guidelines in Xiamen and Qingdao hospitals. According to Mike Roberts, the implementation of new guidelines depends on a number of factors, the most important of which are understanding and managing the change process involved, and developing effective leadership among the interdisciplinary teams adopting the new hypertension and diabetes clinical guidelines.

The training workshop took place over 3 hours and involved presentations on change management by Reetan Patel, effective team leadership by Mike Roberts, combined with an interactive discussion and group work scenarios. The group work emphasised the experience of trying to implement a new set of clinical guidelines and how they may be understood from different perspectives among the stakeholders affected such as management, clinicians and other various implementing teams. The audience were mainly senior officials from Xiamen and Qingdao health authorities, representatives from tertiary and secondary hospitals, nurses, local administrative officials and clinicians.

3- iDSI HTA workshop: knowledge sharing event to support newly launched China HTA network
February 20th – 21st

The role of HTA in international development & National Regulatory Authority strengthening

The iDSI HTA workshop in Xiamen builds on the MOU supporting informed implementation framework for HTA between GHD and CNHDRC. The two-day workshop revolved around 6 main themes: standardised methods for economic evaluation, non-budget constraints and health system strengthening, measuring HTA impact and return on investment, HTA and medical devices, economic evaluation modelling and public health, and adapting HTA to the Chinese context.

The workshop commenced with an opening statement by a representative of CNHDRC on the behalf of Deputy Director Hongwei Yang, who emphasized that the current leadership in China is very supportive of HTA capacity building especially in light of major technology transformation in China.

Kalipso Chalkidou gave an overview of the objectives of the HTA workshop including outlining the role of iDSI HTA hubs for supporting national and regional HTA related activities. Kun Zhao introduced the China HTA network, which is a network of 29 institutions and hospitals backed with a great amount of support by the Chinese healthcare authorities (the presentation can be found here). Tony Culyer briefly introduced the iDSI Reference Case, what it is and how it can be adapted to China context (see his presentation here).

Professor Pete Smith of Imperial College London delivered a presentation on developing a framework for evaluating interventions aimed at health system strengthening. Eleanor Grieve of University of Glasgow talked about developing a theoretical framework for assessing the impact of HTA and the return on investment. Professor Klim McPherson of Oxford University provided a presentation on role of epidemiological modelling to support decisions in public health, and Anastasia Chalkidou and Naomi Herz of KiTEC talked about assessing medical devices and the challenge of incorporating economic evaluations in that field (their presentations can be found here).

Chinese academics linked with the new HTA network also spoke about the role of HTA in China in line with the themes of the workshop. There were presentations on: Standards and procedures of HTA in China by Haiyin Wang, Division Director of Shanghai Health Development Research Center, Performance evaluation on public health system in China by Professor Zhachun of Tongji University, Outcome Evaluation of the Tiered healthcare system in China by Rui Zhao of CNHDRC, Rapid HTA on Proton and Heavy Ion radiotherapy by Michelle Li of CNHDRC; Economic Evaluation of hepatitis B management strategy in China by Steven Qiu of CNHDRC; and finally, a talk by Jenny Sui of CNHDRC on using international evidence to assess cellular immunotherapy.

The iDSI HTA workshop provided an opportunity for new collaborations between Chinese HTA specialists, UK researchers, and colleagues from neighbouring countries. During the second day of the workshop, a roundtable discussion involving health officials and academics from Indonesia, Cambodia and China highlighted the interest in engaging in mutual cooperation, and the opportunity offered by the Chinese HTA network in providing regional support. The rise of China’s HTA capacity comes at a pivotal timing given the upcoming BRICS Summit scheduled to take place in Xiamen next September. The five key priority areas for BRICS collaboration are: deepening cooperation, strengthening global governance, making institutional improvements and building broader partnerships. Within this context, HTA capacity buidling and wider heathcare refirm offers one important route to achieve these aims. The Goa declaration highlights the importance of BRICS cooperation in the area of healthcare regulation.

“We will seek to identify possibilities for cooperation among our health and/or regulatory authorities, with a view to share best practices and discuss challenges, as well as identifying potential areas for convergence”
8^th BRICS Summit- Goa Declaration October 2016.

China’s role in international support has been given added impetus by a number of initiatives including the recent “One Belt One Road” strategy. Such initiatives can provide important opportunities for sustainable development in countries along the Silk Road Economic Belt, and will be crucial in supporting the spread of evidence informed healthcare decision making in LMICs, a key objective of iDSI.

With EU support, NICE International is working with the Cypriot authorities, the Ministry of Health and the National Health Insurance Organisation, in their ambition to “adapt and adopt” existing clinical practice guidelines for their own context and develop mechanisms to support their implementation in Cyprus as part of more comprehensive healthcare reforms. This engagement involves the provision of advice and support in relation to ongoing work by the Cypriots to develop a manual for developing and implementing clinical guidelines in their jurisdiction.

NICE International hosts colleagues from the Cypriot authorities to take part in a final two days of training

November 2014

In the final visit to NICE as part of this EU funded project a delegation from the Ministry of Health and the National Health Insurance Organisation spent two days discussing the importance of Institutionalising evidence-based policy making and how to support implementation and assess the impact of guidance. The delegation also met with the NICE Accreditation team and Professor David Haslam, Chair of NICE.

Challenges to the implementation of clinical guidelines in Cyprus: a workshop looking at barriers and enablers to best practice

July 2014

Francis Ruiz of NICE International and Professor David Haslam, Chair of NICE participated in a workshop on guideline implementation in Cyprus in Nicosia. The workshop included an overview of the importance and role of clinical guidelines in health systems, illustrated with examples from the work NICE does in the UK.

Attendees at the workshop included senior clinicians and allied healthcare professionals from all hospitals in Cyprus, senior representatives from primary care setting, and representatives from the Cypriot Medical Association, National Health Insurance Organization, Ministry of Health, and Cyprus Scientific Societies. In a highly interactive session participants were asked about barriers and enablers to the uptake of best practice recommendations. A number of issues were raised based on a framework that considered implementation at different levels within the Cypriot health system.

Aside from the level of human and financial resources available to support implementation, many participants noted the importance of embedding a culture among all relevant actors in the system that values the generation of evidence and its application in decision making.

In addition to the guidelines workshop, the visit to Cyprus included meetings with the Director General of the Health Insurance Organization, Mr Andreas Demetriades, and the Cypriot Minister of Health, Professor Philippos Patsalis. During the meeting with Mr Demetriades, the planned reforms to the Cypriot health service were discussed including the role of guidelines and incentives to improve quality.

The meeting with the Minister underscored the emphasis on quality as part of the changes being introduced and the importance of effective primary care. The Minister also expressed his wish for continued collaboration with NICE International beyond the end of this present EU supported project.

NICE International hosts colleagues from the Cypriot authorities to take part in a two days of training

April 2014

This first study visit to NICE provided an introduction to the AGREE tool for quality assessing already published guidelines prior to their possible adaptation to the Cypriot context. Using stroke management as an example and the lessons of reforming stroke services in London, the study visit also explored why and how NICE guidelines are developed, the role of cost-effectiveness considerations, and how the recommendations in these UK guidelines are currently being adopted/adapted in Cyprus. The workshop also considered the role of NICE derived “Quality Standards” and the range of tools available (including financial and non-financial incentives) to support implementation. Speakers included the Chair of NICE, Professor David Haslam, and Professor Tony Rudd, National Clinical Director for Stroke (NHS England).

In Vietnam, iDSI has been collaborating as part of a Working Group convened by Medical Services Administration, Ministry of Health and the Oxford University Clinical Research Unit (OUCRU) to develop quality standards for better antibiotic prescribing practices, as a key element of better patient care in specific high-priority clinical conditions. In 2016, we developed draft quality standards on improving antibiotic prescribing in acute exacerbations of chronic obstructive pulmonary disease (COPD) and community-acquired pneumonia. COPD and lower respiratory tract infections together account for 8% of deaths in Vietnam, greater than for heart disease, and there is evidence of significant inappropriate antibiotic prescribing.

Dr Cao Hung Thai, Vice Director of Medical Services Administration, opens the workshop

The draft quality standards were presented to a national Quality Standards & Indicators Committee at a workshop in Hanoi, June 2016. The Committee comprised senior officials from the Ministry of Health, as well as over 40 frontline clinicians from various disciplines among central and provincial hospitals across Vietnam. The workshop generated robust discussion among Committee members, particularly around the the feasibility of international best practice in diagnostic tests in the Vietnamese public hospital setting, and the choice of first-line treatment where a substantial proportion of patients may have used antibiotics recently, and there is little scientific evidence about local microbial strains and antibiotic resistance patterns.

Doctors, pharmacists and microbiologists from across Vietnam debate the quality standards

These discussions will serve as valuable inputs for the Working Group who will finalise the quality standards and submit them for the Committee’s approval in Q4 2016.

Quality Standards Committee

After over 12 months of development, the first drafts of two of these guidelines are complete. The draft STG’s on Diabetic foot and Snake Bite were submitted to the National Director General of Health Services (DGHS) and have undergone expert peer review.  These documents are now available for public consultation on the official website of the  National Health Mission. Links to the draft guidelines can also be accessed through the Ministry of Health and Family Welfare website.

This  marks the beginning of a new foundation for evidence-based clinical practice in India, and is the first instance of adapting robust evidence-based guidelines to the Indian context based on inclusive and transparent processes. The clinical groups and the NHSRC have also  produced  patient information leaflets and Quality Standards as implementation tools to complement the STG’s. The next frontier of this project will be the pilot implementation of the Quality Standards for hypertension (soon to be submitted to the DGHS) and diabetic foot. This is presently being planned with involvement from both central and  state government officials.

Responding to a direct request by the STG Task Force and NHSRC, iDSI is contributing on three fronts:

• It is a member of the STG Task Force, which has representation from the Directorate General of Health Services (DGHS), Indian Council for Medical Research (ICMR), public and private sector agencies, research and clinical institutes from across India, as well as clinicians from renowned hospitals.  (Members of a parallel Task Force on Primary Care also provide input into the group in recognition of the need for national guidance to tackle the rise of preventable NCDs.)

• It is helping to develop the process and methods manual underpinning the guidelines and associated Quality Standards for India. The manual aims to guide the STG developers in producing STGs that are of high quality, inclusive and relevant to India. It provides details on the adaptation of existing STGs that adhere to international criteria, as well as the development of de novo evidence-informed STGs.

• It is providing technical assistance to the 10 Clinical Subgroups that have been convened to develop STGs on 14 prioritised topics in the next 12 months. Each Clinical Subgroup includes clinicians (doctors, nurses and allied health professionals) with expertise in the respective clinical topics, both from the private and public sectors, and from different states of India. As a first step, NHSRC and NICE International jointly convened a workshop in May 2015 on the methods and processes for guideline adaptation. The workshop was attended by members of the STG Task Force and facilitators from the 10 Clinical Subgroups.

This iDSI practical support is funded by the Department for International Development (DFID) India. The list of specialties and topics for the first set of STGs are in the table below: