The readers of JPRAS will probably already agree that plastic surgery is indeed a very nice specialty and that the skills that allow us to restore form, function and cosmesis are more than just niceties! This editorial, however, aims to direct the readers to the UK-based National Institute for Health and Clinical Excellence (NICE) website and to outline existing NICE guidance relevant to plastic surgery.
NICE is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in the United Kingdom. NICE produces guidance in three areas of health, namely: public health, health technologies and clinical practice.1 The website may also be of use to international readers; providing useful evidenced-based information on both plastic surgery topics and general patient management. The information is freely available and easily accessible on the NICE website: www.nice.org.uk (Figure 1). The data is broadly categorised by guidance topic and guidance type, namely: cancer service guidance, clinical guidelines, interventional procedures and technology appraisals. Information provided in the guidelines includes key guidance recommendations or priorities, background information, evidence used to compile the report, cost effectiveness, expected benefits and recommendations on implementation and research. The focus is on patient-centred care, with versions available for patients, carers and the public carefully explaining topics in layman's terms. The process of formulating the guidance documents varies according to the type of guideline (Figure 2). Briefly, clinical guidelines are referred by the Department of Health following which stakeholders are registered. The latter includes health professionals and organisations representing patients and carers. A scope and draft guideline is prepared and following a period of consultation, the final guideline is produced. Technology appraisals are also referred by the Department of Health. NICE then commissions an independent academic centre to prepare an assessment report. An independent appraisal committee makes recommendations and, following a consultation period, produces a final document for approval by NICE before the guidance is issued. Interventional procedures are notified to NICE, usually by clinicians, following which interest can be registered by individuals or organisations, via the website. An overview is then prepared by three specialist advisors and reviewed by an independent advisory committee before a consultation document is produced. Consultees are notified and resolution requests dealt with before the guidance is issued.2
The NICE guidance documents relevant to plastic surgery and date of publication are shown in Table 1. Table 2 indicates the number of documents for each sub-specialty.
Cancer care
A significant number of documents pertain to the delivery of care to patients with skin cancer, breast cancer, sarcoma and head and neck cancers. Guidance is given regarding service provision in an attempt to standardise and formalise patient care. Patient-centred care is emphasised together with the importance of the multidisciplinary approach, streamlined referral systems and consistent cancer network protocols. The breast cancer guidelines have relevance to the plastic surgeon in not only providing recommendations with regards breast reconstruction but also in terms of breast cancer management. This will have particular relevance to oncoplastic surgeons who perform both tumour excision and reconstruction. The guidance states that breast reconstruction should be performed by an appropriately trained plastic or breast surgeon and should be available at the time of the initial surgery. If the surgery cannot be done within one month then the patient should be offered the choice of delaying the initial surgery or having a delayed reconstruction.3
Plastic surgeons that perform skin cancer surgery should be well acquainted with the cancer service guidance for skin tumours. Not only was the speciality involved in compiling the guidance document but many local (LSMDT) and specialist skin cancer multidisciplinary teams (SSMDT) will have a core membership of one or more plastic surgeons. Implementation of the guidelines will have significant implications in terms of redistribution of patient care and related resources within the NHS. For example, the manual recommends that patients requiring nodal dissections should be referred to SSMDTs and the surgeons carrying out these procedures should perform at least 15 per year. This will impact on the workload of specialist and local hospitals and appropriate changes to current practices and clinical and financial resources should be made to achieve the anticipated outcomes set out in the guidance document.4
The guidance on improving outcomes for patients with sarcoma provides detailed recommendations for management of bone and soft tissue sarcoma. No reference, however, is made to soft tissue reconstruction.5 The cancer service guidance on head and neck cancer does however provide specific recommendations for the reconstructive surgeon. The surgeon should be proficient in microvascular techniques and dedicate half their programmed activities to head and neck cancer. Appropriate access to intensive care and emergency theatre facilities should also be made available.6
Interventional procedures
The guidance issued on interventional procedures relates to the efficacy and safety of the relevant procedure following a review of the available evidence and consultation with specialist advisors. Together with recommendations, each published document contains an overview of the procedure, a summary of the safety and efficacy data and indicates the sources of evidence.
The number of procedures that have been reviewed is not great and tends to focus on newer treatment modalities. Guidance documents have been produced confirming safety and efficacy for procedures such as division of tongue-tie for breastfeeding7 and photodynamic therapy for non-melanoma skin tumours (excluding squamous cell carcinoma).8
In hand surgery, guidance related to the use of silicone joint replacement for the treatment of pain related to end-stage arthritis concluded that there was adequate evidence on the efficacy and safety of the procedures.9, 10 The NICE guidance on needle fasciotomy for Dupuytren's contracture indicates that the procedure is safe and effective for the short-term improvement of contracture.11
A number of interventional procedures have been reviewed by NICE and deemed to have inadequate evidence on safety and/or efficacy for the procedures to be carried out without specific arrangements for consent or within a research setting. These procedures include: intralesional photocoagulation of subcutaneous congenital vascular disorders,12 minimally invasive placement of pectus bar (Nuss procedure),13 exposed titanium implants for orofacial reconstruction14 endoscopic axillary lymph node retrieval for breast cancer15 and liposuction for chronic lymphoedema.16
General patient care
A number of clinical guidelines related to general patient care have been published by NICE. Recommendations are provided for reducing the risk of venous thromboembolism in surgical patients.17 Although the guidance does not specifically refer to prophylaxis for patients undergoing plastic surgery procedures, the document may be used to develop local guidelines. Also of interest to the plastic surgeon are guidance documents on performing pre-operative tests for elective surgery,18 nutritional support for adults19 and infection control20 although the latter document focussed on primary care. No guidance is provided on infection control in the hospital setting and in relation to hospital acquired infections. Given the recent patient, public and media interest surrounding this topic in the UK, it is possible that NICE may be challenged to deal with this in the near future.
The NICE website has an interesting section on audit that could aid individuals, departments and organisations in conducting clinical audit.21
NICE has not issued guidance or any guidelines relevant to plastic surgery in the areas of burns, lower limb, genitourinary, craniofacial, clefts and aesthetic surgery. The recently highlighted ‘postcode lottery’ for whether aesthetic procedures are performed on the NHS,22 may ultimately be addressed by NICE. Such guidelines may reduce inequalities in the NHS but may also result in a further rationing of services.
NICE is frequently quoted in the British media with reference to high profile anticancer therapy and Alzheimer's disease treatment but its interventional procedures guidance has been somewhat overlooked. It is likely that with increasing media interest, patients will become more aware of the guidelines produced by NICE. This may lead to patients presenting to surgeons with pre-conceived ideas about their care based on NICE guidance. Furthermore, the medical profession is under constant pressure to adhere to evidence-based medicine as well as local and national guidelines. It is therefore important that plastic surgeons are aware of published guidance to be able to counsel patients appropriately and ensure quality of care. Conversely, this website may be recommended as a source of information to patients and to reassure patients that they are receiving care compatible with national standards. The NICE website may also be a useful educational tool for plastic surgeons in training and aid preparation for examinations.
We believe it is important that plastic surgeons submit topics to NICE for consideration. Surgeons should also be aware that the Institute states that if a procedure is being used for the first time in the NHS the doctor concerned is responsible for notifying NICE.
Plastic surgeons have been involved in producing guidelines for treating a variety of conditions, most notably skin cancer,23 and are clearly aware of the importance of guidelines that are informative but yet not dictatorial. As such, plastic surgery management is tailored to an individual patient's needs based on their clinical problem, their activities and ultimately their wishes. Guidelines may be helpful to aid decision-making but are not the answer for all aspects of patient care. Nevertheless, the NICE website should be watched with interest.
Conflict of interest statement
None.
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