assessment for harmful drinking and alcohol dependence · assessment for harmful drinking and...
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Assessment for harmful drinking and alcoholAssessment for harmful drinking and alcoholdependencedependence
NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/alcohol-use-disordersNICE Pathway last updated: 10 October 2017
This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.
Alcohol-use disordersAlcohol-use disorders© NICE 2018. All rights reserved. Subject to Notice of rights.
Page 1 of 21
Assessment for harmful drinking and alcohol dependenceAssessment for harmful drinking and alcohol dependence NICE Pathways
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1 Person aged 10 or over who may be drinking harmfully or dependenton alcohol
No additional information
2 Information and support
When working with people who misuse alcohol:
build a trusting relationship and work in a supportive, empathic and non-judgmental manner
take into account that stigma and discrimination are often associated with alcohol misuseand that minimising the problem may be part of the service user's presentation
make sure that discussions take place in settings in which confidentiality, privacy anddignity are respected.
When working with people who misuse alcohol:
provide information appropriate to their level of understanding about the nature andtreatment of alcohol misuse to support choice from a range of evidence-based treatments
avoid clinical language without explanation
make sure that comprehensive written information is available in an appropriate languageor, for those who cannot use written text, in an accessible format
provide independent interpreters (that is, someone who is not known to the service user) ifneeded.
NICE has written information for the public explaining its guidance on treating harmful drinking
and alcohol dependence and physical health problems caused by drinking alcohol.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
1. Awareness training for health and social care staff
Assessment for harmful drinking and alcohol dependenceAssessment for harmful drinking and alcohol dependence NICE Pathways
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3 Principles for assessment
Make sure that assessment of risk is part of any assessment, that it informs the development of
the overall care plan, and that it covers risk to self (including unplanned withdrawal, suicidality
and neglect) and risk to others.
When conducting an initial assessment, as well as assessing alcohol misuse, the severity of
dependence and risk, consider the:
extent of any associated health and social problems
need for assisted alcohol withdrawal.
Use formal assessment tools to assess the nature and severity of alcohol misuse, including the:
AUDIT for identification and as a routine outcome measure
SADQ or LDQ for severity of dependence
CIWA–Ar for severity of withdrawal
APQ for the nature and extent of the problems arising from alcohol misuse.
When assessing the severity of alcohol dependence and determining the need for assisted
withdrawal, adjust the criteria for women, older people, children and young people, and people
with established liver disease who may have problems with the metabolism of alcohol.
Staff treating people with alcohol dependence presenting with an acute unplanned alcohol
withdrawal should refer to acute alcohol withdrawal, alcohol-related liver disease and alcohol-
related pancreatitis.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
5. Assessment in specialist alcohol services – adults
13. Outcomes monitoring
Assessment for harmful drinking and alcohol dependenceAssessment for harmful drinking and alcohol dependence NICE Pathways
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4 Person aged 10-17
No additional information
5 Agree treatment goals
In the initial assessment in specialist alcohol services of all people who misuse alcohol, agree
the goal of treatment with the service user. Abstinence is the appropriate goal for most people
with alcohol dependence, and people who misuse alcohol and have significant psychiatric or
physical comorbidity (for example, depression or alcohol-related liver disease). When a service
user prefers a goal of moderation but there are considerable risks, advise strongly that
abstinence is most appropriate, but do not refuse treatment to service users who do not agree
to a goal of abstinence.
For harmful drinking or mild dependence, without significant comorbidity, and if there is
adequate social support, consider a moderate level of drinking as the goal of treatment unless
the service user prefers abstinence or there are other reasons for advising abstinence.
For people with severe alcohol dependence, or those who misuse alcohol and have significant
psychiatric or physical comorbidity, but who are unwilling to consider a goal of abstinence or
engage in structured treatment, consider a harm reduction programme of care. However,
ultimately the service user should be encouraged to aim for a goal of abstinence.
When developing treatment goals, consider that some people who misuse alcohol may be
required to abstain from alcohol as part of a court order or sentence.
For all children and young people aged 10-17 years who misuse alcohol, the goal of treatment
should usually be abstinence in the first instance.
6 Brief triage assessment
If alcohol misuse is identified as a potential problem, with potential physical, psychological,
educational or social consequences, in children and young people aged 10–17 years, conduct
an initial brief assessment to assess:
the duration and severity of the alcohol misuse (the standard adult threshold on the AUDITfor referral and intervention should be lowered for young people aged 10–16 years becauseof the more harmful effects of a given level of alcohol consumption in this population)
Assessment for harmful drinking and alcohol dependenceAssessment for harmful drinking and alcohol dependence NICE Pathways
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any associated health and social problems
the potential need for assisted withdrawal.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
6. Assessment in specialist services – children and young people
7 Comprehensive assessment
Refer all children and young people aged 10–15 years to CAMHS for a comprehensive
assessment of their needs, if their alcohol misuse is associated with physical, psychological,
educational and social problems and/or comorbid drug misuse.
When considering referral to CAMHS for young people aged 16–17 years who misuse alcohol,
use the same referral criteria as for adults.
A comprehensive assessment for children and young people (supported if possible by additional
information from a parent or carer) should assess multiple areas of need, be structured around
a clinical interview using a validated clinical tool (such as the ADI or the T-ASI), and cover the
following areas:
consumption, dependence features and patterns of drinking
comorbid substance misuse (consumption and dependence features) and associatedproblems
mental and physical health problems
peer relationships and social and family functioning
developmental and cognitive needs, and educational attainment and attendance
history of abuse and trauma
risk to self and others
readiness to change and belief in the ability to change
obtaining consent to treatment
developing a care plan and risk management plan.
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See also what NICE says on coexisting severe mental illness and substance misuse:
community health and social care services.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
6. Assessment in specialist services – children and young people
8 Person aged 18 or over
No additional information
9 Agree treatment goals
In the initial assessment in specialist alcohol services of all people who misuse alcohol, agree
the goal of treatment with the service user. Abstinence is the appropriate goal for most people
with alcohol dependence, and people who misuse alcohol and have significant psychiatric or
physical comorbidity (for example, depression or alcohol-related liver disease). When a service
user prefers a goal of moderation but there are considerable risks, advise strongly that
abstinence is most appropriate, but do not refuse treatment to service users who do not agree
to a goal of abstinence.
For harmful drinking or mild dependence, without significant comorbidity, and if there is
adequate social support, consider a moderate level of drinking as the goal of treatment unless
the service user prefers abstinence or there are other reasons for advising abstinence.
For people with severe alcohol dependence, or those who misuse alcohol and have significant
psychiatric or physical comorbidity, but who are unwilling to consider a goal of abstinence or
engage in structured treatment, consider a harm reduction programme of care. However,
ultimately the service user should be encouraged to aim for a goal of abstinence.
When developing treatment goals, consider that some people who misuse alcohol may be
required to abstain from alcohol as part of a court order or sentence.
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10 Brief triage assessment
All adults who misuse alcohol who are referred to specialist alcohol services should have a brief
triage assessment to assess:
the pattern and severity of the alcohol misuse (using AUDIT) and severity of dependence
(using SADQ)
the need for urgent treatment including assisted withdrawal
any associated risks to self or others
the presence of any comorbidities or other factors that may need further specialistassessment or intervention.
Agree the initial treatment plan, taking into account the service user's preferences and
outcomes of any previous treatment.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
5. Assessment in specialist alcohol services – adults
11 Comprehensive assessment
Consider a comprehensive assessment for all adults referred to specialist alcohol services who
score more than 15 on the AUDIT. A comprehensive assessment should assess multiple areas
of need, be structured in a clinical interview, use relevant and validated clinical tools, and cover
the following areas:
alcohol use, including:
consumption: historical and recent patterns of drinking (using, for example, aretrospective drinking diary), and if possible, additional information (for example,from a family member or carer)
dependence (using, for example, SADQ or LDQ)
alcohol-related problems (using, for example, APQ)
other drug misuse, including over-the-counter medication
physical health problems
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psychological and social problems
cognitive function (using, for example, the MMSE)
readiness and belief in ability to change.
Assess comorbid mental health problems as part of any comprehensive assessment, and
throughout care for the alcohol misuse, because many comorbid problems (though not all) will
improve with treatment for alcohol misuse. Use the assessment of comorbid mental health
problems to inform the development of the overall care plan. See also what NICE says on
coexisting severe mental illness and substance misuse: community health and social care
services.
For service users whose comorbid mental health problems do not significantly improve after
abstinence from alcohol (typically after 3–4 weeks), consider providing or referring for specific
treatment.
Consider measuring breath alcohol as part of the management of assisted withdrawal.
However, breath alcohol should not usually be measured for routine assessment and monitoring
in alcohol treatment programmes.
Consider blood tests to help identify physical health needs, but do not use blood tests routinely
for the identification and diagnosis of alcohol-use disorders.
Consider brief measures of cognitive functioning (for example, MMSE) to help with treatment
planning. Formal measures of cognitive functioning should usually only be performed if
impairment persists after a period of abstinence or a significant reduction in alcohol intake.
See what NICE says on multimorbidity.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
5. Assessment in specialist alcohol services – adults
12 Interventions
See Alcohol-use disorders / Interventions for harmful drinking and alcohol dependence
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13 Family and carers
Encourage families and carers to be involved in the treatment and care of people who misuse
alcohol to help support and maintain positive change.
When families and carers are involved in supporting a person who misuses alcohol, discuss
concerns about the impact of alcohol misuse on themselves and other family members, and:
provide written and verbal information on alcohol misuse and its management, includinghow families and carers can support the service user
offer a carer's assessment where necessary
negotiate with the service user and their family or carer about the family or carer'sinvolvement in their care and the sharing of information; make sure the service user's,family's and carer's right to confidentiality is respected.
When the needs of families and carers of people who misuse alcohol have been identified:
offer guided self-help, usually consisting of a single session, with the provision of writtenmaterials
provide information about, and facilitate contact with, support groups (such as self-helpgroups specifically focused on addressing the needs of families and carers).
If the families and carers of people who misuse alcohol have not benefited, or are not likely to
benefit, from guided self-help and/or support groups and continue to have significant problems,
consider offering family meetings. These should:
provide information and education about alcohol misuse
help to identify sources of stress related to alcohol misuse
explore and promote effective coping behaviours
usually consist of at least five weekly sessions.
All staff in contact with parents who misuse alcohol and who have care of or regular contact with
their children, should:
take account of the impact of the parent's drinking on the parent–child relationship and thechild's development, education, mental and physical health, own alcohol use, safety, andsocial network
be aware of and comply with the requirements of the Children Act (2004).
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Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
7. Families and carers
14 Staff competencies
Staff working in services provided and funded by the NHS who care for people who potentially
misuse alcohol should be competent to identify harmful drinking and alcohol dependence. They
should be competent to initially assess the need for an intervention or, if they are not competent,
they should refer people who misuse alcohol to a service that can provide an assessment of
need.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Alcohol-use disorders: diagnosis and management quality standard
1. Awareness training for health and social care staff
3. Referral to specialist alcohol services
4. Trained and competent specialist staff
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Glossary
ADI
adolescent diagnostic interview
Alcohol dependence
A cluster of behavioural, cognitive and physiological factors that typically include a strong desire
to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may
persist in drinking, despite harmful consequences. They will also give alcohol a higher priority
than other activities and obligations. For further information please refer to: 'Diagnostic and
statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and
'International statistical classification of diseases and related health problems – 10th revision'
(ICD-10) (World Health Organization 2007).
Alcohol treatment
a programme designed to reduce alcohol consumption or any related problems; it could involve
a combination of counselling and medicinal solutions
Alcohol-related harm
Physical or mental harm caused either entirely or partly by alcohol. If it is entirely as a result of
alcohol, it is known as 'alcohol-specific'. If it is only partly caused by alcohol it is described as
'alcohol-attributable'.
Alcohol-use disorders
Alcohol-use disorders cover a wide range of mental health problems as recognised within the
international disease classification systems (ICD-10, DSM-IV). These include hazardous and
harmful drinking and alcohol dependence.
CI
Confidence interval. There is always some uncertainty in research. This is because a small
group of people is studied to predict the effects of an intervention on the wider population. The
confidence interval is a way of expressing how certain we are about the findings from a study,
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using statistics. It gives a range of results that is likely to include the 'true' value for the
population.
The CI is usually stated as '95% CI', which means that the range of values has a 95 in a 100
chance of including the 'true' value. For example, a study may state that 'based on our sample
findings, we are 95% certain that the 'true' population blood pressure is not higher than 150 and
not lower than 110'. In such a case the 95% CI would be 110 to 150.
A wide confidence interval indicates a lack of certainty about the true effect of the test or
treatment – often because a small group of patients has been studied. A narrow confidence
interval indicates a more precise estimate (for example, if a large number of patients have been
studied).
APQ
alcohol problems questionnaire
ASA
Advertising Standards Authority
AUDIT
AUDIT is an alcohol screening test designed to see if people are drinking harmful or hazardous
amounts of alcohol. It can also be used to identify people who warrant further diagnostic tests
for alcohol dependence.
OR
Odds ratio. Odds are a way to represent how likely it is that something will happen (the
probability). An odds ratio compares the probability of something in one group with the
probability of the same thing in another.
An odds ratio of 1 between two groups would show that the probability of the event (for example
a person developing a disease, or an intervention working) is the same for both.
Sometimes probability can be compared across more than two groups – in this case, one of the
groups is chosen as the 'reference category', and the odds ratio is calculated for each group
compared with the reference category. For example, to compare the risk of dying from lung
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cancer for non-smokers, occasional smokers and regular smokers, non-smokers could be used
as the reference category. Odds ratios would be worked out for occasional smokers compared
with non-smokers and for regular smokers compared with non-smokers.
BAC
blood alcohol concentration
Brief interventions
This can comprise either a short session of structured brief advice or a longer, more
motivationally-based session (that is, an extended brief intervention). Both aim to help someone
reduce their alcohol consumption (sometimes even to abstain) and can be carried out by non-
alcohol specialists.
CIWA–Ar
The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated
10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal
syndrome, and to monitor and medicate patients throughout withdrawal.
RCT
Randomised controlled trial. A study in which a number of similar people are randomly assigned
to two (or more) groups to test a specific drug or intervention. One group (the experimental
group) receives the intervention being tested, the other (the comparison or control group)
receives an alternative intervention, a dummy intervention (placebo) or no intervention at all.
The groups are followed up to see how effective the experimental intervention was. Outcomes
are measured at specific times and any difference in response between the groups is assessed
statistically. This method is also used to reduce bias.
CAMHS
child and adolescent mental health service
DCSF
Department for Children, Schools and Families
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Decompensated liver disease
liver disease complicated by jaundice, ascites, variceal bleeding or hepatic encephalopathy
Diversion
when the drug is being taken by someone other than for whom it was prescribed
Extended brief intervention
This is motivationally-based and can take the form of motivational-enhancement therapy or
motivational interviewing. The aim is to motivate people to change their behaviour by exploring
with them why they behave the way they do and identifying positive reasons for making change.
Extended brief interventions
This is motivationally-based and can take the form of motivational-enhancement therapy or
motivational interviewing. The aim is to motivate people to change their behaviour by exploring
with them why they behave the way they do and identifying positive reasons for making change.
ES
Effect size. A measure that shows the magnitude of the outcome in one group compared with
that in a control group.
For example, if the absolute risk reduction is shown to be 5% and it is the outcome of interest,
the effect size is 5%.
The effect size is usually tested, using statistics, to find out how likely it is that the effect is a
result of the treatment and has not just happened by chance (that is, to see if it is statistically
significant).
Fixed-dose medication regimen
involves starting treatment with a standard dose, not defined by the level of alcohol withdrawal,
and reducing the dose to zero over 7-10 days according to a standard protocol
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Fixed-dose medication regimens
involve starting treatment with a standard dose, not defined by the level of alcohol withdrawal,
and reducing the dose to zero over 7-10 days according to a standard protocol
FRAMES
FRAMES is an acronym summarising the components of a brief intervention. Feedback (on the
client's risk of having alcohol problems), responsibility (change is the client's responsibility),
advice (provision of clear advice when requested), menu (what are the options for change?),
empathy (an approach that is warm, reflective and understanding) and self-efficacy (optimism
about the behaviour change).
GHB
gammahydroxybutyrate
i
NICE analysts have calculated this figure using data from the original study.
GGT
gamma glutamyl transferase
ICER
Incremental cost effectiveness ratio. A measure of the cost effectiveness of a treatment or
health intervention. It estimates how much more the benefits of a certain treatment cost,
compared with other treatments or health interventions.
GUM
genito-urinary medicine
NNT
Number needed to treat. The average number of people who need to receive an intervention to
get a positive outcome. For example, if the NNT is four, then 4 people would have to receive the
intervention to ensure one of them gets better. The closer the NNT is to one, the better the
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intervention. However, as with most data, caution is needed when considering whether results
apply to populations beyond the sample described in the original study.
GMC's
General Medical Council's
LDQ
Leeds dependence questionnaire
Looked-after children
The term 'looked after' has a specific legal meaning. It refers to children and young people who
are provided with accommodation on a voluntary basis for more than 24 hours. This compares
with the term 'in care' which refers to those who are compulsorily removed from home and
placed in care under a court order.
MMSE
mini-mental state examination
PCTs
primary care trusts
PAT
Paddington alcohol test
QALY
Quality-adjusted life year. A measure of the state of health of a person or group in which the
benefits, in terms of length of life, are adjusted to reflect the quality of life. One QALY is equal to
1 year of life in perfect health.
QALYS are calculated by estimating the years of life remaining for a person following a
particular treatment or intervention and weighting each year with a quality of life score (on a
zero to one scale). It is often measured in terms of the person's ability to perform the activities of
daily life, freedom from pain and mental disturbance.
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Responsible authorities
Responsible authorities have to be notified of all licence variations and new applications and
can make representations regarding them. The Licensing Act 2003 lists responsible authorities.
They include the police, environmental health, child protection service, fire and rescue and
trading standards.
SADQ
severity of alcohol dependence questionnaire
SD
Standard deviation. A measure used to summarise numerical data and describe how 'spread
out' a set of measures (or 'values') are from the average. For example, the average height of a
group of schoolchildren can be calculated using the total of all their heights added together and
then divided by the number of schoolchildren in the group. Standard deviation measures the
'spread' of those heights. So, in the example it tells you whether all those in the group were
about the same height or whether some were very tall and some were short.
Saturated
In relation to licensed premises, this describes a specific geographical area where there are
already a lot of premises selling alcohol – and where the awarding of any new licences to sell
alcohol may contribute to an increase in alcohol-related disorder.
Schools
For the purposes of this guidance, schools include: state-sector, special and independent
primary and secondary schools; city technology colleges, academies and grammar schools;
pupil referral units, secure training and local authority secure units; and further education
colleges.
Screening
For the purposes of this guidance, screening involves identifying people who are not seeking
treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may
use any contact with clients to carry out this type of screening. The term is not used here to
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refer to national screening programmes such as those recommended by the UK National
Screening Committee.
SSRIs
selective serotonin reuptake inhibitors
SPC
summary of product characteristics
Structured brief advice
a brief intervention that takes only a few minutes to deliver
T-ASI
teen addiction severity index
Treatment
a programme designed to reduce alcohol consumption or any related problems. It could involve
a combination of counselling and medicinal solutions
Unit
In the UK, alcoholic drinks are measured in units. Each unit corresponds to approximately 8 g or
10 ml of ethanol. The same volume of similar types of alcohol (for example, 2 pints of lager) can
comprise a different number of units depending on the drink's strength (that is, its percentage
concentration of alcohol).
Sources
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol
dependence (2011) NICE guideline CG115
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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
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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 proceduresguidance
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.
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