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Profile of the Consensus Development Program in the United Kingdom: The King's Fund Forum Jackie Spiby NATIONAL CONTEXT The consensus development program in the United Kingdom was initiated by Barbara Stocking and Bryan Jennett. These two indi- viduals had observed the consensus development program in the United States and were eager to develop similar conferences in the United Kingdom. They approached various funding bodies to sup- port the initiative and eventually obtained funding for the first con- ference from the Kings Fund. This funding was then extended for three additional conferences and subsequently for another four, for a total of eight. The King's Fund is an independent charitable organization con- cerned with the development of health services, management train- ing, and policy analysis in the heady care arena. The independence of the Fund allows the consensus development program to bring together a wide variety of individuals from different organizations to work together and speak freely on medical technology assess- ment. The King's Fund has a very extensive network within the health services and is generally wed regarded. The purpose of the consensus development program is to promote public debate about important controversial issues. The program aims to produce an authoritative independent consensus statement that can be used to initiate changes in health services and stimulate i3i

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132 CONSENSUS DEVELOPMENT research. The initial program was also established to experiment with and investigate the usefulness of consensus development con- ferences within the U.K. context. The primary users of the statement vary according to the topic but include national and local policymakers, clinicians, hospital manag- ers, health professionals, and consumers. SCOPE OF THE PROGRAM The King's Fund established the consensus development program specifically to investigate the applicability of the format of a con- sensus development conference for different topics in health care; therefore, the program has included clinical, public health, and so- cial policy issues (Table I). The topics are chosen by the King's Fund Fora Steering Group, a multidisciplinary group of senior members in the health care field that oversees the whole program of conferences. This group is chaired by Bryan Jennett. Suggestions for topics are received from a variety of sources, and a short list is produced by the Steering Group. The main criteria used for inclusion of a topic in the program are the following. It is an important public health issue. There is multidisciplinary involvement. There is real controversy. There are data available. There is public interest. It is timely. It is considered that the consensus development format is ac- ceptable for investigation of the particular problem. It is considered that change can be identified and that there is potential for initiating change. Specific technologies or clinical problems may be assessed in the program. Once the Steering Group chooses a topic, all relevant issues are included in the assessment, for example, legal, economic, political, social, and organizational issues. A technology may be considered at any stage in its life cycle.

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KING'S FUND FORUM TABLE ~ Consensus Development Conferences in the United Kingdom, 1984-1989 133 Title Date Special Features Coronary Artery Bypass Surgery Breast Cancer Treatment Role of Asylum in Society Prenatal Screening Treatment of Spoke Intensive Care December 1987 Cholesterol Measurement In the June 1989 Prevention of Coronary Heart Disease November 1984 October 1986 April 1987 First U.K. conference Nonrnedic al charm an Broader policy issues considered Major ethical issues considered June 1988 Return to more clinically based topic April 1989 1h collaboration with the K~ng's Fund Institute- expert panel producing statement prior to the conference Less than half of the panel was medically qualified FORMAT AND CONDUCT OF THE PROCESS The consensus development process for each conference lasts approximately one year from the time the Steering Group selects the topic to the publication of the final consensus statement. The actual conference itself lasts for three days. Staff of the King's Fund Fora conduct a wide-ranging search to identify speakers and other contributors. They are informed in this process by a planning group that participates in the development of each conference. Each conference has a unique planning group. The search includes a computer search; interviews; literature re- view; and discussions with leading experts, policy institutes, the Department of Health, etc. The King's Fund staff and the planning group choose the 12- person panel to provide a broad range of expertise. No more than six members are medically trained. Any panel would generally in- clude clinicians, an epidemiologist, a statistician, an economist, a consumer, a nurse, and a manager. However, the final balance of the professionals is dependent on the actual subject. The pane} is

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34 CONSEI`JSUS DEVELOPMENT nonexpert on the topic of the conference. However, one or two unbiased experts are included with the intent that they ensure that the pane} does not misinterpret the information. The relationship between the speaker and the data varies depend- ing on the particular topics. Speakers may be asked to present their own data, but often speakers present an overview. On occasion, the Fora program has commissioned specific work, especially economic analysis for a conference. The general format of the conference follows the style of the U.S. National Institutes of Health quite closely. The first day and a half consist of expert presentations and audience discussion. Sufficient time is provided for audience discussion, and the chairman is ex- pected to ensure that the public is allowed to participate. Consider- able effort is made to ensure that the audience is composed of profes- sionals from different disciplines. Space in the audience is provided for members of the public. On the second day of the conference, during an open session, approximately ten members of the audience provide three-minute presentations on the topic. The panel then retires for the second afternoon and the morning of the third day to produced their statement. Each panel has managed to get some sleep on the night of the second day. The statement is then taken back to the audience for general discussion on the afternoon of the third day. The panel finalizes the statement during the end of the afternoon of the third day. Approximately 50 percent of the audi- ence return to discuss the statement, and a lively debate usually occurs. The consensus statement cannot be modified once the panel completes the review during the conference. DOCUMENTATION AND USE OF EVIDENCE IN CONSENSUS DEVELOPMENT The King's Fund Fora staff assembles the information for the consensus development process. Initially, the staff conducts com- puter searches and wide-ranging literature reviews, along with inter- views of experts and other knowledgeable people, to identify major issues and controversies. In view of the variety of issues considered by the conference, the staff uses many different types of literature in the search process (e.g., national reports, clinical trials, epidemio- logic studies, literature reviews, editorials, and books). Before the conference, the pane} members receive a comprehen-

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ACING'S FUND FORUM 135 sive selection of readings from the literature. The reading packet has included one or two introductory texts for those members who lack specific knowledge of the topic. Pane} members also receive a 1,000-word abstract on the conference presentations from each speaker. There is no prior weighting of the evidence by the confer- ence staff. The panel is instructed to place considerable primary emphasis on the scientific evidence presented. Expert opinion should serve to support the available scientific evidence. inevitably, during the course of the conference, the pane} receives conflicting expert opinions. The comments of consumers from the audience are often important to the panel. The conference organizers try to provide an objective consumer view based on available scientific research. The consensus statements do not cite references. Citations are not relevant for the statement, as it is produced in a format of ap- proximately 3,000 words. References and identification of the evi- dence used can be found in the abstract book produced for each conference. DISSEMINATION AND IMPACT The announcement of the conference is made both in the relevant journals and by direct mailings. Evidence from the field of market research and from an unpublished study on the conference indicates that direct mailing is much more successful in increasing attendance. A press conference is held on the afternoon of the third day of the conference to make direct contact with members of the press. Sev- eral of Me conferences have succeeded in attracting attention from the radio and television media. Within a week, the statement is published and copies are sent to the press, relevant organizations, every district and regional health authority, and relevant clinicians. The statement is then available on request. The statement is usually published in the British Medical Journal the week following the conference. Editorials and articles in other relevant journals are also produced. The intended impact of the statement depends on the content of the statement. The program aims to influence national and local policymakers, clinicians, other health professionals, and consumers. The statement does not always influence all of these groups. The statements are used by organizations as appropriate for their pur- / /

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136 CONSENSUS DEVELOPMENT poses. The King's Fund uses me statement within the Acute Serv- ices Program to develop standards and create health service develop- ment. The Fora program has been evaluated formally and informally (Table 2~. The results of these evaluations provide an ongoing form of assessment and are continually used to modify and enhance the program. Table 2 provides evidence of the impact of the consensus development process. The King's Fund continues to review and evaluate the consensus development program. TABLE 2 Evaluation Activities in Relation to King's Fund Fora Program Program Aspect Evaluation Activity Consensus meeting procedure Role of consumers Intemational comparison Review of impact After all conferences the panel, speakers, and audience are surveyed as part of the regular monitoring and development of the program. Following the breast cancer conference, the role of the consumer in a consensus development conference and the accessibility of the state- ment to the public were reviewed. Ph.D. thesis comparing U.S. and U.K. conferences. Survey of managers and clinicians following Coronary Artery Bypass Surgery conference to assess awareness of tile statement and resultant change. Survey of nurses and consumers following Breast Cancer Treatment conference to review use made of statement. Survey of regional health authorities to consider impact of genetic screening statement on influencing regional policy. First phase of a study to review the impact of the statement of the Impact of Stroke conference has been undertaken to identify how close services mirror the recommendations. Follow- up is to take place two years postconference. Contact established with a small group of indi- viduals who identified themselves as wishing to utilize the statement of the Impact of Stroke conference to initiate change. The progress that has been achieved is being monitored.