Developing guidance in NHS Highland

Revised Policy for Management of Policies, Procedures, and other Written Controlled Documents. NHS Highland’s controlled documents are subdivided into: Clinical, Organisational, Financial, Staff and eHealth. This procedure relates to clinical controlled documents (herein called [therapeutic] guidance). Therapeutic guidance can be submitted by any Health or Social Care Professional employed by NHS Highland.

TAM Subgroup

The TAM subgroup is a multidisciplinary, interface working group of NHS Highland’s Area Drug and Therapeutics Committee with Primary & Secondary Care, medical, nursing, allied health professional, pharmacy and lay representatives. Its remit is to maintain the Highland Formulary and the TAM app for Highland Health and Social Care Partnership (HHSCP).

It meets bimonthly (subgroup dates). Guidance received up to 3 weeks prior to a subgroup will be discussed at that subgroup. If considered necessary, the Lead Author may attend to present the guidance.

TAM recommends having multidisiplinary, cross-sector and lay representation in developing guidance. 

Patients

  • Person-centred care includes having patients involved in developing guidance and information about their care. 
  • Information on how to develop a network of lay representatives for your service is included here: Communications and Engagement Team (scot.nhs.uk) (NHS Highland intranet access required)

Primary care

  • Where guidance will impact on GP practice workload, advice from the GP subcommittee should be sought.
  • To contact an individual GP representative, contact Claire Copeland, Deputy Medical Director.

Argyll and Bute:

  • The majority of the content on TAM has been produced by and for North NHS Highland. Where guidance is produced by and for Argyll and Bute, this is stated.

Introduction to the TAM app

TAM (Treatment and Medicines) is a publicly available website and downloadable mobile app. It hosts NHS Highland’s therapeutic guidance, the Highland Formulary and ancillary formularies, patient information and links to recommended national resources. TAM is the recommended resource for point-of-care therapeutic guidance for clinicians working in North NHS Highland.

  • Information that is not suitable for public access, eg. forms and charts for clinical use, is available via a secure link to the forms library of the NHS Highland intranet.
  • No patient identifiable information is hosted on TAM.

PROCESS, CHECKLIST AND TEMPLATE

Documentation 

(Right click the link and copy and paste into a new browser window for the form to open).

  1. Lead Author to download the relevant form(s) as above.
    These give a standardised guidance structure and good governance for the author to follow.
  2. Working group involvement
    It is recommended that guidance is developed collaboratively with multidisciplinary, cross-sector and multiagency involvement. A suggested working group membership is given in the CGC.
  3. Guidance style
    All guidance will be transposed onto the TAM software templates, including in-house flowcharts. Simply prepared guidance is appropriate, such as Word/PowerPoint, and it should remain editable.
  4. Guidance finalisation
    Guidance is to be finalised within the relevant Department prior to submission as per the approval section of the CGC. The TAM subgroup will not accept or comment on draft guidance.
  5. Submission
    Submit the finalised guidance and its completed CGC to nhsh.tam@nhs.scot
  6. TAM subgroup responses
    The subgroup will advise the Lead Author:
    • ACCEPTANCE: Guidance is suitable for uploading to TAM.
    • ACCEPTANCE PENDING: minor amendments will be suggested – Guidance can be published after these have been actioned. No further submission required.
    • REJECTION: major amendments will be suggested - Guidance to be resubmitted.
  7. Guidance upload to TAM
    Accepted guidance is uploaded onto TAM and the Lead Author notified to accuracy check the transcription.
  8. Guidance review
    The TAM team will contact the Lead Author 6, 3 and 1 month before a guideline is due for review. If there is no timely response the request will be escalated to the Clinical Lead. If the guidance is allowed to remain out of date it will be discussed at the next TAM subgroup whether it should be removed, or further action recommended.
  9. Guidance update process
    • Minor amendments:
      Lead Author to complete the Guideline Update Document and send to: nhsh.tam@nhs.scot
    • Major amendments:
      It may be more appropriate to rewrite the guidance and follow the new guideline process above.  
  10. Further information and support
    Contact the TAM team at nhsh.tam@nhs.scot