Changes

September 2024 — new topic. A literature search was conducted in August 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

Goals

To support primary healthcare professionals to:

• Be aware of when to suspect a diagnosis of functional neurological disorder.
• Arrange referral to a neurology, or other, specialist for confirmation of the diagnosis and initial management.
• Arrange referral to the multidisciplinary team, including physiotherapy, occupation therapy, speech and language therapy, and/or mental health services, depending on clinical judgement.
• Advise about sources of information and support.
• Arrange re-referral to neurology or other specialists if clinically appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

NICE quality standards

Suspected neurological conditions: recognition and referral 

• Adults diagnosed with a functional neurological disorder are supported to manage symptoms that are a part of the disorder in non-specialist care.

[NICE, 2021]

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

What is it?

• Functional neurological disorder (FND) is a condition in which a person experiences neurological symptoms caused by a disorder of neurological system functioning, rather than a structural disorder [NICE, 2023]. It can be considered a disorder of 'brain network functioning' [Stone, 2020; Bennett, 2021; Aybek, 2022; FND Action, 2022].
• The term FND is used when these symptoms reach a threshold at which they are causing significant morbidity. More minor symptoms may be termed 'functional neurological symptoms'.
  • FND may affect any part of the nervous system. It can cause a variety of symptoms including motor, sensory, balance, and speech symptoms and functional seizures [Stone, 2020].
  • Diagnosis is made by identifying positive signs of FND in association with symptoms consistent with the disorder. Positive signs include demonstration of internal inconsistency, or signs incongruent with recognized neuroanatomical pathways or pathophysiological disease [Stone, 2020].
• The terminology surrounding FND has been widely debated in the literature, and synonyms include:
  • 'Psychogenic neurological symptoms' [Stone, 2020; Aybek, 2022], 'psychogenic non-epileptic seizures', 'non-epileptic attack disorder', or 'dissociative seizures' [Espay, 2018].
  • 'Conversion disorder/functional neurological symptom disorder' in the section on somatic symptoms and related disorders in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V) [APA, 2020].
  • 'Dissociative neurological symptom disorder' in the International Classification of Diseases 11th Edition (ICD-11) [WHO, 2023].
  • Note: the terms 'pseudoseizures', or 'non-organic' are no longer recommended [Espay, 2018; Aybek, 2022].

What causes it?

The exact pathophysiological cause(s) of functional neurological disorder (FND) is not known, but functional neuroimaging studies suggest it is likely to result from a 'brain network disorder' [Bennett, 2021] [Aybek, 2022; FND Action, 2022].  A biopsychosocial framework model may be helpful, using predisposing, precipitating, and perpetuating factors involving genetics, neural networks, temperament, cognition, emotion, and environmental influences [Espay, 2018].

• The brain network disorder is likely to be within and across several sensorimotor, limbic, pain processing, cognitive, self-agency, and motor planning brain circuits [Bennett, 2021; Aybek, 2022; FND Action, 2022]. It may lead to disturbances in attention, self-agency, prediction/inference, emotion/threat processing, homeostatic balance, and cognitive/motor control [Aybek, 2022].
• Expert opinion in a review article cites evidence from studies that suggest in FND, 'the early pre-conscious phases of motor planning are corrupted by a combination of abnormal involuntary brain-generated predictions about bodily states and interference from more emotionally orientated brain networks such as the limbic system and amygdala' [Stone, 2020].

What are the risk factors?

There are multiple risk factors that may increase the likelihood of, trigger, or maintain functional neurological disorder (FND), but these are not necessary or sufficient to make the diagnosis. Many people do not have an identifiable stressor or life event preceding the onset of symptoms [Keatley, 2022; Stone, 2020; FND Action, 2022].

• Female sex — FND affects about three times more women compared with men. As the age of onset increases, the relative proportion of men affected increases [Bennett, 2021; Aybek, 2022].
• History of coexisting disorder(s) — such as anxiety, chronic pain, depression, fatigue, irritable bowel syndrome, and migraine [Bennett, 2021; Aybek, 2022]. See the CKS topics on Chronic pain, Depression, Generalized anxiety disorder, Irritable bowel syndrome, Migraine, and Tiredness/fatigue in adults for more information.
• History of pre-existing neurological condition(s) [FND Action, 2022].
• History of neurodivergence [Cole, 2023]. See the CKS topics on Attention deficit hyperactivity disorder, Autism in children, and Autism in adults for more information.
• History of either childhood or adult stressful or traumatic life events. If there is a past history of child maltreatment, there is an increased risk of severe symptoms and coexisting mental health problems [Gilmour, 2020; Aybek, 2022; Hallett, 2022]. See the CKS topics on Child maltreatment - recognition and management and Post-traumatic stress disorder for more information.
• Physical trauma — such as an accident or head injury [Espay, 2018; FND Action, 2022; Keatley, 2022]. See the CKS topic on Head injury for more information.

How common is it?

There is a lack of high-quality incidence studies of functional neurological disorder (FND) in the general population, reflecting different study definitions, difficulties with recruitment, and varying study methodologies, populations, and geographic settings [Carson, 2016]. Due to the potential underdiagnosis and variable coding of FND in medical records, the population prevalence may be higher than noted in published studies.

• A handbook of clinical neurology cites limited evidence from grouped epidemiological studies of different sub-types of FND [Carson, 2016].
  • FND accounts for about 6% of neurology outpatient appointments.
  • The community incidence rate for mixed symptoms is estimated at 4–12 per 100,000 population per year; for motor symptoms, it is estimated at 4–5 per 100,000 population per year; and for seizure-type FND, it is estimated at 1.5–4.9 per 100,000 population per year for video-EEG confirmed cases.
  • The community prevalence of mixed symptoms is estimated at 50 per 100,000 population from data in population-based case registers.
  • There is comorbid neurological disease in about 10% of cases.
  • It is more common in women than men, and the peak incidence is between the ages of 35 and 50 years, but it can occur at any age.
• A review article has extrapolated epidemiological study data to estimate that there are about 8000 new diagnoses of FND per year in the UK, and about 50,000–100,000 people affected in the community [Bennett, 2021].
• In a consecutive series of new patients attending outpatient neurology clinic in Scotland over a 15-month period (n = 3781), 5.4% had a primary diagnosis of FND, and 30% had symptoms that were described as only partially or not at all explained by disease [Stone, 2010].

What are the complications?

Functional neurological disorder (FND) is a common cause of persistent and disabling neurological (and other) symptoms [Gilmour, 2020]. Possible complications associated with FND include:

• Distress and disability; negative impact on physical daily functioning and reduced quality of life affecting home, work, social life and relationships, which may be equivalent to that experienced by people with multiple sclerosis or epilepsy [Carson, 2016; Stone, 2020; Bennett, 2021; Aybek, 2022].
• Impact on psychological functioning, including anxiety and depression [Carson, 2016; Bennett, 2021; Aybek, 2022].
• Social stigma and/or suspicion of malingering, including from healthcare professionals [Aybek, 2022; Keatley, 2022; NNAG, 2023].
• Increased mortality rate compared with the general population, but the causes are unclear [Aybek, 2022; Hallett, 2022].
• Healthcare costs, including primary care and outpatient neurology appointments. FND represents the second most common reason for new neurology referral after headache [Stone, 2020; Bennett, 2021].

What is the prognosis?

People with functional neurological disorder (FND) often experience poor long-term physical health and psychosocial outcomes [Keatley, 2022]. This may be partly due to under-recognition of the diagnosis, poor understanding or acceptance of FND, and a lack of specialist FND services [Espay, 2018].

• FND can be a relapsing-remitting condition, and many people experience fluctuations in symptom severity and develop new symptoms over time [Stone, 2020; NNAG, 2023].
• Expert opinion in a review article notes that people with FND are as disabled and have similar impairments in their quality of life as people with other neurological conditions, such as epilepsy and multiple sclerosis [Bennett, 2021].
• A handbook of clinical neurology cites limited evidence from epidemiological studies that [Gelauf, 2016]:
  • Functional motor and seizure-type symptoms remain the same or are worse in the majority of patients at follow-up, and it is difficult to predict outcome.
  • A systematic review of motor symptoms found that 40% of patients had the same or worse outcome, and only 20% had complete remission of symptoms, after a mean duration of 7.4 years of follow-up. In a different systematic review of seizure-type symptoms, the 'total weighted remission rate' was 33% of patients.
  • The frequency of misdiagnosis at follow-up was as low as other neurologic and psychiatric disorders.
  • The studies cited used varying methodologies, and small sample sizes, which limited the conclusions that could be drawn.
• Risk factors associated with a poor prognosis may include:
  • Long duration or very severe symptoms [Stone, 2014; Gelauf, 2016; Espay, 2018].
  • Comorbid depression, personality disorder, and/or chronic pain [Stone, 2014; Espay, 2018; Aybek, 2022; Keatley, 2022].
  • Dissociation and other somatic symptoms [Aybek, 2022].
  • Fixed dystonia or functional seizures [Gelauf, 2016; NNAG, 2023].
  • Dysfunctional interpersonal relations/family dynamics [Aybek, 2022].
  • Escape-avoidance coping mechanisms, negative illness perceptions, perceived stigma about FND diagnosis, and medication adverse effects [Aybek, 2022].
  • Very fixed views about an alternative diagnosis and medicolegal proceedings [Stone, 2014; Espay, 2018].
  • Social isolation and reduced support [Keatley, 2022].

When should I consider a diagnosis of functional neurological disorder?

A 'rule-in' diagnosis of functional neurological disorder (FND) should be made by identifying positive signs of FND in association with symptoms consistent with the disorder. Positive signs include demonstration of internal inconsistency, or signs incongruent with recognized neuroanatomical pathways. FND should not be a diagnosis of exclusion.

• Possible presenting symptoms include:
  • Motor — gain of function such as tremor, dystonia, fixed postures, jerks, or tics; and loss of function such as recurrent limb or facial weakness.
  • Sensory — gain of function such as tingling or tinnitus, and loss of function such as numbness, vision loss, hearing loss, and speech disturbance.
  • Gait impairment — may be caused by multiple factors such as weakness, loss of sensation, and loss of coordination.
  • Persistent postural perceptual dizziness — typically non-vertigo dizziness provoked by upright posture, active or passive motion, and exposure to moving visual stimuli or complex visual patterns.
  • Cognitive — memory problems, mild subjective word-finding difficulties, and concentration difficulties. There may be a discrepancy between self-reported symptoms and objective testing.
  • Functional seizures — suggested if seizure has a fluctuating or irregular course; pauses in the event; or long duration of events. A seizure lasting more than 5 minutes may be suggestive, but is not diagnostic and a diagnosis of epilepsy/status epilepticus must not be missed. See the CKS topic on Epilepsy for more information.
• There should be one or more (usually a combination of) positive clinical signs on examination. This list is not exhaustive. The FND Action publication Information and guidance for medical professionals provides illustrations of positive diagnostic signs that may help to rule in a diagnosis of FND.
  • General
    • Symptom variation with redirection of attention — engage the person in another motor or cognitive task and observe changes in any abnormal movement. Symptoms may worsen when attention is focused on it, and improve when attention is directed elsewhere.
    • Observe changes during history-taking, examination, arriving or leaving the room, and periods of unexplained improvement or disappearance of the symptom.
    • Abnormal eye movements during examination such as excessive blinking, effortful facial expression, increased latency, limited range, and absent frontalis contraction during upgaze.
    • Disproportionate effort for a task during examination, such as huffing, grunting, grimacing, breath holding, heavy breathing, or crying.
  • Gait
    • Monoplegic leg dragging — the weak leg is dragged like a piece of wood or inanimate object, without spastic circumduction, usually along the floor surface.
    • Tendency to fall in the direction of support, such as a wall or furniture.
    • Disproportionate slowness in gait (slow stepping movements with lack of limb bradykinesia).
    • Disproportionate hesitation and caution in gait (contrasting with good balance, strength, and sensation).
    • Sudden knee buckling (sudden loss of tone, usually with each step).
  • Balance
    • Large movements of imbalance during Romberg test, but no history of falls; may improve when attention is directed elsewhere.
  • Limb weakness
    • Weakness present with voluntary, but not involuntary, movement.
    • Discordance or inconsistency of arm or leg weakness, such as weakness of ankle plantar flexion on the bed, but the person is able to walk on tiptoes; global weakness affecting extensors and flexors equally.
    • Give-way weakness — when testing strength against resistance, initially good and then sudden loss of resistance (providing pain is not a cause for symptoms).
    • Leg weakness — there may be weakness of hip extension that improves with contralateral hip flexion against resistance ('Hoover's sign'). This can be assessed lying or sitting.
    • Leg weakness — there may be hip abduction weakness that improves with contralateral hip abduction against resistance ('hip abductor sign').
    • Leg weakness — if severe unilateral leg weakness, passively position both legs in flexion with the soles of the feet on the bed while lying down; observe if the weak leg shows a discordance in strength and stays in this position (rather than falling back on the bed).
  • Dystonia
    • General —  typically presents with a fixed position, such as clenched fist or inverted ankle.
    • Facial — typically presents with episodic contraction of platysma or orbicularis oculi.
  • Tremor
    • Unilateral tremor — the person is asked to copy a rhythmical movement with their unaffected limb. The tremor in the affected limb either ‘entrains’ to the rhythm of the unaffected side, stops completely, or the person is unable to copy the simple rhythmical movement (tremor entrainment test).
  • Sensory
    • Sensory change may have variable boundaries on repeat examination, or not following a known anatomical distribution.
  • Seizures (obtain a collateral description of the event from a witness, and ask if a typical event can be video recorded by a family member or carer, if possible).
    • May be a decrease or increase of motor events and/or pauses in the seizure course.
    • May be suggested by pelvic thrusting, side-to-side head movements, and arching back.
    • Preserved awareness during seizure — others may be able to intensify or alleviate symptoms; eyes may respond to environment and stimuli; person may respond during an event; shaking of limbs without loss of consciousness; may have recall of event.
    • Closed eyes or fluttering eyelids, hyperventilating, or tearfulness during or immediately after seizures.
    • Rapid recovery after seizure and lack of confusion or disorientation after seizure.
• A history of possible coexisting condition(s) or risk factors may further support the diagnosis.
  • Depression, anxiety, panic disorder, and/or post-traumatic stress disorder. See the CKS topics on Depression, Generalized anxiety disorder, and Post-traumatic stress disorder for more information.
  • Chronic pain syndrome — including migraine, chronic headache, joint hypermobility, and fibromyalgia. See the CKS topics on Chronic pain and Migraine for more information.
  • Fatigue. See the CKS topic on Tiredness/fatigue in adults for more information.
  • Irritable bowel syndrome. See the CKS topic on Irritable bowel syndrome for more information.
  • Neurodivergence. See the CKS topics on Attention deficit hyperactivity disorder, Autism in children, and Autism in adults for more information.

How should I assess a person with suspected functional neurological disorder?

If a person presents with clinical features suggesting possible functional neurological disorder (FND):

• Ask about:
  • Motor and sensory symptoms, and any additional symptoms (such as fatigue, pain, sleep disturbance, memory, and dissociative symptoms) including onset and course, duration, frequency, variability, and fluctuations.
    • If there is a history of seizures, obtain a collateral description of the event from a witness where possible.
    • Dissociative symptoms may include 'depersonalisation' (a feeling of being disconnected from your own body) and 'derealisation' (a feeling of being disconnected from the world around you). They may occur at the onset of motor symptoms or seizures, or as part of a seizure. The person may find these symptoms hard to describe.
  • Any specific triggers for symptoms, such as migraine, acute pain or injury, panic disorder, syncope, infection, or medication adverse effect.
  • The person's typical day, impact of symptoms on daily functioning, and good and bad days.
  • Any psychological comorbidity including stress, anxiety, and/or depression, or other risk factors, depending on clinical judgement.
  • Any other associated conditions.
  • Any clinical features suggesting an alternative or coexisting diagnosis.
  • Social situation including relationship dynamics, any dependents including children or elderly, and social support.
  • Any family history of neurological conditions including tics.
  • Previous healthcare professional involvement, diagnostic explanations, and the person's ideas and concerns about symptoms and expectations.
• Examine the person.
  • Make a general assessment of appearance, mental state, behaviour, language, and level of distress caused by symptoms; and whether they are accompanied or attending alone.
  • Perform a full neurological examination, including peripheral and cranial nerves, and gait assessment to check for:
    • Signs of neurological deficit suggesting an alternative or coexisting diagnosis.
    • Positive signs suggesting FND including variability of symptoms/signs and disproportionate effort when performing a task. There is typically a discrepancy between impaired voluntary movement and sensation and intact automatic movement and sensation. See the section on Diagnosis for more information.
    • If there is a history of seizures, ask if a typical event can be video recorded by a family member or carer, if possible.
• If there are clinical features suggesting an alternative or coexisting diagnosis, consider arranging additional investigations and/or specialist referral, depending on clinical judgement.
  • If FND is clinically the most likely diagnosis, consider informing the person that tests for pathophysiological disease are likely to be negative or might show incidental changes.

What else might it be?

Alternative conditions which may present similarly or coexist with functional neurological disorder (FND) are listed below. Be aware that this list is not exhaustive.

• Anxiety disorder. See the CKS topics on Generalized anxiety disorder and Post-traumatic stress disorder for more information.
• Attention deficit hyperactivity disorder and other causes of difficulties with concentration. See the CKS topic on Attention deficit hyperactivity disorder for more information.
• Bell's palsy. See the CKS topic on Bell's palsy for more information.
• Blackouts (transient loss of consciousness) including epilepsy, syncope, and recurrent dizziness or lightheadedness — other causes. See the CKS topics on Blackouts and syncope and Epilepsy for more information.
• Brain and central nervous system cancers. See the CKS topic on Brain and central nervous system cancers - recognition and referral for more information.
• Carpal tunnel syndrome, tingling, and numbness — other causes. See the CKS topic on Carpal tunnel syndrome for more information.
• Chronic pain — can cause give-way weakness on examination due to pain inhibiting motor function. See the CKS topic on Chronic pain for more information.
• Delirium and other causes of acute confusion; dementia and other causes of memory problems; cognitive impairment or decline including sleep disturbance; anxiety and depression; medication adverse effects; and substance misuse. See the CKS topics on Delirium and Dementia for more information.
• Giant cell arteritis and polymyalgia rheumatica. See the CKS topics on Giant cell arteritis and Polymyalgia rheumatica for more information.
• Factitious disorder (wilfully simulating symptoms) or malingering (simulating symptoms for other gain).
• Headache. See the CKS topics on Headache - assessment and Migraine for more information.
• Head injury. See the CKS topic on Head injury for more information.
• Hearing loss. See the CKS topic on Hearing loss in adults for more information.
• Hypothyroidism. See the CKS topic on Hypothyroidism for more information.
• Insomnia and other sleep disorders. See the CKS topic on Insomnia for more information.
• Multiple sclerosis. See the CKS topic on Multiple sclerosis for more information.
• Neuropathic pain including post-herpetic neuralgia, trigeminal neuralgia, and other causes of facial pain. See the CKS topics on Post-herpetic neuralgia and Trigeminal neuralgia for more information.
• Parkinson's disease and other causes of tremor, tics, and involuntary movements, including Tourette's syndrome and tardive dyskinesia; and other neurodegenerative conditions. See the CKS topics on Parkinson's disease for more information.
• Restless legs syndrome. See the CKS topic on Restless legs syndrome for more information.
• Stroke and transient ischaemic attack (TIA); gait unsteadiness, recurrent limb or facial weakness, sensory loss, speech, swallowing, and language problems — other causes. See the CKS topic on Stroke and TIA for more information.
• Tinnitus. See the CKS topic on Tinnitus for more information.
• Tiredness and fatigue — other causes. See the CKS topic on Tiredness/fatigue in adults for more information.
• Vertigo. See the CKS topics on Benign paroxysmal positional vertigo, Vertigo, and Vestibular neuronitis for more information.
• Vitamin B12 deficiency. See the CKS topic on Anaemia - B12 and folate deficiency for more information.

Scenario: Management of functional neurological disorder

From age 18 years onwards.

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of functional neurological disorder.

Unrestricted - August 2024

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Psychogenic neurological symptoms.tw., psychogenic non-epileptic seizures.tw., non-epileptic attack disorder.tw., dissociative seizures.tw., conversion disorder.tw. functional neurological symptom disorder.tw., dissociative neurological symptom disorder.tw.

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work(occupational health practice)

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

• Bandolier
• Drug & amp; Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

• Department of Health
• Health Management Information Consortium(HMIC)

• Healthtalkonline
• BMJ - Patient Journeys

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary(BNF)
• electronic Medicines Compendium(eMC)
• European Medicines Agency(EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency(MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

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• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
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Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

• Animal studies
• Original research is not written in English

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

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None.