Changes

October 2026 — reviewed. A literature search was conducted in September 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring, including consolidation of the Assessment section into one node, to improve clarity and navigation. The recommendations have been updated in line with current evidence in the literature. Various web links to patient and carer information have been added to the topic.

Update

Goals

To support primary healthcare professionals to:

• Assess a person with constipation in a palliative care setting.
• Make a diagnosis and treat the underlying cause of constipation in the palliative care setting, if clinically possible and appropriate.
• Provide information and advice about preventing constipation in people receiving palliative care.
• Provide symptom relief for constipation in the terminal phase of illness and last days of life.

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.

QIPP - Options for local implementation

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

NICE quality standards

End of life care for adults

• Adults who are likely to be approaching the end of their life are identified using a systematic approach.
• Adults approaching the end of their life have opportunities to discuss advance care planning.
• Adults approaching the end of their life receive care that is coordinated between health and social care practitioners within and across different services and organisations.
• Adults approaching the end of their life and their carers have access to support 24 hours a day, 7 days a week.
• Carers providing end of life care to people at home are supported to access local services that can provide assistance.

[NICE, 2021]

Decision-making and mental capacity

• People aged 16 and over who may lack capacity to make decisions are supported with decision-making in a way that reflects their individual circumstances and meets their particular needs.
• People aged 16 and over at risk of losing capacity to make decisions, and those with fluctuating capacity, are given the opportunity to discuss advance care planning at each health and social care review.
• People aged 16 and over who are assessed as lacking capacity to make a particular decision at the time that decision needs to be made, have a clear record of the reasons why they lack capacity and the practicable steps taken to support them.
• People aged 16 and over who lack capacity to make a particular decision at the time that decision needs to be made have their wishes, feelings, values and beliefs accounted for in best interests decisions.

[NICE, 2020]

What is it?

• Constipation is a symptom defined as the slow movement of faeces through the large intestine, resulting in infrequent bowel movements and the difficult passage of dry, hard stools [Regnard, 2010] [Larkin, 2018].
  • The causes of constipation may be primary (colonic or anorectal dysfunction) or secondary (disease- or medication-related). The average colonic transit time is 20–72 hours [Larkin, 2018].
  • The definition of constipation is subjective, depending on the person's individual perception of normal bowel habit [Larkin, 2018].
• Chronic constipation may be defined as any two of the following clinical features for at least 12 weeks in the previous 12 months [Larkin, 2018]:
  • Straining during bowel movements.
  • Lumpy or hard stool.
  • Sensation of incomplete evacuation.
  • Sensation of anorectal blockage or obstruction.
  • Manual evacuation needed to remove stool.
  • Less than three bowel movements per week.
• Opioid-induced constipation is defined as the onset of new or worsening of pre-existing constipation symptoms during the initiation, modification, or escalation of opioid therapy [Dzierzanowski, 2025].

How common is it?

The prevalence of constipation in the palliative care setting varies with the underlying cause or site of disease, the stage of illness, and treatment(s). It is common in advanced illness and is often under-recognised and under-treated [Larkin, 2018] [Twycross, 2021].

• The prevalence of constipation in people with advanced cancer ranges between 40–90%, depending on the diagnostic criteria used [Larkin, 2018].
• Expert opinion in a palliative care textbook cites evidence that about 50% of people admitted to a hospice in the UK are noted to have constipation [Sykes, 2015].
• Expert opinion in a review article cites evidence from prospective observational studies that opioid-induced constipation occurs in about 59% of people with cancer, the exact prevalence varying with the specific opioid used and its route of administration [Dzierzanowski, 2025]. Another review article cites evidence that opioid-induced constipation occurs in up to 87% of people in the terminal phase of illness [Bolland, 2022].
• The prevalence of constipation increases with age, and older people are five times more likely to have constipation than young people, due to factors such as polypharmacy, disease progression, reduced mobility, reduced hydration, and reduced urge to defaecate [Larkin, 2018].

What causes it?

There is a wide range of possible underlying causes of constipation in advanced disease in the palliative care setting, including direct and indirect effects of disease, psychological, social, and environmental factors.

• Direct causes due to cancer [Regnard, 2010] [Sykes, 2015] [Larkin, 2018] 
  • Bowel obstruction due to abdominal tumour mass or external compression from abdominal or pelvic mass.
  • Anorectal pain or abdominal pain due to tumour.
  • Compression or infiltration of the lumbosacral spinal cord or brain, cauda equina, or pelvic plexus.
  • Peritoneal carcinomatosis.
  • Autonomic neuropathy, for example due to small cell lung cancer or carcinoid tumours.
• Indirect causes due to cancer or other advanced disease [Regnard, 2010] [Sykes, 2015] [Larkin, 2018] [Twycross, 2021]
  • Reduced fluid and food intake, including dietary fibre; loss of appetite. See the CKS topic on Adult malnutrition for more information.
  • Dehydration (causing excessive dryness of faecal content).
  • Uraemia. See the CKS topics on Acute kidney injury and Chronic kidney disease for more information.
  • Hypercalcaemia. See the CKS topic on Hypercalcaemia for more information.
  • Breathlessness or pain preventing effective straining. See the CKS topics on Palliative care - breathlessness and Palliative cancer care - pain for more information.
  • Confusion, drowsiness, or delirium. See the CKS topic on Delirium for more information.
  • Depression or anxiety. See the CKS topics on Depression and Generalized anxiety disorder for more information.
  • Radiation fibrosis.
  • Physical inactivity and deconditioning.
  • Unfamiliar toilet arrangements, need to use a commode or bed pan, need for assistance during toileting, and/or lack of privacy.
• Non-cancer causes [Regnard, 2010] [Sykes, 2015] [Larkin, 2018] [Twycross, 2021]  
  • Diverticular disease, including colonic stricture. See the CKS topic on Diverticular disease for more information.
  • Inflammatory bowel disease. See the CKS topics on Crohn's disease and Ulcerative colitis for more information.
  • Irritable bowel syndrome. See the CKS topic on Irritable bowel syndrome for more information.
  • Endocrine and metabolic causes including diabetes mellitus, hypercalcaemia, hypokalaemia, hypothyroidism, and uraemia. See the CKS topics on Acute kidney injury, Chronic kidney disease, Diabetes - type 1, Diabetes - type 2, Hypercalcaemia, and Hypothyroidism for more information.
  • Inguinal and abdominal hernia. See the CKS topic on Scrotal swelling and pain for more information.
  • Other causes of colonic stricture, such as bowel ischaemia or surgery.
  • Rectocele, rectal prolapse, or rectal ulcer.
  • Anal fissure or stenosis, haemorrhoids. See the CKS topics on Anal fissure and Haemorrhoids for more information.
  • Disordered defecation (incomplete evacuation of faeces from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate) or weak levator ani muscles.
  • Spinal cord damage, neuromuscular, and/or neurodegenerative disease (may reduce perception of rectal distension with loss of urge to defaecate, and/or cause rectal sphincter dysfunction). See the CKS topics on Parkinson's disease and Stroke and TIA for more information.
  • Learning disability. See the CKS topic on Learning disabilities for more information.

• Drugs [Regnard, 2010] [Sykes, 2015] [Larkin, 2018] [Twycross, 2021]
  • Opioids.
  • Antimuscarinics such as cyclizine, hyoscine butylbromide, and oxybutynin; phenothiazines such as levomepromazine; tricyclic antidepressants; antiepileptic drugs such as carbamazepine, phenytoin, gabapentin, and pregabalin; and antiparkinsonian drugs.
  • Antacids (calcium and aluminium compounds).
  • Diuretics such as furosemide.
  • Iron or calcium supplements.
  • Antihypertensive drugs such as calcium-channel blockers.
  • Antiemetic 5-HT3 antagonists such as ondansetron.
  • Platinum-based chemotherapy agents (such as cisplatin or carboplatin) or vincristine.

What are the complications?

• Constipation tends to worsen as illness progresses and can cause multiple complications impacting a person's quality of life, due to [Regnard, 2010] [Sykes, 2015] [Larkin, 2018] [Twycross, 2021] [Dzierzanowski, 2025]:
  • Dehydration, electrolyte imbalance, acute kidney injury, increased agitation, and/or delirium. See the CKS topics on Acute kidney injury and Delirium for more information.
  • Bowel obstruction due to abdominal or pelvic malignancy or adhesions, bowel perforation, and/or bacterial translocation leading to sepsis. See the CKS topics on Constipation and Sepsis for more information.
  • Faecal impaction and incontinence due to overflow diarrhoea. See the CKS topic on Faecal incontinence in adults for more information.
  • Urinary tract infection, urinary retention and incontinence due to faecal impaction. See the CKS topics on Incontinence - urinary, in women, Urinary tract infection (lower) - men, and Urinary tract infection (lower) - women for more information.
  • Rectal bleeding, anal fissure, haemorrhoids, rectal prolapse. See the CKS topics on Anal fissure and Haemorrhoids for more information.
  • Pressure ulcer and/or rectal ulcer due to faecal impaction. See the CKS topic on Pressure ulcers for more information.
  • Anxiety, depression, embarrassment, social withdrawal and isolation, fear of defaecation and/or fear of taking medications contributing to constipation, including opioid analgesia. See the CKS topics on Depression and Generalized anxiety disorder for more information.

When should I suspect a diagnosis of constipation?

• Suspect a diagnosis of constipation if a person presents with:
  • Stools which are hard, uncomfortable, or difficult to pass, and are less frequent than usual; or there is a sense of incomplete evacuation after defaecation.
  • Associated symptoms, such as malaise, flatulence, colicky abdominal pain, abdominal distension, loss of appetite, weight loss, nausea or vomiting, halitosis, and/or faecal incontinence.
  • New urinary symptoms such as difficulty passing urine, frequency, urinary retention, or urinary incontinence.
  • New agitation or confusion, particularly in the elderly or people with cognitive impairment.
• Suspect faecal loading or impaction if a person presents with:
  • Stools which are hard and lumpy, and either large and infrequent, or small and relatively frequent.
  • Straining is ineffective.
  • Manual methods are needed to remove stool.
  • Overflow faecal incontinence and/or loose stools.
  • A faecal mass palpable abdominally or on digital rectal examination (DRE) or gentle digital examination of the stoma if the person has a colostomy. See the section on Assessment for more information.
• Suspect bowel obstruction if a person presents with the following. The pattern of symptoms depends on the level of obstruction:
  • Absence of passage of flatus and stool per rectum (in complete lower gastrointestinal obstruction; may be intermittent in partial obstruction; constipation is often a late sign in gastric or proximal small bowel obstruction).
  • Colicky abdominal pain, tenderness, and/or abdominal distension.
  • Loss of appetite, nausea, and vomiting (which may be faeculant if distal small bowel or large bowel obstruction).
  • Active, tinkling bowel sounds, or quiet or absent bowel sounds (a late sign).

How should I assess a person with suspected constipation in the palliative care setting?

If a person presents with suspected constipation in the palliative care setting:

• Ask about:
  • The clinical features of constipation, including symptom onset, usual bowel habit, date of last bowel movement, stool consistency and frequency, urge to defaecate and ease of defaecation, progression or change of symptoms over time, precipitating and contributing factors, and relieving factors. See the CKS topic on Constipation for more information.
    • Use of a symptom diary may be helpful in the initial assessment of severity and monitoring of response to treatment.
  • Any faecal incontinence including rectal leakage (may be suggested if underwear is regularly and involuntarily soiled). See the CKS topic on Faecal incontinence in adults for more information.
  • Any clinical features of bowel obstruction, particularly if there is known intra-abdominal or pelvic pathology, and manage appropriately. See the section on Managing constipation for more information.
  • Any associated symptoms including abdominal discomfort, distension, nausea, vomiting, rectal pain, bleeding, or mucus on defaecation.
  • The person's oral intake, whether assistance is needed for eating and drinking, and physical activity levels, depending on the stage of illness.
  • Any comorbidities or clinical features suggesting underlying cause(s).
  • Any causative or contributory medications.
  • The person's functional status and social situation, including toileting arrangements, independence level, and impact on daily functioning and quality of life, level of distress, coping strategies including use of incontinence pads, commode, bed pan, and support available.
  • Any previous treatments including over-the-counter and prescribed laxatives, non-drug measures, and symptom response.
• Examine the person, depending on the person's stage of disease and estimated prognosis, to assess severity and underlying cause(s), if possible and appropriate.
  
  • General examination including signs of cognitive impairment, breathlessness affecting ability to strain, current weight and evidence of weight loss, nutritional and hydration status. See the CKS topics on Adult malnutrition and Palliative care - breathlessness for more information.
  • Abdominal examination for signs such as abdominal distension, mass including faecal loading, tenderness, absent or reduced bowel sounds suggesting bowel obstruction; or a palpable bladder or blockage of urinary catheter (if using) suggesting urinary retention.
  • Digital rectal examination (DRE) for signs of faecal impaction, rectocele or rectal prolapse, rectal mass, anal fissure, haemorrhoids, or perianal ulceration.
    • Note: avoid performing a DRE if the person is neutropenic, thrombocytopenic, or has anorectal disease or recent anorectal surgery or pelvic radiotherapy.
    • DRE can usually distinguish a faecal mass from a tumour, as firm finger pressure will leave a palpable indentation in hard faeces. DRE will not detect faecal impaction in the proximal rectum or sigmoid colon.
    • Examination of the stoma pouch contents can be helpful if the person has a colostomy.
    • Assess for weak levator ani muscles (suspect if the person needs to apply pressure behind the anus to help pass stool); rectocele (suspect if a woman needs to insert a finger into the vagina to help pass stool).
  • Neurological examination including anal sphincter tone and rectal sensation if there is suspected spinal cord pathology causing symptoms.
• Investigations are not routinely needed in primary care. Consider arranging tests depending on clinical judgement and any likely reversible underlying cause(s):
  
  • Serum urea and electrolytes to assess for hypokalaemia, acute kidney injury, or chronic kidney disease. See the CKS topics on Acute kidney injury and Chronic kidney disease for more information.
  • Serum calcium level to assess for hypercalcaemia. See the CKS topic on Hypercalcaemia for more information.
  • Thyroid function blood tests to assess for hypothyroidism. See the CKS topic on Hypothyroidism for more information.
  • Plain abdominal X-ray to assess the extent of faecal loading and to exclude a diagnosis of bowel obstruction, depending on clinical judgement and the person's stage of illness and wishes.

Scenario: Management

From age 16 years onwards.

Laxative modes of action

Laxatives aim to treat constipation by restoring the amount of water in the faeces and/or improving rectal evacuation by improving faecal consistency and promoting peristalsis [Twycross, 2021].

• Bulk-forming laxatives (ispaghula husk, methylcellulose, and sterculia) act by retaining fluid within the stool and increasing faecal mass, leading to stimulation of peristalsis. They also have stool-softening properties.
• Osmotic laxatives (lactulose, macrogols, phosphate and sodium citrate enemas) act by retaining and increasing the amount of fluid in the large bowel. This produces distension, leading to stimulation of peristalsis. Lactulose and macrogols also have stool-softening properties.
• Stimulant laxatives cause peristalsis by stimulating colonic nerves (senna) or colonic and rectal nerves (bisacodyl, sodium picosulfate).
  • Senna is hydrolyzed to the active metabolite by bacterial enzymes in the large bowel.
  • Bisacodyl and sodium picosulfate are hydrolyzed to the same active metabolite. However bisacodyl is hydrolyzed by intestinal enzymes, whilst sodium picosulfate relies on colonic bacteria.
  • Stimulant laxatives may also have a softener effect by reducing the time available for water absorption in the bowel and a direct secretory action.
• Surface-wetting agents (docusate) reduce the surface tension of the stool, allowing water to penetrate and soften the stool. Docusate also has a relatively weak stimulant effect.
• Glycerol suppositories act as a lubricant, and have a weak stimulant action (probably due to an irritant effect).
• Arachis oil enemas lubricate and soften faeces.
• Peripheral opioid-receptor antagonists (such as methylnaltrexone or naldemedine) antagonize opioid actions at specific gastrointestinal opioid receptors without impairing central analgesic effects.

[Sykes, 2015; Twycross, 2021; Dzierzanowski, 2025; HIS, 2025; BNF, 2026] 

Laxative types and preparations

The choice of laxative(s) will often depend on individual preference and drug palatability and tolerability [Twycross, 2021]. The relative advantages and disadvantages of different laxatives are detailed in Table 1.

• Off-label higher and more frequent dosing than specified in the product licence may be needed in the palliative care setting.

Table 1. Relative advantages and disadvantages of different laxatives.

Laxative dose regimens

• Off-label higher and more frequent dosing than specified in the product licence may be needed in the palliative care setting.

Table 2. Laxative doses that may be needed to manage constipation in the palliative setting.

Laxative adverse effects

Most adverse effects of laxatives can be reduced or avoided by increasing the dose of oral laxatives gradually.

• Advise people to start at the lowest dose and, if necessary, increase it every few days, aiming for a regular bowel movement without straining every 1–3 days. Common adverse effects include:
  • Bulk laxatives: flatulence and bloating.
  • Lactulose: flatulence, cramps, and bloating.
  • Macrogols: bloating, nausea. The absorption of other medications can be transiently reduced when taking macrogols. Other medications should not be taken orally for one hour before, during, and one hour after taking macrogols.
  • Stimulant laxatives: abdominal cramps, diarrhoea.
  • Peripheral opioid-receptor antagonists: abdominal pain, nausea, diarrhoea, flatulence, postural hypotension, injection site reactions (if subcutaneous route of administration), hyperhidrosis.
• The timing of stimulant laxatives can be particularly important for the frail or elderly, so that they provoke a bowel movement at a time when the person has adequate time to reach the toilet. Usually stimulant laxatives are given at bedtime, to produce a bowel movement the next morning. The stimulant effect may be excessive in people who are very ill or frail.
• Excessive doses of laxatives may cause diarrhoea and, if prolonged, electrolyte disturbances such as hypokalaemia.

[Larkin, 2018; BNF, 2026]

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of constipation in palliative care.

Search dates

March 2021 - September 2026

Key search terms

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

• exp Palliative Care/, exp Terminal Care/, exp Terminally Ill/, palliat$.tw., (terminal adj care).tw., (palliative or terminal$ or end of life).tw., (advanced adj disease).tw.
• exp Constipation/, constipat$.tw., exp Fecal Impaction/, ((fecal or faecal) adj impact$).tw., ((fecal or faecal) adj load$).tw., ((difficult$ or delay$ or irregular$ or infrequent or pain$) adj (defecat$ or stool$ or faec$ or fec$)).tw., (bowel adj movement).tw.

Sources of guidelines

• 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
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

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

Sources of health technology assessments and economic appraisals

• 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

Sources of randomized controlled trials

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

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

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

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

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)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
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  • The British National Formulary team.
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Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

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.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• 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

Organizational, behavioural and financial barriers

Our policy

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.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.