SMJ 2005 50(2): 51-52
Introduction
The
Scottish Intercollegiate
Publicly-funded
Initially funded by the Clinical Resource and Audit Group (CRAG) of the Scottish Office,2 from 1 January 2005 SIGN became part of NHS Quality Improvement Scotland, continuing its public funding and facilitating guideline implementation throughout NHS Scotland through linking of SIGN guidelines with other quality improvement processes such as clinical standards and national audits. From 1 April 2005, the SIGN office moved from its former host college (the Royal College of Physicians, Edinburgh) to new accommodation in Thistle Street, Edinburgh. The SIGN website is unchanged (www.sign.ac.uk) where details of all SIGN guidelines, methodology and procedures can be accessed.
Professionally led
SIGN remains professionally-led through SIGN Council. This comprises 30 representatives of Royal Colleges and other healthcare professional bodies in Scotland (including general practitioners, physicians and surgeons both general and specialist, dentistry, radiology, anaesthetics, pathology, public health, nursing, midwifery, pharmacy, professions allied to medicine, social work, and NHSScotland management) together with lay representatives and senior management of SIGN Executive and NHS Quality Improvement Scotland. SIGN Council meets three times yearly; determines the overall direction of SIGN’s strategy, methodology and programme; and ensures appropriate multiprofessional and lay input into guideline development, implementation and review. Such input is important to ensure “ownership” of guidelines, which assists facilitation of their implementation.
Professionally developed
SIGN Executive comprises 20 clinical guideline developers, who have developed an internationally recognised methodology for development of guidelines,3 including a system for grading recommendations in evidence-based guidelines4 which accords with international criteria.5 The quality of the SIGN programme is assured by standard operating procedures for SIGN Council and Executive (monitored by the SIGN Strategy Group); the SIGN Methodology Development Group; and the SIGN Guideline Programme Advisory Group. Patient, carer and public involvement in SIGN has recently been addressed at all levels: lay representation on SIGN Council; membership of guideline development groups; identification of key questions and messages relevant to patients and carers; key messages for patients and the public; and involvement in raising awareness of SIGN guidelines.
Independence from industrial and political influence
Much medical education is sponsored by the healthcare industry, whose prime concern is to sell its products. Many "guidelines" are directly sponsored by industry; while other guidelines produced by specialist societies are potentially (or overtly) biased by industrial sponsorship, by lack of involvement of all relevant stakeholders and by lack of due process.6 On the other hand, political influence may also potentially affect guideline recommendations. From its inception, SIGN has strived to ensure independence from both industrial and political influences, ensuring that its guidelines are respected as “products with integrity".
Addressing the patient “journey of care”
SIGN’s philosophy is to address the whole “journey of care" of the patient across primary, secondary and tertiary care; emphasising the need for clear recommendations on criteria for referral, arrangements for hospital discharge, and key elements of communication. This contrasts with other forms of guidance for clinicians, which often focus on specific new diagnostic or therapeutic interventions: in Scotland these are addressed by the Scottish Medicines Consortium (SMC) or Health Technology Assessments. SIGN guidelines therefore aim to assist healthcare practitioners across NHS Scotland (and also patients) to assimilate, evaluate and implement evidence on “current best practice”. Its guidelines are based on international evidence, interpreted for NHS Scotland by guideline development groups which involve all relevant stakeholders: healthcare professionals dealing with patients across Scotland at the daily “coalface" in primary, secondary and tertiary care; representatives of patients and carers; and appropriate input from other stakeholders including representatives from public health.
How are guidelines selected and developed for SIGN guidelines (which can come from any healthcare professional or patient in Scotland) are assessed; and how guidelines are processed, disseminated and revised? Full details are given in SIGN guideline 50, available on the SIGN website.
How are guidelines implemented to improve healthcare?
SIGN is not funded to implement its guidelines, but works closely with its partners in clinical effectiveness across NHSScotland to this end. Such partners include:
• NHS Quality Improvement Scotland. As noted, the integration of SIGN with NHS Quality Improvement Scotland should facilitate implementation of SIGN guidelines through improved links with clinical standards and national clinical audits
• Clinical effectiveness coordinators in NHSScotland Boards (who distribute and promote guidelines locally, e.g. through production and audit of local guidelines, protocols, and integrated care pathways, based on the national guideline); and local clinical governance committees
• Funders of research in NHS Scotland (Chief Scientist Office): SIGN guidelines routinely make recommendations for further research.
A survey in 2002 on implementation of SIGN guidelines by NHS Scotland identified key facilitators (e.g. important topic; uncontroversial recommendations; local champion) and key barriers (e.g. lack of resources; lack of clarity as to who should lead implementation).7 The integration of quality improvement within unified Boards may address the latter barrier; while the routine addition of resource implications to SIGN guidelines may start to address the problem of resources. Meanwhile, SIGN guideline developers must ensure “implementable" guidelines by repeated “reality checks"; while guideline implementers have an increasing evidence-base to guide implementation initiatives8.
The future of SIGN
SIGN has an established place in improving the quality of healthcare in NHS Scotland. Its guidelines include most common conditions: 75% address NHSScotland priorities (CHD and stroke, cancer, mental health, and child health), while the other 25% address other common conditions such as infections, diabetes, epilepsy, asthma, osteoporosis and rheumatoid arthritis,. SIGN continues its international partnerships with other producers of national clinical guidelines through the Guidelines International Network (G-I-N), including NICE, which in recent years has produced guidelines for England and Wales, albeit with a rather different methodology from SIGN (see SIGN website for a summary of methodological differences). SIGN and NICE routinely share their tables of evidence, reducing duplication of effort in national guideline development on both sides of the Border. Scotland can be proud of its national guideline developer: the challenge for NHS Scotland in the next 10 years is for all healthcare professionals, their patients and managers to improve the quality of healthcare by implementing SIGN guidelines.
REFERENCES
1 Petrie JC, Grimshaw JM, Bryson A. The Scottish Intercollegiate Guidelines Network Initiative. Getting validated guidelines into local practice. Health Bull (Edin) 1995; 53: 345-8
2 Clinical Resource and Audit Group (CRAG). Clinical Guidelines. The Scottish Office: National Health Service in Scotland, 1993
3 SIGN. SIGN 50: a guidelines developers’ handbook. Edinburgh: SIGN, 2004(available at SIGN website: www.sign.ac.uk)
4 Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334-6
5 The AGREE Collaboration. Appraisal of guidelines for research and evaluation (AGREE) instrument. London: St George’s Hospital Medical School, 2001.
6 Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty societies: the need for a critical appraisal. Lancet 2000; 355: 103-6
7 CRAG Implementation Subgroup. Implementation of SIGN guidelines in NHSScotland. Edinburgh: CRAG, 2002.
8 Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003; 362: 1225-30.