Graeme McAlister, Communications Manager, SIGN


The Scottish Intercollegiate Guidelines Network (SIGN) was established in 1993 by the Scottish Medical Royal Colleges. Its aim is to improve the effectiveness of clinical care for patients in Scotland by developing, publishing and disseminating evidence-based guidelines that identify and promote good clinical practice. If implemented locally, these will help to address variations in clinical practice throughout Scotland.

SIGN is a collaborative initiative, involving health professionals from all of the medical specialties, nursing, pharmacy, dentistry, professions allied to medicine, NHS management, social work and patients, with a total of 40 member organisations.

Since it was established, SIGN has published more than 50 evidence-based clinical guidelines. They cover a variety of areas, including:

  • Visual impairment in diabetes
  • Stroke
  • Breast cancer in women
  • Schizophrenia
  • Control of pain in patients with cancer
  • Lipids and the primary prevention of coronary heart disease
  • Management of early rheumatoid arthritis
  • Attention deficit and hyperkinetic disorders in children and young people.

SIGN has gained international recognition for its work. SIGN guidelines have been translated into several languages and are used in countries as diverse as Iceland and Malaysia. SIGN is also now working closely with the WHO on guideline development.


SIGN has a rather unusual status: although the running costs of the guideline development programme are funded by the Clinical Resource and Audit Group of the Scottish Executive, it is a professionally led, multidisciplinary, independent organisation.

This unique working arrangement has been vital to the success of SIGN in gaining the respect and involvement of healthcare professionals and the trust of the public, because it keeps the guideline development process at arm's length from the policy-making process.

The importance of gaining professional and public credibility in this way has been reinforced by the recent Bristol Inquiry,1 which found that if healthcare organisations involved in producing national information about clinical effectiveness measures are to succeed collectively in improving standards of healthcare, it is vital that they are independent from the policy-making process.


Figure 1 (below) gives an overview of the SIGN organisational structure.

Figure 1: Overview of the SIGN organisational structure

Although SIGN is responsible for developing national clinical guidelines for NHS Scotland, it is not responsible for their implementation in practice. This is the responsibility of each individual Trust and is underpinned by the twin 'levers' of clinical governance and the Clinical Standards Board for Scotland.

However, this does not mean that SIGN cannot influence the implementation of guidelines. The whole SIGN guideline development process has been designed to facilitate their implementation.

The guideline development process is summarised in Figure 2 (below) and is covered in much greater detail in the recent SIGN handbook on guideline development.2 The handbook was published earlier this year in response to demand from guideline developers throughout the UK and internationally, who were keen to learn about the process.

Figure 2: Overview of the SIGN guideline development process
flow chart

In short, SIGN develops national guidelines to a standardised methodology (to ensure maximum validity) which can then be adapted for local implementation.

By actively encouraging multidisciplinary participation from throughout Scotland at all stages of the guideline development process, SIGN has found that it can increase the relevance of the guideline to local clinicians and develop national clinical guidelines that offer a sense of local ownership.

Another extremely important aspect of the process, in gaining both the involvement and credibility of health professionals, has been that all topics for future guideline development are suggested by practising healthcare professionals within NHS Scotland, rather than being referred to SIGN as part of a policy-making process.

Any healthcare professional working within NHS Scotland can suggest a topic for guideline development. It must satisfy the criteria that are considered by SIGN in selecting and prioritising topics. These are:

  • Evidence of wide variation in practice
  • Evidence of effective practice
  • A significant burden of disease
  • Relevance to the clinical priority areas for NHS Scotland*
  • A perceived need for the guideline, as indicated by a network of relevant stakeholders.

* Presently these are coronary heart disease and stroke, cancer, and mental health. The strategic aims of the NHS in Scotland are also considered. These are improving health and tackling inequalities, especially with regard to children and young people, developing primary and community care, and reshaping hospital services.


The systematic literature review process applied during the development of all SIGN guidelines has been described in a number of earlier Guidelines in Practice articles.3,4,5 The guidelines covered include:

  • Management of Early Rheumatoid Arthritis6
  • The Control of Pain in Patients with Cancer7
  • The Management of Stable Angina8

SIGN has recently introduced a new grading system9 which it hopes will link the levels of evidence to the grading of the recommendations more clearly. We would value any feedback from users on this new grading system.


With the methodology for developing SIGN guidelines now well established, SIGN is building on the early work carried out during its developmental phase. It is currently focusing on how to ensure that the guidelines are disseminated effectively at a clinical level.

In autumn 2000 SIGN introduced a new distribution strategy for its guidelines in which locally appointed clinical effectiveness facilitators in each of the NHS Trusts act as SIGN Guideline Distribution Coordinators. Early indications are that this new distribution system is more effective at ensuring that specific guidelines reach the health professionals to whom they are most relevant. Guideline users appear to value this targeted approach.

SIGN has also produced a CD-ROM containing electronic versions of most of the SIGN guidelines published to date. This is updated twice a year to incorporate recent guidelines, and includes both the full guidelines and the quick reference guides that accompany each one. It is anticipated that this will be the preferred format for GPs and other members of the primary care team, who will each be interested in different aspects of the various SIGN guidelines.

The CD-ROM was launched last year, and approximately 17 000 GPs throughout Scotland, England, Wales and Northern Ireland now receive SIGN guidelines in this format through an arrangement with a UK medical publisher.

Work is also underway on the presentation of the clinical content within SIGN guidelines and whether this may influence use of the guidelines.

Although implementation and audit of SIGN guidelines have not been within its remit, SIGN has, over the years, accumulated a sizeable amount of data regarding the use of its guidelines throughout the UK and internationally. A new section of the SIGN website, featuring examples of best practice, local implementation tools, and audit information, is now in development.


SIGN has undoubtedly been very successful in developing authoritative evidence-based clinical guidelines, and is happy to share its experiences with other similarly committed organisations and individuals.

As with all areas of clinical effectiveness, implementation is the key to improving the standards of patient care throughout the UK. In this regard, SIGN guidelines offer a dual challenge:

  • The evidence-based recommendations within our guidelines, developed by multidisciplinary groups, challenge all health professionals to implement proven best practice.
  • Equally important, they challenge policy-makers to ensure that health professionals have the necesary resources to provide the highest standards of care.
Home page of the SIGN website


Set up 1993
Objectives To improve the effectiveness of clinical care for patients in Scotland by developing, publishing and disseminating evidence-based guidelines that identify and promote good clinical practice
Funding Clinical Resource and Audit Group of the Scottish Executive
Key personnel Acting Chairman: Dr Grahame Howard
  Acting Vice-chairman/Primary Care Advisor: Dr Tricia Donald
  Director: Juliet Miller
Contact details Address: SIGN, Royal College of Physicians, 9 Queen Street, Edinburgh EH2 1JQ
  Tel: 0131 225 7324
  Fax: 0131 225 1769

For further information about SIGN, visit the website at or contact: Graeme McAlister, Communications Manager, SIGN Executive, Royal College of Physicians, 9 Queen Street, Edinburgh EH2 1JQ (tel 0131 247 3693; email

See also 'Professor James Petrie 1941-2001: Founder of SIGN' in News.


  1. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995. Command Paper: CM 5207.
  2. Scottish Intercollegiate Guidelines Network. SIGN 50. A Guideline Developers' Handbook. Edinburgh, February 2001.
  3. Morrison E, Capell H. RA guideline advocates early intervention with disease-modifying drugs. Guidelines in Practice 2001; 4(4): 19-28.
  4. Millar D. SIGN guideline paves the way for better control of cancer pain. Guidelines in Practice 2001; 4(5): 32-42.
  5. Swainson C. SIGN guideline on stable angina could reduce CHD deaths. Guidelines in Practice 2001; 4(7): 27-32.
  6. Scottish Intercollegiate Guidelines Network. Management of Early Rheumatoid Arthritis. Edinburgh: SIGN, 2000; No. 48
  7. Scottish Intercollegiate Guidelines Network. Control of Pain in Patients with Cancer. Edinburgh: SIGN, 2000; No. 44
  8. Scottish Intercollegiate Guidelines Network. Management of Stable Angina: A national clinical guideline. Edinburgh: SIGN, 2001; No.51
  9. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. Br Med J 2001; 323: 334-6.

Guidelines in Practice, October 2001, Volume 4(10)
© 2001 MGP Ltd
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