SIGN (Scottish Intercollegiate Guidelines Network) aims to develop evidence-based guidelines and to facilitate their implementation into local practice for the benefit of patients. It was set up in 1994 as a collaborative venture between the Royal Colleges and their faculties in Scotland.
This was a bold project to bring together various stakeholders to explore how research evidence could be presented to encourage changes in clinical practice. SIGN has evolved with enthusiastic support and constructive criticism from all involved. To date 30 guidelines have been published, with another 30 in development.
SIGN includes representatives from all the Royal Colleges, nursing, pharmacy, dentistry, professions allied to medicine, and patients. The programme is supported by CRAG (Clinical Resource and Audit group) of the NHS in Scotland, and has links with other major professional groups.
The recent reorganisation of the NHS in Scotland provides an opportunity to establish stronger networks that can take full advantage of the synergy between various initiatives.
SIGN has tried to select topics for guideline development where variations in practice are known to occur and affect outcomes, where effective care may not be delivered uniformly, and where there is a strong research base providing evidence of best practice. Some published SIGN guidelines do not fulfil these criteria at present, but the process for selecting topics has been refined and guidelines are now developed to a closely defined remit.
SIGN uses systematic literature reviews to identify and synthesise the evidence to answer key questions defined by the group. The guideline development group must be multi-disciplinary from the start, with a methodologist to help.
Once the group has prepared a rough draft of the guidelines, a national meeting is held to discuss the evidence and recommendations. The draft is also posted on the SIGN website for wider consultation and comment.
The group then reviews the comments received and produces a final draft. This is sent to a variety of clinicians for review and to expert external referees. Their comments are reviewed by the chairman and the final pilot guidelines are checked by the group and editorial board before publication.
The publication is distributed widely, free of charge, throughout Scotland and published on the SIGN website. The distribution is getting larger all the time, but dissemination is still a challenge and is being tackled by the various member groups of SIGN.
The guidelines include the reasons for concern about the topic, as well as the research evidence linked to recommendations for best practice The guidelines will usually contain suggestions for audit and further research, a minimum data set with common coding to encourage sharing of information, and a quick reference guide.
All SIGN guidelines have a 'sell-by' date and will be reviewed after two years, or sooner if more evidence becomes available. A new section is being developed to highlight key messages for patients.
Patient representatives are invited to join SIGN development groups and to participate in national meetings to discuss draft guidelines. SIGN is evolving its policy to involve patients in guidelines, and recruiting the help of voluntary organisations and health councils.
While striving for a 'gold standard' in systematic review and grading of evidence, it is important not to lose sight of what is relevant and useful to clinicians, taking into account limited resources and imperfect information. The next challenge is to achieve successful local implementation. SIGN guidelines aim to be a pragmatic and practical tool which can assist the implementation of evidence-based medicine where and when appropriate.