Translating evidence into practice

For nearly 20 years the Scottish Intercollegiate Guidelines Network or SIGN has been producing evidence-based clinical practice guidelines for the NHS in Scotland. Here Summons speaks to SIGN Chair Dr Keith Brown and Director Dr Sara Twaddle 

  • Date: 01 January 2012

DR KEITH BROWN became the Royal College of Psychiatrists’ representative on the SIGN Council in 2001 and was appointed Chair in 2007. Dr Sara Twaddle is a health services researcher and economist by background and had worked in the NHS in a variety of roles since 1988. In 2000 she joined a SIGN guideline development group as an economist and subsequently became the network’s part-time economics adviser. In 2003 she was appointed Director.

What do you see as the prime remit of SIGN?

KB: SIGN’s remit remains the same as it was back in 1993, to produce high-quality, multi-disciplinary, evidence-based recommendations for NHS Scotland.

Is it the Scottish equivalent of NICE?

KB: We have the same remit as the guideline development arm of NICE, but other NICE responsibilities are picked up by Healthcare Improvement Scotland (HIS), of which SIGN is a part.

How do you decide on topics for guidelines?

ST: This depends on whether we already have a guideline covering the topic, or whether it is a totally new topic.

For our extant guidelines, we look at the requirement for review at three years post publication. We look at the new evidence published since the last guideline and assess the degree to which it would alter the recommendations. We then consult on the review reports with clinical experts in the field to ensure that we have correctly interpreted the new evidence.

Anyone can make a proposal to SIGN for a new guideline topic (by downloading a form from These are then assessed within SIGN to ensure that they are suitable for a clinical guideline. We do this by considering whether the topic involves more than one discipline and whether it is actually a clinical topic. Once this is established we work with the proposer to develop a more detailed proposal, including looking at the size of the evidence base and evidence of variation in practice. These proposals are then reviewed by SIGN Council, which is made up of the representatives of all the Royal Colleges, professional organisations and lay members. If SIGN Council supports the proposal we submit these to the process within HIS which allocates budgets for pieces of work.

What goes into guideline development?

ST: Essentially, the main elements are a multi-disciplinary guideline development group including patients and carers, a review of published literature, recommendations for clinical practice based on available evidence along with open consultation and peer review. Full details of the methodology are available on our website (

Why is evidence graded and how do healthcare professionals make use of that?

KB: All SIGN recommendations are graded to reflect the underlying quality of the evidence which supported the recommendation. Most importantly the grade of the recommendation does not reflect its clinical importance. For example, in our postnatal depression guideline we have a recommendation that ‘PND and puerperal psychosis should be treated’. This is clearly the most important recommendation, but it is a Grade B recommendation, reflecting the fact that randomised controlled trials comparing treatment with no treatment don’t exist and are unlikely to be carried out in the future.

How do you avoid bias in guideline development?

KB: Research shows that guidelines are less susceptible to bias if they are developed by multi-disciplinary groups involving all the relevant specialties, recommendations are based on a systematic review of the evidence and all declarations of interest are recorded and acted upon. We base our methodology around these principles.

How long does it normally take between proposal and publication?

ST: A long time! Once we’ve had agreement to develop a guideline we need to find a ‘slot’ in the guideline programme and then identify the chair and the guideline development group. The development process for a new topic then takes around two years, so it may take up to four years from proposal to guideline. We agree this is too long, but what we can do about it is another matter – all guideline developers have this sort of issue.

What is a SIGN ROCKET?

ST: SIGN ROCKETs are online summaries of our guidelines that allow you to manoeuvre, click by click, quickly around the clinical content to help you find the specific piece of information that you are looking for. ROCKETS are based on our quick reference guides, but may contain additional supporting material from the full guideline.

How has the focus at SIGN shifted from guideline development to implementation?

KB: Over the last few years we have recognised that an implementation strategy based around sending hard copies out to healthcare professionals isn’t really the best. We therefore looked at the literature on implementation support and have come up with an approach which is multifaceted. Most importantly we actively involve the multi-disciplinary group in thinking about implementation support during the development process, rather than as an add-on at the end. We also publish an implementation strategy for each guideline at the time of launch.

You recently launched You Tube broadcasts for patients. How does the SIGN remit extend to patients?

KB: Everything we do is ultimately for the benefit of patients, so provision of information about guidelines and our work in easily accessible language is important. We have patient involvement in everything we do, led by Karen Graham our Patient Involvement Co-ordinator, who supports the patients and carers on our groups. We provide patient versions of many of our guidelines in both electronic and paper form and we are about to provide our first Smartphone app designed wholly for patients. We are advised that YouTube is a good way of reaching a wide range of people, so watch this space for more broadcasts.

Congratulations on your recent award from eHealth for the SIGN guideline app. How does this work and how did the idea come about?

ST: Thank you. As part of our refocusing on implementation support we recognised that we need to produce guidelines in lots of different formats to maximise dissemination. Credit for the original app idea should go to Safia Qureshi, our previous Programme Director, but Stuart Neville, Publications Coordinator, and Roberta James, Programme Director, were the team who worked with an app developer to get it in its current form. The app is based on the quick reference guide of each guideline, with some additional material. It is available free of charge for Apple phones, iPads and Android phones. We now have more than 31,000 downloads, so the message is getting out there.

What do you enjoy most about your job?

ST: Two main things – firstly the opportunity to make a difference to the healthcare of thousands of patients every year by working with front-line clinicians to produce high-quality, Scottish-relevant, recommendations for clinical practice. Secondly, working with the SIGN team, who are a great bunch of people and are all willing to go the extra mile to produce a fantastic product.

KB: The opportunity to work within an organisation as internationally respected as SIGN.

What do you find most frustrating?

ST: NHS bureaucracy!

KB: Ill-considered change which is more of a challenge than an opportunity.

Are there any special challenges to providing healthcare guidelines in Scotland?

ST: Scotland is a small country and when embarking on a specialist topic, forming a guideline development group may result in inviting all of the specialists in Scotland onto the group. Obviously this has consequences for the service but also creates the possibility of bias in the process. More challenging is managing expectations – we would all love to have completely up-to-date guidelines on every topic, but this is just not possible given the resources available to us. Other challenges aren’t particularly Scotland specific, such as problems with people being released to work on guidelines, which is true of all national activities.

 Interview by Jim Killgore, editor of MDDUS Summons

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