SIGN’s stakeholder feedback report was published in August of this year and it’s my job as Chair of the Strategy subgroup of SIGN Council to ensure we listen to that feedback and act upon it.
A lot has changed in NHSScotland since we published our first SIGN clinical guideline on prophylaxis of venous thromboembolism in 1996. The World Wide Web had only come into being in 1991 and busy healthcare professionals had to search for information about new therapies from scientific journals held in medical libraries, or rely on clinical update lectures, whilst trying to avoid the lures of pharmaceutical advertising and sponsorship. Today, information about the latest clinical trial is available anytime, anywhere and accessible from a smartphone – the challenge, for clinicians and patients alike, is how to identify the information which is useful and trustworthy and separate it from the rest.
“Healthcare professionals no longer need to know whether an intervention is better than placebo: they want to know how best to influence the outcomes for the patient in front of them. They want to know how to address their patients’ co-morbidities and help their patients choose the interventions that impact on the outcomes that matter to them.”
In addition to the speed of access to new information, the purpose of guidelines has changed too. Healthcare professionals no longer need to know whether an intervention is better than placebo: they want to know how best to influence the outcomes for the patient in front of them. They want to know how to address their patients’ co-morbidities and help their patients choose the interventions that impact on the outcomes that matter to them.
The stakeholder feedback report confirmed that we have a reputation we can be proud of at SIGN: users are positive about clinician engagement in the production of guidelines, trust the robust methodology and approve of the ease of access, range of products and content and format of our guidelines. However, there is definitely room for improvement in some areas, especially the thorny problem of keeping guidelines up to date, and we face new challenges, for instance providing rapid responses to new developments, improving our support for the implementation for guidelines, and working more collaboratively with other parts of Healthcare Improvement Scotland and the wider health systems in the Scotland, UK and further afield.
It has been really exciting to be involved with SIGN in the time of Realistic Medicine: the heath service is budget-constrained and healthcare professionals need guidance to avoid or reduce ineffective and inappropriate interventions. It is not obvious that guidelines are the answer to the problems of the NHS in terms of spending, overdiagnosis and overtreatment, and the challenge is to share the understanding that guidelines provide part of the context in which careful conversations can be had with patients. ‘What matters to you?’ is a question we do not ask often enough, and can open the door to discussions about how to steer the right path, for that individual person, through the often overwhelming, sometimes conflicting, and often burdensome demands of that person’s particular situation.
As a GP, I frequently meet people who have visited several different hospital clinics and received instructions that for them seem irrelevant and confusing. We need to appreciate the burden associated with some evidence-based advice (for instance the number of different medications recommended as secondary prevention in ischaemic heart disease or glycaemic control in Type 2 diabetes and find a way of discussing this with people as they live their lives. Stopping smoking, for example, will often make more of a difference to someone than anything else, and if I can find a way to facilitate this for my patient, it might be better in the long run to focus on this for now and worry less about the best possible diabetic or blood pressure control. For another person, simply providing a food bank voucher might be the most useful thing I can do for them today. And for yet another – someone already living the healthiest lifestyle, of the required weight and fitness, and able to follow all the advice they are given – then ensuring their blood pressure and diabetic control is near perfect will be entirely appropriate.
“It is not obvious that guidelines are the answer to the problems of the NHS in terms of spending, overdiagnosis and overtreatment, and the challenge is to share the understanding that guidelines provide part of the context in which careful conversations can be had with patients.”
We realised at the recent Guidelines International Network Conference in Manchester that our work on ‘patient versions’ of the guidelines is world-leading, and another thing we can be justifiably proud of. I’ve found that signposting my patients to these – especially those about autism spectrum disorders, and other difficulties facing children and their families – very helpful, and another way to support informed conversations we have about choices to be made.
So, as we mark our 25th anniversary at SIGN, I look forward to the next 25 years, understanding that listening to patients and professionals in a dynamic, fast-changing world is crucial to supporting Scotland’s healthcare professionals and their patients, as they seek to make the most appropriate choices about health and lifestyle.
Jenny Bennison is Vice-Chair of SIGN Council and Chair of the SIGN Strategy Group. She represents Royal College of GPs on SIGN Council and is a GP at Niddrie Medical Practice in Edinburgh.