Intended for healthcare professionals

Education And Debate

Wrong SIGN, NICE mess: is national guidance distorting allocation of resources?

BMJ 2001; 323 doi: (Published 29 September 2001) Cite this as: BMJ 2001;323:743
  1. Richard Cookson, senior lecturer in health economicsa,
  2. David McDaid, research officerb,
  3. Alan Maynard (, directorc
  1. a School of Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ
  2. b LSE Health and Social Care, London School of Economics and Political Science, London WC2A 2AE
  3. c York Health Policy Group, Department of Health Studies, University of York, York YO10 5DQ
  1. Correspondence to: A Maynard
  • Accepted 19 July 2001

The Scots and the English and Welsh are producing national guidance on NHS practice in different ways. Two apparently competing national agencies have already been established in Scotland—the Health Technology Board for Scotland and the Scottish Intercollegiate Guidelines Network (SIGN). Yet another one is in the pipeline—the Scottish Medicines Consortium. In England and Wales there is one agency—the National Institute for Clinical Excellence (NICE). Are these national agencies contributing effectively to the enhancement of performance in the NHS or are they merely fuelling demand and distorting the processes by which resources are prioritised?

Summary points

The Scottish Intercollegiate Guidelines Network, a precursor to the National Institute for Clinical Excellence (NICE) in England and Wales, has not yet started to consider cost effectiveness

NICE considers cost effectiveness but has been reluctant to advise against funding many costly new pharmaceuticals in the NHS in England and Wales

NICE must devise politically acceptable ways of refusing to spend taxpayers' money on costly new drugs and devices that lack demonstrable incremental cost effectiveness

Otherwise, new and often inefficient technologies will continue to fuel the widening gap between public expectations and public willingness to pay for the NHS

NICE should prioritise new national guidance within a fixed growth budget for the net cost of new technologies and in relation to incremental cost effectiveness

If reducing postcode rationing would compromise more important goals of equity or efficiency, NICE should sometimes refuse to issue definite national guidance

Wrong SIGN

SIGN's objective is “to improve the quality of health care for patients in Scotland by reducing variation in practice and outcome, through the development and dissemination of national clinical guidelines containing recommendations for effective practice based on current evidence.”1 SIGN has been reluctant to consider resource issues,2 and economic considerations have been limited to some “back of the envelope” calculations …

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