Intended for healthcare professionals

Letters

National guidance and allocation of resources

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7334.427/b (Published 16 February 2002) Cite this as: BMJ 2002;324:427

Acting chairman of SIGN's response

  1. G C W Howard, acting chairman
  1. Scottish Intercollegiate Guidelines Network (SIGN), Royal College of Physicians, Edinburgh EH2 1JQ
  2. Medicines Monitoring, Department of Clinical Pharmacology, Ninewells Hospital, Dundee DD1 9SY

    EDITOR—I think that Cookson et al in their criticisms of the Scottish Intercollegiate Guidelines Network (SIGN) show a lack of understanding of the role of this organisation and the methods it uses to develop its guidelines.1 Evidence based guidelines will not resolve all healthcare issues, just as randomised controlled trials are not appropriate to resolve all therapeutic controversies. There are, however, areas of healthcare delivery where there are variations in practice and outcome, and where there is also evidence to support one practice over another.

    This is where SIGN concentrates its resources to produce guidelines. SIGN does not differentiate in its methodology between costly and non-costly treatments, and, contrary to the authors' supposition, the adherence to such guidelines will reduce variations in treatments of all costs and therefore the possibility of decision making behind the scenes. In addition to this, SIGN guidelines are not only in the public domain, but the public have a key part in their development, and this involvement is an important driver for change.

    Cookson et al are also concerned that resource allocation might be distorted. The opposite is the case. Adherence to evidence based guidelines will lead to a more efficient use of resources and concentrate this on areas where there is a clear benefit from a therapeutic intervention. It should also be made clear that SIGN guidelines are not just about advising on treatment but offer guidance to assist with the management of patients at all stages of their disease, and where there is robust economic information, this is incorporated into the guideline.

    References

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    Economics has both strengths and weaknesses in health resource allocation

    1. Peter Davey (peter{at}memo.dundee.ac.uk), professor of pharmacoeconomics
    1. Scottish Intercollegiate Guidelines Network (SIGN), Royal College of Physicians, Edinburgh EH2 1JQ
    2. Medicines Monitoring, Department of Clinical Pharmacology, Ninewells Hospital, Dundee DD1 9SY

      EDITOR—One of the greatest strengths of economists lies in drawing inferences from imperfect data, and, as Maynard knows, the data about the value of reducing risk of hospital acquired infection are certainly imperfect. 1 2 Cookson et al dismissed guideline 45 from the Scottish Intercollegiate Guidelines Network (SIGN) as a calculation done on the back of the envelope, about the budgetary impact of antibiotic prophylaxis for surgery.3 The guideline provides two decision rules that challenge policymakers to identify a point at which antibiotic prophylaxis may be effective but not cost effective. Antibiotic resistance, rather than budget impact, is the primary concern. Like all SIGN guidelines the final document was the result of months of peer review. Succinct it may be, but “back of the envelope” it is not.

      Scotland's history shows a strong preference for institutions that are inclusive and cooperative rather than centrally imposed. Both SIGN and the Scottish Medicines Consortium exist because of the vision and energy of clinicians such as Jim Petrie and David Lawson. They have created respected institutions that include all the regions of Scotland in national decision making, to complement rather than compete with the health technology board for Scotland. Economists in Scotland are working with all these institutions to ensure that issues about efficiency and equity are communicated in a language that is understandable and acceptable to clinicians. That debate is not going to be helped by a paper prefaced by a title and cartoon that would make a tabloid editor blush. This language merely antagonises and offends.

      Cookson et al argue that national guidance from the National Institute for Clinical Excellence (NICE) will increase efficiency but there is a fundamental flaw in NICE's economic methodology. The Department of Health has imposed different discount rates for future costs (6%) and outcomes (1%), presumably to disguise the inefficiency of certain screening programmes that have strong public support. The BMJ should consider providing a forum for a debate on NICE's economic methods. In the meantime I am very glad to live in a country in which national health technology assessment is complemented by professionally led institutions that are not politically controlled.

      References

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