Implementing clinical governance policy: NICE

Clinical governance, manifested in the form of the NICE guidelines, has become a core component of the English government's health policy directives for improving health care effectiveness. However, NICE guidelines appear to be difficult to implement. Previous research has addressed clinicians' influence on guidelines implementation, but little is known about the potential influence of NHS managers in this process. This paper aims to explore managerial influence in the implementation of two NICE guidelines - obesity and chronic heart failure guidelines. The implementation process was explored retrospectively, prospectively and longitudinally, using a comparative case-study design involving four organizational settings in primary and secondary care and 74 in-depth interviews between 2007 and 2009. National policy requirements for performance management led senior managers to be more interested in financial accountability and in demonstrating that they had the appropriate documentation related to the implementation, rather than collecting evidence about the actual use of the guidelines in everyday practice. Further, NICE guidelines that required major financial investment for their implementation rarely reached the decision agendas. Blurred lines of professional and organizational accountability between managers led to a lack of agreement on the perceived successful outcomes for NICE guidelines implementation. Implications for health care management and policy are discussed.