An implementation post-mortem: a study of coordinated care at the end of life

Background: Health policy in England has increasingly promoted coordinated and integrated health and social care services delivered through partnerships with public, private and voluntary sector organisations. End of life care would likely benefit from improved coordination as patients in the last few months of life with incurable, irreversible illness often require access to a range of services. A regional partnership project, which served as a case to study the implementation process, proposed to coordinate end of life care through establishing a Navigation Centre, shared electronic palliative care patient record (EPaCCS) and working groups to develop new patient pathways within the region. There is a gap in understanding how such complex, multi-innovative programmes are implemented by partnerships.

Aim: This study draws on implementation theory to explore the implementation process of a project delivered by a partnership, specifically the shape of the process, what influenced the shape and what implementation outcomes were achieved.

Design and Methods: The study adopted a pragmatic, pluralist design using primarily qualitative methods including: document review, observations, interviews, focus group and telephone interviews. A thematic analysis was conducted using the Framework approach which allows for the data to be reduced and sifted through to find linkages and patterns in the data by both source and theme as part of an inductive and deductive analytical process.

Findings: The implementation of the Project was characterised by an interactional, over-lapping process in which planning, development, implementation and adaptation of the various innovations proceeded simultaneously, though at the end of the two year project period many tasks were incomplete. Barriers to implementation included: the NHS reforms, lack of robust project management, interconnected project elements, and competition from similar innovations. Facilitating factors included: leadership by the Hospice as experts in end of life care, work benefit, individual motivation, and sole ownership and management over implementation. External threats to the Project had variable influence on the partners and suggests that project resiliency is particularly important for complex multi-organisational programmes which are implemented over time and by multiple stakeholders from different sectors. This study's contribution to knowledge is that resilience to unplanned events in a project appears to be the product of implementation strategies, innovation adaptiveness and implementer characteristics. Future research should look further at what contributes to project resiliency and how projects can develop resilient factors to ensure their success.