Opening the 'black box' : a study of the process of NICE guidelines implementation

Providing rigorous evidence about the effectiveness and efficiency of healthcare interventions is not sufficient to account for whether they are introduced into practice or no. This study informs ‘evidence-based’ implementation by using an innovative methodology to provide further understanding of the implementation process. Within the English National Health System the ‘new public management’ (NPM) has spawned new arrangements for the healthcare delivery and one manifestation of these is the National Institute of Health and Clinical Excellence that develops clinical guidelines to set standards of care, which are centrally monitored. The aims of the study was to explore the nature of the implementation process by which ‘new’ interventions are implemented in the healthcare sector and identify factors that may influence the shape of the implementation process using NICE guidelines as exemplar case studies. A conceptual framework was developed based on the analysis of the theoretical, policy and empirical literature on the implementation process and drew on theories of professionalism, managerialism and power. A comparative case study was adopted to study the process retrospectively, prospectively and longitudinally. 74 face-to- face informal interviews were conducted involving clinicians and managers between 2007 and 2009. The implementation process might be characterised as linear and staged to begin with but becomes ‘non-linear’ as it moves from the planning phase to adoption in every day practice. While, national priorities determine the context for implementation the shape of the process is influenced by the power relations between doctors and managers. The findings suggest that structuralist and post-structuralist theories of power have limited explanatory value. A new conceptual framework is proposed that bridges ‘structural’ and ‘relational’ power and constitutes a hybrid position that suggests that even though professionalism qualifies, it does not fully denies, the transformative power of the NPM to move beyond ‘traditional’ forms of organizing clinical work.

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