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

Ioanni Spyridonidis, Dimitri (2010) Opening the 'black box' : a study of the process of NICE guidelines implementation. Doctor of Philosophy (PhD) thesis, University of Kent. (doi:10.22024/UniKent/01.02.94671) (KAR id:94671)


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.


Item Type: Thesis (Doctor of Philosophy (PhD))
DOI/Identification number: 10.22024/UniKent/01.02.94671
Additional information: This thesis has been digitised by EThOS, the British Library digitisation service, for purposes of preservation and dissemination. It was uploaded to KAR on 25 April 2022 in order to hold its content and record within University of Kent systems. It is available Open Access using a Creative Commons Attribution, Non-commercial, No Derivatives ( licence so that the thesis and its author, can benefit from opportunities for increased readership and citation. This was done in line with University of Kent policies ( If you feel that your rights are compromised by open access to this thesis, or if you would like more information about its availability, please contact us at and we will seriously consider your claim under the terms of our Take-Down Policy (
Uncontrolled keywords: health care
Subjects: H Social Sciences > HV Social pathology. Social and public welfare
Divisions: Divisions > Division for the Study of Law, Society and Social Justice > School of Social Policy, Sociology and Social Research
SWORD Depositor: SWORD Copy
Depositing User: SWORD Copy
Date Deposited: 17 Feb 2023 11:39 UTC
Last Modified: 17 Feb 2023 11:39 UTC
Resource URI: (The current URI for this page, for reference purposes)

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