Abstract
BackgroundA major healthcare reform agenda in Ireland is underway which underpins the establishment of a series of National Clinical Programmes (NCPs), which aim to take an evidence based approach to improve quality, access and value. The current study aimed to determine the enablers and barriers to implementation of the NCPs.MethodsA qualitative methodology advocated by the Medical Research Council (MRC) framework on conducting process evaluations of complex interventions guided this research. Purposive sampling techniques were used to recruit participants from seven NCPs across both acute and chronic healthcare domains, comprised of orthopaedics, rheumatology, elective surgery, emergency medicine, paediatrics, diabetes and chronic obstructive pulmonary disease. A total of 33 participants were interviewed using a semi-structured interview guide. Participants included current and previous Clinical Leads, Programme Managers, Health Service Executive management, hospital Chief Executive Officers, representatives of General Practice, and a Nursing and a Patient representative. Thematic analyses was conducted.ResultsA range of factors of different combinations and co-occurrence were highlighted across a total of six themes, including (i) positive leadership, governance and clinical networks of the NCPs, (ii) the political and social context in which the NCPs operate, (iii) constraints on resources, (iv) a passive attitudinal resistance to change borne from poor consultation and communication, (v) lack of data and information technology, (vi) forces outside of the NCPs such as the general practitioner contract thwarting change of the model of care.ConclusionsThe MRC framework proved a useful tool to conduct this process evaluation. Results from this research provide real world experiences and insight from the people charged with implementing large-scale health system improvement initiatives. The findings highlight the need for measured responses that acknowledge both direct and non-direct challenges and opportunities for successful change. Combined, it is recommended that these elements be considered in the planning and implementation of large-scale initiatives across healthcare delivery systems, both in Ireland and internationally.
Highlights
A major healthcare reform agenda in Ireland is underway which underpins the establishment of a series of National Clinical Programmes (NCPs), which aim to take an evidence based approach to improve quality, access and value
The United Kingdom’s Medical Research Council (MRC) identifies the value in conducting a process evaluation which can play an important role in considering the feasibility of an innovative intervention and suggesting ways in which to optimise its design, delivery and mechanisms of impact [10]
The MRC process evaluation guidance can assist in the understanding of the causal assumptions which underpin the intervention, and how the interventions work in a real-world context
Summary
A major healthcare reform agenda in Ireland is underway which underpins the establishment of a series of National Clinical Programmes (NCPs), which aim to take an evidence based approach to improve quality, access and value. What is required to provide an innovation ‘at scale’ is a responsive health system which is effective, efficient and has engagement at all levels [5, 6] These ‘large-system transformations’ [7] can only be achieved by addressing the range of complexities that can co-exist within any health system such as culture and climate, organisational governance, financial systems, health technologies, and workforce attitudes and behaviours [4]. Health service interventions are often highly complex and comprise multiple interacting components [8] Added to this complexity includes the challenges of innovation implementation and the targeting of multiple organisational levels at any one time [9]. The MRC process evaluation guidance can assist in the understanding of the causal assumptions which underpin the intervention, and how the interventions work in a real-world context This in turn can be helpful in building an evidence base for practice and policy
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