Local Implementation Teams Research Articles

Implementing clinical guidelines in psychiatry: a qualitative study of perceived facilitators and barriers

BackgroundTranslating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care.MethodsThis qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data.ResultsThe identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction.ConclusionsIdentifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify efficient strategies to overcome barriers on an organizational and individual level. Getting evidence into practice and implementing clinical guidelines are dependent upon more than practitioners' motivation. There are factors in the local context, e.g. culture and leadership, evaluation, feedback on performance and facilitation, -that are likely to be equally influential.

Why is it difficult to promote public mental health? A study of policy implementation at local level

The promotion of public mental health is a challenging endeavour for policy actors and stakeholders. In particular, the implementation of public mental health initiatives highlighted in Standard One of the National Service Framework for Mental Health has been poor and patchy (Department of Health, 2004a). This paper attempts to illuminate the complex process of public mental health policy implementation at local level through the exploration of stakeholders' actions.An exploratory case study design was selected, focusing on one local health and social care community within inner London. A conceptual framework about policy implementation and the concept of partnership working are used to shape the analysis of the empirical findings.This paper addresses the challenges associated with the promotion of public mental health initiatives within one local NHS health and social care community. It attempts to increase the understanding and insights into public mental health policy and practice at local level from a policy implementation standpoint. Using an empirical case study of public mental health in an English locality, some of the key issues explored in this paper are about perceptions of public mental health concepts among key policy actors and also stakeholders' behaviour in Local Implementation team (LIT) partnerships. Furthermore, the authors address the issue of how local policy actors engage the local community in supporting the needs of vulnerable groups such as service users and black and minority ethnic (BME) groups.Although functional partnership are essential for the promotion of public mental health initiatives, the interdependencies of the stakeholders, competition for resources, power dynamics and the difficulty of engaging a diverse range of voices have a significant limiting effect on achieving successful policy implementation on the ground.

An approach to measure compliance to clinical guidelines in psychiatric care.

BackgroundThe aim of this study was to measure six months compliance to Swedish clinical guidelines in psychiatric care after an active supported implementation process, using structured measures derived from the guidelines.MethodsIn this observational study four psychiatric clinics each participated in active implementation of the clinical guidelines for the assessment and treatment of depression and guidelines for assessment and treatment of patients with suicidal behaviours developed by The Stockholm Medical Advisory Board for Psychiatry. The implementation programme included seminars, local implementation teams, regular feedback and academic visits. Additionally two clinics only received the guidelines and served as controls. Compliance to guidelines was measured using indicators, which operationalised requirements of preferred clinical practice. 725 patient records were included, 365 before the implementation and 360 six months after.ResultsAnalyses of indicators registered showed that the actively implementing clinics significantly improved their compliance to the guidelines. The total score differed significantly between implementation clinics and control clinics for management of depression (mean scores 9.5 (1.3) versus 5.0 (1.5), p < 0.001) as well as for the management of suicide (mean scores 8.1 (2.3) versus 4.5 (1.9), p < 0.001). No changes were found in the control clinics and only one of the OR was significant.ConclusionCompliance to clinical guidelines measured by process indicators of required clinical practice was enhanced by an active implementation.

Four years on: The impact of the National Service Framework for Older People on the experiences, expectations and views of older people

Evaluation of the impact of the National Service Framework for Older People (NSFOP) on the experiences and expectations of older people, 4 years into its 10 year programme. the NSFOP is a comprehensive strategy designed to promote fair, high quality, integrated health and social care services for older people in England. It emphasises (i) the need for services to support independence and promote health, (ii) the specialisation of services for key conditions (stroke, falls and mental illness) and (iii) advocates a cultural change in services so that the older people and their carers are treated with respect, dignity and fairness. It has a 10-year timetable for implementation, starting in 2001. A mixed methods approach to evaluation was taken in ten purposively selected localities in England. A portfolio of methods (listening events, nominal groups and interviews) was used with older people and carers to focus on processes as well as on outcomes and to allow for the possibility of conflicting or differing judgements about service quality. One thousand eight hundred and thirty-nine people participated in public listening events, 1,639 took part in nominal groups and 120 were interviewed individually. The existence of the NSFOP was not widely known beyond the NSFOP local implementation teams and voluntary sector activists. Many, but not all older people, identified themselves as members of a group that was subject to age prejudice that altered the quality and standard of their care. This identity included a role as carer for others, but there was less emphasis on the rights of older people. Positive changes in primary care services were offset by difficulties in accessing general practice and a sense that services were becoming impersonal. The quality of social care at home varied from sensitive and personal to fragmentary, hurried and impersonal. Hospitals treatment was perceived as improved in speed and quality in most places, but hospitals were also seen as risky and insufficiently caring, with discharge sometimes being unprepared, over-zealous and disorganised. If asked, older people do not perceive improvements as the result of a NSFOP, but nonetheless they do perceive improvements in systems. It is difficult to attribute any of the changes in experiences that we identified to the NSFOP itself, but we can see that other change processes run contrary to some aspects of the NSFOP whilst some trends are congruent with the aspirations of the NSFOP. Government initiatives face the difficulty of distinguishing experiences that may be attributable to multiple causes. They are influenced nonetheless by the outcome of public consultation since these provide relatively rapid means of feedback and commentary by citizens and regulators on the performance of services.

Single Assessment Process in Hertfordshire: Investing in Change Management

This paper describes how Hertfordshire met the challenge of providing a training programme to improve services for older people, with the introduction of single assessment, in the complex setting of a shire county with a number of PCTs, acute trusts, a county partnership trust and a county council social care service.Having set the context for single assessment, it describes the Hertfordshire approach. It focuses on some of the key drivers for successful implementation of such a radical programme of change: the siting of sessions by geographical location, the crucial role of managers and team leaders, setting the context of the sessions in the reality of staff experience, the importance of a shared language, common paperwork and clear protocols, and the role of the local implementation teams in supporting the process both through its implementation phase and into the future.Finally, it recognises that this training programme was only one aspect of equipping staff to be confident and competent in their assessments of older people, and that service improvements will be achieved gradually, requiring commitment from managers and support from the local implementation teams.

Blackburn with Darwen Action Learning Set ‐ A Model for Improving the Interface Between Inpatient and Community Teams

lackburn with Darwen action learning set was commissioned by the Blackburn with Darwen mental health local implementation team to improve collaboration between community teams and wards in order to develop the quality of care in Blackburn’s inpatient settings. The action learning set (ALS) was introduced during a period of significant organisational change and flux in the senior management team and prior to the publication of an external investigation about a serious incident involving the death of a former inpatient. The overall aim of the initiative was to improve the quality of inpatient care by bringing together first-tier nurse managers of wards and community teams in a learning environment over an extended period. Most of the managers had not taken part in any post-qualification management training and none had any prior experience of action learning. This article was written one year after the commencement of the ALS and prior to the formal evaluation. It suggests that action learning is an appropriate method of bringing together team leaders and that the subsequent improved joint working is beginning to have a significant impact on the way managers cope with the day-to-day stresses of their work and upon the inpatient experience.

The ABCD lecture. The diabetes NSF—what is the role of the consultant physician‐diabetologist?

Sue Roberts thought there had never been a better time to help improve the lot of people with diabetes. She acknowledged that it did not always feel like that to those who were working in the specialist diabetes services so she wanted to make clear that she thought it would be impossible to deliver the Diabetes NSF if diabetes specialists were not properly valued. On the negative side, there were problems with recruitment, the stress and strain of having to balance the service demands of general medicine and diabetes, the long wait for the NSF, and concerns about the shifting of focus to primary care and the impending European Working Time Directive. But diabetes could surely capitalise on new DoH thinking about the importance of chronic disease management (CDM) and self-management. Systematic care, originally developed by specialist diabetologists, was seen to be capable of handling very large populations and had taken on a life of its own, away from hospital-based diabetologists. The reasons were of course the epidemic of diabetes and the huge variations in services and outcomes, particularly in ethnic and lower socio-economic groups. NSF targets for systematic care had to be delivered by 2013. Systematic care meant traditional and familiar surveillance and intermediate outcome programmes. The patient-centred approach was reflected in the requirement that every patient should have a named contact, structured education and a care plan. How was the vast task to be addressed? Dr Roberts felt the first thing to do was to set up a Local Implementation Team. This would comprise all those involved in diabetes care in a natural community, including patients, primary care and of course the diabetes specialist. Dr Roberts thought that there would be a wide variety of diabetes networks set up round the country but they would only be successful if they got the power relationships within the NHS right. Specialist care must reconfigure to acknowledge the fact that within 10 years 85% of CDM would be carried out in primary care. New models were being developed already in different parts of the country. These included hospital-led intermediate care outreach programmes and PCT-led initiatives of community diabetologists and GPs with a special interest in diabetes. In terms of the patient's life journey through diabetes, it was obvious that the specialists worked very largely at the expensive end. It would be better to put efforts and resources into the other end. Specialists within a new integrated system would continue to assess the most complex multi-dimensional problems and to manage specialist disease areas such those arising in children and pregnancy. Specialists would co-ordinate and quality assure all the programmes and would run education and training, help to get evidence into practice, co-ordinate joint evaluation and take part in research and development. Above all, they could contribute leadership. Thanking Sue Roberts for her very informative talk and answers to questions, Dr Greenwood said it would have been obvious to her that there was enormous apprehension and anxiety amongst ABCD members about the NSF and the possible dumbing down of the specialist service. Would it be of use if the Association were to provide examples of what was happening? Dr Roberts said she would be very interested in receiving such information. She had no direct powers but could work on the DoH environment so as to improve the chances of better local solutions.

‘Doing Our Own Thing’: An Alternative Process for Building User Capacity

For patients to be at the heart of the NHS they have to be meaningfully involved (Department of Health, 2000). This is no different for mental health services. User involvement forms one of the standards of the National Service Framework for Mental Health (Department of Health, 1999) and the engagement of users in decision making through the local implementation teams is performance managed. There are some strong and vibrant user organisations but many are small and lack strength as shown in recent user-led research (Wallcraft, 2003) and some geographical areas have no user groups or their input may be seen as tokenistic. Developing such organisations raises real ethical dilemmas; how can an outsider, a professional, develop an organisation which should by its very nature be user led? How can such development be as the users would wish and to what extent can it realistically be a response to their own concerns and drivers? This article describes The Project which sought to build meaningful independent user capacity through processes driven by users themselves.

Involving Older People in the Implementation of the National Service Framework: Making Progress in the North West

The National Service Framework for Older People (DoH, 2001) is a ten‐year plan which aims radically to improve health services for older people. Central to the plan is the belief that older people should be involved as ‘genuine partners’ in the implementation process. In this article we describe how regional and local implementation teams in the North West of England are working in partnership to develop a coherent and sustainable strategy for engaging with older people.

Assessing needs for psychological therapies in the context of the National Service Framework for Mental Health

At the initiative of the Local Implementation Team for the National Service Framework for Mental Health, an assessment of current need for psychological therapy was undertaken across all tiers of provision within the mental health services for the localities served by a specialist NHS Trust. The methodology chosen involved collecting information about the current provision of psychological therapies in terms both of staff establishment and service usage (referral rates, throughput and waiting times). From this data it was possible to estimate shortfall in services to manage current referrals. In addition, the ‘hidden’ need – referrals which are suppressed by this shortfall and would emerge with more adequate provision – was estimated through surveys undertaken by members of the services with a sample of their major referrers. Results indicated very substantial shortfalls in provision, both for current referrals and additionally for the ‘real’ potential demand. This was true in differing degrees at each tier of the service. The required increases in provision to meet identified shortfalls were calculated. Required increases in Primary Care and Secondary Intermediate tiers approach 100 per cent, as did the Secondary Complex tier for one half of the area. Increases in the Specialist Psychotherapy services varied for the different types of provision but appeared to be similarly high. Methodology and results are discussed in relation to their generalisability to other services, their implications for workforce planning and current and future patterns of service provision.

Beyond Involvement: Making Choices and Taking Control

he growth of the service user/survivor movement over the last 20 years has provided an opportunity for people to speak openly about their experiences of mental health services and to be involved in local health and social care organisations, regional and national initiatives, and to influence Government policy. The Government’s mental health strategy (Department of Health, 1998) and National Service Framework for Mental Health (Department of Health, 1999) emphasise a more user-centred service and state that their commitment to a modern, decent and inclusive society provides the context for mental health services. The first of the guiding values and principles of the National Service Framework states that: ‘People with mental health problems can expect that services will involve service users and their carers in planning and delivery of care.’ This principle is further echoed in the NHS Plan (Department of Health, 2000) and in the Mental Health Policy Implementation Guide (Department of Health, 2001, p6) which states that: ‘Above all, mental health services must place the needs of ... service users at the centre of their planning and their practice.’ Despite government intentions to put the service user at the centre, there is little evidence of this in the application of policy and practice at a local level. The IAHSP’s work with approximately 50 local implementation teams in the South East, North West, South West and Trent regions of England shows that 90% of their plans and actions do not include user involvement. There are pockets of good practice but T in the main this is limited to involvement on the local implementation teams in commissioning services and, in a few cases, on the boards of trusts. There has also been little action on other stated aims of the National Service Framework – promoting mental health, tackling stigma and discrimination, person-centred planning or promoting independence – and no targeted action in relation to a key issue that service users want; that is, involvement in care planning and treatment provision.

DataStreme: Weather Education from the AMS to the Classroom

The American Meteorological Society's DataStreme Project is a Society effort to educate K–12 teachers in meteorology. The course utilizes a combination of printed material, Web-based information, and real-time meteorological data in a distance learning format. Learning is facilitated by a Local Implementation Team (LIT). The following paper discusses the program from the perspective of the eastern Iowa LIT.