Background Health service redesign involves several interventions across multiple organisations and stakeholders. It is important to understand the conditions for successful implementation including how outcomes are attained. Realist evaluation explores ‘what works for whom in what circumstances and why’. Our aim is to use this approach to evaluate the implementation of the National Clinical Programme for Diabetes (NCPD), a multifaceted change programme led by healthcare professionals (HCP).
Methods The evaluation is being conducted in three phases. During phase 1, semi-structured interviews were conducted with a purposive sample of members of the national working group (n = 20). Framework analysis was used to identify the initial programme theory (underlying rationale) and develop hypotheses regarding the conditions (context, mechanisms) that facilitated or impeded implementation (outcome). These hypotheses will be examined in phase 2 using a mixed methods multiple case study design. Interviews will be conducted with local stakeholders in four geographical regions (HCP, management, patients), supplemented with analysis of routine activity data. Data will be integrated during interpretation and synthesised on a thematic basis. During phase 3, the programme theory will be refined and cross-case comparison will examine whether the components for successful implementation differed across regions.
Results Preliminary analysis suggests that in the context of service ‘black spots’ and ‘pockets’ of good practice, the purpose of the programme was to develop ‘a cohesive strategy’ for resource allocation to ensure a standardised service across the country. Part of the programme theory was that establishing national clinical leadership would foster buy-in and empower frontline staff. However, implementation has been impeded by ‘missed opportunities’ to utilise local clinical experience. One participant suggested that the poor uptake of the national retinopathy screening programme was due in part to the lack of a clear ‘connexion with the clinicians on the ground’.
Two priority areas, the retinopathy screening programme and national foot care model, were ‘at least moving in the right direction’. However, there has been little change in the shared management of patients between primary and secondary care.
Discussion There is consensus among national stakeholders on the need for and purpose of the programme. However, the lack of progress on integrated care challenges the intended outcome of a standardised diabetes service for all patients. Findings on the more successful contexts and mechanisms for change will inform the future implementation plans for the NCPD as well as other programmes seeking to work with and across disciplines to introduce change.
- health services research