Senior Lecturer and Associate Medical Director, Islington Primary Care Trust
James Hickling MSc MRCGP
Irwin Nazareth PhD MRCGP
Departmet of Primary Care and Population Sciences, Royal Free and University College London Medical School, London, UK
Accepted date: May 2003
The National Service Framework for Coronary Heart Disease provides indicators and criteria, which can guide improvement activity in primary care, but this guidance will need to be complemented by local initiatives to promote change. The need forchange strategies to be tailored to the problems and settings they are meant to address is only now clearly understood.E¡ective evidence-based implementation will require a correct diagnosis of underlying barriers to change, an understanding of the e¡ectiveness and appropriateness of alternativechange strategies and a judicious selection fromthe available options. In this paper we show howlocal investigations of barriers to change might beused to generate change proposals for implementationby primary care organisations. Although thechange proposals we developed were complex, thepolicy context in primary care is favourable forengaging practitioners and patients and for deliveringchange. It is our hope that local investigationswill be used alongside the research literature on theimplementation of change, to develop change proposalsthat are grounded in evidence and tailored toparticular settings.
Coronary heart disease (CHD) is among the biggest killers in the United Kingdom. In England alone, more than 1.4 million people su¡er from angina, 300 000 have heart attacks and 100 000 die from heart problems every year. The National Service Framework for Coronary Heart Disease indicates that generalpractitioners (GPs) should identify all patients with confirmed CHD, record risk factors and assure that appropriate treatments are o¡ered. Thereafter the importance of detecting and treating patients at high risk of developing CHD is emphasised, with smoking, hyperlipaemia and hypertension targeted for inter-vention (see Box 1).
Surveys in general practice have indicated that there is some way to go. For example in a study of 1319 Scottish CHD patients, 63% took aspirin, 18% were still smoking and lipids were managed according to guidelines in only 16%. Amongst the 257 patients with heart failure, only 40% were on angiotensin converting enzyme (ACE) inhibitors. Similarly, areas of primary prevention are in need of attention, especially adequacy of blood pressure con-trol in the elderly and the application of multiple risk factor assessment techniques in primary care.[3–5]
Local initiatives and practical support will be crucial to the e¡ective delivery of change in primary care and primary care trusts (PCTs) will carry re-sponsibility for identifying strategies for implement-ing change that are applicable to their particular settings. The recommendations made in the National Service Framework for Coronary Heart Disease arebased on a large body of research evidence and well-conducted systematic reviews. The strategies selected to support the implementation of these recommenda-tions should also be evidence based.
Intervention trials directed towards improving cardiovascular disease management or prevention in the general practice setting have generally failed to deliver more than modest improvements.[6–8] Typically such trials have evaluated alternative service frame-works, or di¡erent models for the organisation of care. A complementary area of literature that may be equally if not more important to primary care organ-isations is the very considerable research on interven-tions designed to bring about behavioural change in both health professionals and patients. Many di¡erent interventions directed towards changing professional practice have been tested in randomised controlled trials. Most have found their place in systematic reviews organised according to a widely accepted taxonomy. Similarly, randomised studies of inter-ventions to change patient behaviour have been summarised in systematic reviews. Many of these reviews appear in the health promotion literature.[10–13]
The need for change strategies to be tailored to the problems and settings that they are meant to address is only now clearly understood. For those involved in implementing National Service Frameworks, the trick will be to select those interventions most suitable for the purpose. A single intervention is unlikely to be su¤cient and for some improvement areas, patients, practitioners and organisations will need to be tar-geted. E¡ective evidence-based implementation will require a correct diagnosis of underlying barriers to change, an understanding of the e¡ectiveness and appropriateness of alternative change strategies and a judicious selection from the available options. In this paper we show how local investigations on barriers to the adoption of evidence across topics of relevance to the National Service Framework for Coronary Heart Disease might be used to generatechange proposals for implementation by primary care organisations.
Developing change proposals
Survey and interview methods, observational tech-niques and group methods have been suggested as ways of investigating barriers to e¡ective practice (see Box 2).[17–22] Each has strengths and weaknesses. For example, surveys may be conducted remotely, but require a predetermined list of possible barriers. Through interviews it may be possible to explore perceived barriers in more depth, but these are time consuming and can be di¤cult to interpret and assimilate. Group processes such as focus groups can be useful, but may be in• uenced by dominant participants and produce stereotypical results.[21,22]
An alternative group method to focus groups is the nominal group process. This is a highly structured method, which elicits the consensus views of multi-disciplinary groups of professionals and results in a ranked list of outcomes. It utilises helpful aspects of group dynamics through discussion, while allowing independent contributions by all participants.
We conducted a series of nominal group meetings among health professionals in a group of 12 practices that had previously participated in a survey of current practice with respect to the management of various aspects of cardiovascular disease. Each of three dif-ferent topics was investigated on di¡erent occasions. These were the use of ACE inhibitors in heart failure, the use of statins in the secondary prevention of CHD and the treatment of systolic hypertension in the elderly. Meetings began with a presentation of the performance of the practice on the implementation of a particular clinical change. Participants then listed factors which they thought might act as barriers, and ranked these in descending order. In order to provide summary data for barriers operating across practices, a thematic framework was devised to classify factors identified into broader groups. The factors were coded, weighted according to their rankings in indi-vidual practices, and then aggregated across practices within thematic groups presented in order of import-ance (see Box 3).
We then went on to identify the interventions that might best address the barriers identified. No attempt was made to deduce underlying psycho-logical or behavioural causes for perceived barriers to change, as has been suggested by other authors.[14,24] Rather, our selection was based on our understanding of the problem as expressed by informants, togetherwith a knowledge of the task, the setting and the literature.
The barriers elicited and the change proposals generated for each of the three cardiovascular disease topics appear in Boxes 4–6. The evidence base for the interventions selected across all three topics included four Cochrane reviews, three other systematic reviews, two narrative reviews and one observational study identified through Medline searches. The Clin-ical Outcomes Group of the NHS Executive grades recommendations for clinical practice as ‘A’ where there is a body of literature of good quality and consistency including at least one randomised con-trolled trial to support the specific recommendation. Applying the same principles to our change proposals, the strength of the recommendations would be grade A for four of five component interventions identified to address the use of ACE inhibitors in heart failure, grade A for all five component interventions identi-fied to address the use of statins in CHD and grade A for four of the six interventions identified to address the treatment of systolic hypertension in the elderly.
A common feature of implementation activity in the health service is that project management draws on experience and local knowledge, while neglecting careful consideration of the research literature. In this paper we argue that implementation strategies should be evidence based and tailored to the local setting and we share three examples of where we have used information on barriers to change to support the development of evidence-based change proposals.
The change proposals we developed were complex. Constraints on delivering improvements in the man-agement of CHD exist at the level of the practitioner, the patient, the practice and the local configuration of services. Also, the patterns of constraints depend on the area of clinical practice examined. For example, physician education, system and organisational issues figured high on the agenda for assuring e¡ective management of heart failure, while patient education and negotiation around treatment were much more important for improving the management of hyper-tension in the elderly. Such findings will be important for those developing change proposals and rather preclude the implementation of blanket proposals in the hope that they might impact across a range of clinical outcomes.
Despite the challenges, the climate is favourable for primary care organisations to be considering the evidence-based implementation model. Most are in the process of building their clinical governance expertise and are integrating public health functions with the day-to-day business of developing ser-vices.[36,37] Governance and educational activities are becoming more closely linked, and a focus on per-formance will be reinforced through periodic Com-mission for Health Improvement and Audit (CHAI) reviews.[38,39] Simultaneously, annual appraisal of GPs and a new contract, which emphasises quality of care above quantity of care, will enhance the motivation of doctors to become engaged with change interventions directed towards improving clinical e¡ectiveness.[40–42] Finally, patients themselves are demanding more information on the clinical e¡ectiveness of treatment options and government policy is emphasising patients’ rights in this respect.[43–47]
Consideration will need to be given to where one would start in actually implementing such change proposals. Pointers might include: (1) the importance attached to a particular barrier by the informants; (2) the degree to which change in one area is likely to be necessary for subsequent changes to occur; (3) the likely impact of a particular intervention; and (4) the feasibility and cost of implementing the intervention, given local constraints and other demands on re-sources. Various activities might be construed as components in a continuous quality improvement sequence, where progress is monitored and new interventions build on what has already been achieved.
CHD continues to be a major cause of illness and death in the United Kingdom. The National Service Framework for Coronary Heart Disease is directedtowards improving prevention and treatment of CHD and draws attention to the need for better management in primary care settings. PCTs have access to a formidable literature on the e¡ectiveness of a range of strategies for the implementation of change. It is our hope that local investigations will be used alongside the research literature on the imple-mentation of change to develop change proposals that are grounded in evidence and tailored to particular settings.
The research was funded in part from the NHSE Implementation Methods Programme and the North Thames Primary Care Research Network. Twelve practices from the MRC General Practice Research Framework participated in the nominal groups. Azeem Majeed, Jeremy Wyatt and an unknown referee commented on earlier drafts.