Implementation science: why using evidence doesn’t guarantee success

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Using evidence in policy making is not a new concept. In recent years it has become commonplace across all areas of policy in the UK, with the introduction of the What Works centres being just one example of this. Policy makers also use evidence to defend the rationale of their initiatives and programmes. But a large evidence base does not necessarily guarantee a successful outcome for a programme or initiative. Without an effective implementation strategy, evidence might as well not exist.

Linking evidence use to implementation within policy is one of the key challenges for policy-makers and those on the frontline of service delivery. Implementation science is an emerging discipline which looks at the nature of implementation, and how it can affect the success of a programme or policy.

Introducing the Hexagon Tool

This tool was developed by the National Implementation Research Network. It outlines six broad factors that should be considered to promote effective implementation of programmes. Designed in a US context for application at state and district levels, many of the ideas about what makes for good implementation are relevant more broadly.

  1. Needs (of service user) – consider how well the programme or practice being implemented might meet identified needs.
  2. Fit – with current and pre-existing initiatives, priorities, structures, support, and local community values and context.
  3. Resource availability – for training, staffing, technology supports, data systems, and administration
  4. Evidence – indicating the outcomes that might be expected if the programme practices are implemented well (assessment criteria)
  5. Readiness for replication – including any expert assistance available, the number of existing replications, examples of best practice for observation, and how well the programme is operationalised.
  6. Capacity to implement – as intended, and to sustain and improve implementation over time
The Hexagon Tool How to cite: Blase, K., Kiser, L. and Van Dyke, M (2013) The Hexagon Tool: Exploring context. Chapel Hill, NC: National Implementation Research Network, FPG Child Development Institute, University of North Carolina.

The Hexagon Tool
Blase, K., Kiser, L. and Van Dyke, M (2013) The Hexagon Tool: Exploring context. Chapel Hill, NC: National Implementation Research Network, FPG Child Development Institute, University of North Carolina.

In addition to the hexagon, other useful frameworks for implementation exist. Some are more practical and others are more conceptual. These may link to theories underpinning the practice of implementation of programme strategies, or discuss the idea of values within systems.

However, frameworks only provide some of the knowledge and infrastructure for implementation. They do not take account of the skills, abilities, values and existing experience of “implementers”. All of these can have a significant impact on how a programme or strategy is implemented.Solution and business words jigsaw

Systems change and innovation

Implementation science has previously focused on changing the behaviour of individual practitioners. However, unless you change the understanding of the wider structures and systems, and implement whole system change, you won’t achieve practitioner change.

Alignment within systems, both within organisations in a hierarchical sense, but also across systems in order to create coherence across services, is important. Many service users have experience of receiving support simultaneously from a number of different organisations. Implementation scientists stress that it is important to align funding, outcomes, compliance and overall goals of parallel organisations in order to effectively implement programmes. This can be a major challenge.

One reason why this can be so challenging is the difference in values and experiences of the individual front line workers implementing a new programme on the ground. Teachers have a very different understanding, training and set of experiences relating to children than those of social workers, or those who work in youth criminal justice. The inherent and fundamental philosophical beliefs which drive the practice of different professionals will have an impact on how they implement a programme, regardless of how thorough guidelines are.

This, implementation scientists suggest, needs to be taken account of, and steps taken to try and more closely align the thinking of different professionals and agencies (interagency working) in order to effectively, and coherently implement new programmes.

Evidence is contextual

Implementation science raises some interesting points about how to facilitate change and implement new initiatives. It reminds us that no intervention – no matter how much evidence is produced in support of its effectiveness elsewhere – is guaranteed to be a success. It highlights the often overlooked elements to intervention strategies, such as the need to be context aware, and aware of the values of the people who are implementing the changes, and those affected by the changes.

Finally, it highlights the need to encourage wider structural and systems change, rather than just changing the behaviour of individual practitioners. This is the way to ensure lasting, sustainable and successful implementation of evidence-informed policy interventions and programmes.


Read some of our other blogs on evidence use in policy:

Can the Care Act really provide the transformation in adult social care needed for modern society?

pregnant carer giving pills and medication to her patientBy Heather Cameron

The legislative framework for adult social care in England has been described as out-dated by the Department of Health (DH) as it is focused on crisis intervention rather than prevention and early intervention, and on the provision of services, rather than enabling the system to be centred around the health and wellbeing of people and carers. The DH has therefore highlighted the need for government intervention to reform the legal framework so it better fits the purpose of modern care and support.

The government’s objectives for adult social care are to improve people’s quality of life, delay and reduce the need for care, ensure positive care experiences and safeguard adults from harm. The Care Act 2014 was passed into law on 14th May 2014 with the aim of transforming adult social care in England to meet these objectives.  Although the Act is generally concerned with care and support matters in England, some provisions extend to the devolved nations.  The main focus of the Act is on promoting individual wellbeing and preventing the need for care and support. In particular, it makes provision:

  • to reform the law relating to care and support for adults and the law relating to support for carers;
  • about safeguarding adults from abuse or neglect;
  • about care standards;
  • about Health Education England;
  • about the Health Research Authority;
  • about integrating care and support with health services; and
  • for connected purposes.

According to Care and Support Minister, Norman Lamb: “the Care Act represents the most significant reform of care and support in more than 60 years, putting people and their carers in control of their care and support. For the first time, the Act will put a limit on the amount anyone will have to pay towards the costs of their care.”

Due to come into force in April 2015, with its provisions related to funding reform to be implemented a year later, the success, or otherwise, of the Care Act’s implementation is as yet unknown.

Nevertheless, there has been much discussion over the potential issues and challenges with regard to implementation. The College of Social Work (TCSW) argues that the implementation of the legislative reforms “will be challenging and demand significant cultural and attitudinal changes, both strategically and in professional practice”.

The Act presents significant changes for local authorities which will be challenging to implement in the proposed timescale. Concerns have been raised by both local authorities and charities over the funding of the Act’s provisions and the sustainability of adult social care services. A recent article published in Community Care highlights such concerns among councils, noting that nine out of 10 councils believe key parts of the Act will be jeopardised if the government fails to provide local authorities with adequate funding for implementing the reforms.

According to London Councils, London is facing double the shortfall in funding to prepare for the Care Act than previously thought with proposed new funding arrangements unveiled by the government to leave the capital with a £36 million gap.

Moreover, a subsequent article in Community Care suggests that local authorities need to consider the training challenge now in order to negotiate the issues raised by the new funding reforms.

The main costs of the Act relate to improved legal rights for carers (rising to £175 million per annum). However, there may be additional costs, for example where local authorities face increased demand for services due to improved information. Greater clarification on the support available to carers could potentially increase the workload for social care professionals as the number of carers’ assessments could also increase.

The additional requirements of providing support to self-funders as well as carers could also take its toll on councils. Caroline May, business partner in finance at Havering LBC noted at a recent roundtable that:

“There are a lot of unknowns out there that will present us with financial challenges. I think culture shift is going to be huge across the board.”

The Association of Directors of Adult Social Care (ADASS), which represents local authorities, is unconvinced that local authorities can implement the changes required in the proposed timescale. In a joint report with the Local Government Association, they highlight the financial challenges local authorities face, particularly at a time of budget cuts and increasing demand for services. A recent inquiry into adult social care in England has highlighted that there was an 8% real terms cut in spending between 2010/11 and 2012/13; and demand for care provided by adults is projected to rise by over 50% between 2007 and 2032, while the supply of this care is projected to rise by only 20%, according to Carers UK.

Despite these funding issues, however, cost savings have also been identified in relation to public expenditure savings of improved support for carers, according to the DH’s recent impact assessment, which also states that these cost savings outweigh other new costs overall. The potential benefits of the Act for people with care and support needs which could also lead to savings were identified as: “improved wellbeing, better prevention of care and support need, greater clarity, consistency and equality of access to care and support and reduction of unmet need.”

It will undoubtedly be challenging to implement the provisions of the Care Act and it remains to be seen whether the funding provided will be adequate.

Only time will tell whether the proposed reforms will truly transform the currently outdated adult social care system.


 

Further reading

The Idox Information Service has a wealth of research reports, articles and case studies on a range of adult social care issues. Items we’ve recently summarised for our database include:

The Care Act and the care market: conference summary

Adult social care in England: sixth report of session 2014-15 (HC 518)

Using technology to deliver social care, IN Local Government Chronicle, No 7598 17 Jul 2014

Carers’ quality of life and experiences of adult social care support in England, IN Health and Social Care in the Community, Vol 22 No 4 Jul 2014

Transforming adult social care (improving efficiency in council social care services), IN Local Government Chronicle, 5 Jun 2014

Care Act 2014

Understanding personalisation: implications for social work, IN Journal of Social Work, Vol 14 No 3 May 2014

State of caring 2014

Care home top-up fees: research with local authorities

Making our health and care systems fit for an ageing population

N.B. Abstracts and full text access to subscription journal articles are only available to members of the Idox Information Service.