In this study we found certain generic issues, but some problems were specific to the technologies concerned. In terms of generic factors, the following are relevant: negotiating and implementing changes to the patient pathway; identifying training needs and, often, finding the resources to fund these; changing work practices; locating the resources to fund the purchase and use of the technology concerned, usually in the context of a decrease in patient throughput during the early stages of
implementation and consequent loss of income under PbR; and, lastly, summoning the motivation, energy and commitment to overcome these barriers in the context of little time to devote to implementation while coping with ongoing clinical work. These generic factors demonstrate that clinical technologies are
‘disruptive’in two senses. First, they have the potential to bring about step change improvements in patient care through disrupting traditional and sometimes out-of-date ways of working but, second, because they are disruptive to work practices they can elicit resistance. Theories of disruptive innovations in health care have been proposed, arguing that innovations are disruptive in health because they do not translate easily into‘value-added’business models.234,235Innovation, Health and Wealth: Accelerating Adoption and Diffusion in the NHS1suggests thateaseof implementation influences therateof
implementation, so very disruptive technologies may take much longer to implement.
Current government policy as expressed inInnovation, Health and Wealth: Accelerating Adoption and Diffusion in the NHS1refers to‘... game-changing innovations that change patient pathways and
traditional delivery systems and ... strip(s) out the processes that no longer add value’. This rhetoric neglects the issue that technologies have to be adopted and implemented by NHS clinicians (and managers) in the face of all the generic barriers identified above. Another rallying call is:‘We need to make innovation everybody’s job from the top to the bottom of the NHS’.1At the moment, innovation is
in nobody’s job description: this is a generic barrier. In the case of new clinical technologies, the
responsibility to adopt and implement isassumedby intrinsically motivated technology champions, usually clinicians but sometimes managers. Indeed, if technology implementation was‘everybody’s job’, it would be no one’s responsibility as specific decision-making rights have to be delegated (or assumed) for technology adoption and implementation to progress (cf. Brunsson;236Ahrne and Brunsson237).
Our findings indicate that the NTAC approach to technology adoption and implementation was effective at addressing generic issues around changes to the patient pathway, training needs, rethinking work practices, harnessing energy and commitment for implementation and, to some extent, funding the
TABLE 8 Barriers to implementation
Factor UFRI IPT BLNA
Involves complex new multiprofessional complex working practices
Yes No Yes
Capital cost High Low High
Negative effect on trust income Yes No Yes
Tariff rigidities Not
applicable
Only capital and consumables funded, not infrastructure
No local tariff agreed Necessitates close working across
– High Low Medium
purchase and use of the technology concerned. To overcome these generic issues, NTAC employed the processes of project management and stakeholder engagement. As discussed earlier, NTAC established from the beginning that their work at the trusts was an implementation project rather than a trial. This did appear to ensure commitment and focus energies on a timetable with an end date and, for the MSs, the production of a HTWT guide. Also in relation to the issue that technology adoption and implementation is in nobody’s job description, the project implementation manager role supplied a person around whom energies for implementation could coalesce. In a similar manner to a management consultant, this person was an‘objective’outsider removed from the trust’s internal power and politics agenda and so, possibly, was more able to press ahead with implementation. Attention to stakeholder engagement ensured that all relevant parties were‘at the table’; apparently without NTAC’s input, commissioners had been neglected, resulting in problems with funding. NTAC introduced a structured implementation schedule including meetings, presentations and awaydays, the formality of these processes imposed a dynamic that gave implementation an additional impetus alongside the day-to-day clinical use of the technology concerned. Participants also had the opportunity to share experiences, compare practices and learn from one another.
For IPT, we found that, in the two implementation sites studied, the processes underlying project
management, stakeholder engagement and structured implementation schedules were largely sufficient to overcome the more generic barriers the sites were dealing with. In both sites, there was a general
receptivity to IPT as a technology and a willingness to increase its use. However, the main barriers were around how to get started and how to manage the process of implementation, including the various stakeholders that needed to be involved. This does, however, raise the question of whether or not the more generic support provided by NTAC would work in organisations that would not fit the criteria of
‘early adopters’,27such as the NIS where there was a greater contestation of the evidence and less
receptiveness to the technology of IPT.
As indicated earlier, the NTAC project implementation for UFRI failed as all the interested trusts withdrew. Based on our findings, however, we judge that even if the trusts had remained interested the project would have been unlikely to succeed. The technology was too disruptive. The processes of project management, stakeholder engagement and structured scheduling (to address generic issues) would have been unlikely to solve the complex issues of where the technology is best situated (primary, secondary and tertiary care or all three), how the technology is best used and what target conditions the technology is best used for. The emerging scientific evidence in journals and the ongoing research in tertiary care (including use in the clinic) is resolving the‘how’and‘what’questions, but the‘where’question (apart from in tertiary care itself) is not being addressed. As argued earlier, to reap its potential UFRI requires a close working relationship between partners in primary and secondary care and willingness on the part of tertiary (or secondary) care to educate primary care. Education is required for the‘how’and‘what’issues; in addition, our research found that there is a long learning curve in interpreting the digital images. Without some integration between primary and secondary care, education on this scale seems unlikely to happen, given that there are, currently, no financial incentives for ophthalmologists in secondary and tertiary care to engage. Indeed, if the use of the technology in primary care reduced the number of referrals to secondary care (which seems likely over time), there is a financial disincentive for the trusts, although there should be savings for the health economy as a whole.
Breast lymph node assay adoption called for a number of significant changes in working practices of surgical and pathology teams. First, it made the management of theatre lists more complex as provision had to be made for additional surgical time, but which patients would need it could not be predicted with complete confidence in advance. Second, it demanded much closer co-ordination between surgical teams and pathologists, as test results had to be available within a very short time period. We saw different ways of achieving this at each trust, some of which were acknowledged to introduce some potential risk to the reliability of testing procedures. In general, the implementation of these changes was contingent on local factors, making it difficult, if not impossible, to propose a‘standard’for implementation that could be straightforwardly applied at any trust.