A qualitative study of policy and action: How the Scottish Government has implemented self-management support for people with long-term conditions (LTCs)

Abstract

Objective: The promotion of self-management support for people with LTCs is a health policy priority across the UK (LTCAS 2008; DoH 2012). Self-management support is designed to change and improve care for people with LTCs, who form an increasing proportion of the population requiring healthcare and treatment. For health organisations models of care, which support self-management, require greater emphasis on person-focused rather than disease-focused manifestations of health and represents a new model of care delivery requiring changes in practice.

Current research demonstrates that health policies are increasingly complex, involve multiple organisations and often fail to translate into effective practice (Noyles et al. 2014). The deficit between what works and what happens in practice is referred to as the “implementation deficit” (Pressman and Wildasky 1984) and traditionally it has been difficult to breakaway from the idea that the policy process is best viewed from the top-down (Barett and Fudge 1981). However, there remains a need to understand the processes of implementation, which takes account of the variation, the multiple layers and interactions which takes place between policy-maker and -implementer as policy becomes practice (Hupe 2011).

Implementation of self-management is a contemporary focus in UK health policy and this thesis explains what processes are used to implement self-management policy for people with LTCs into everyday practice in one health board.

Methods: A case study approach was used to investigate the policy process with data collected using thirty-one semi-structured interviews with policy-makers and regional and local policy-implementers plus eight hours of observation of national and regional policy meetings. To provide context to the implementation process data also included thirteen policy documents.

Data analysis used the retrospective application of NPT as a theoretical framework with which to explore the implementation processes. NPT is an emerging theory that is being promoted as a means of understanding implementation, embedding and integration of new ideas in healthcare (McEvoy et al. 2014). The application of NPT focuses on four mechanisms, termed work (May and Finch 2009: 547), which promote incorporation of new ideas in practice. These areas of work are coherence, cognitive participation, collective action and reflexive monitoring (Mair et al. 2012).

Findings: The findings suggest that there are a number of important influences operating behind or as part of the policy implementation process. These included the need for a shared understanding, getting stakeholders involved to drive forward policy, work promoting collaboration and participation was the most detailed and important in the process of policy implementation; the course of policy was affected by factors which facilitated or inhibited stakeholders acceptance of self-management; and NPT fosters key analytical insights.

Conclusion: Understanding the process of policy implementation in healthcare and how practice changes as a result of policy is subject to a wide range of influences. What emerges are five key recommendations relating to understanding policy implementation. (1) understanding the concept of self-management is important in promoting policy implementation. This understanding benefits from dialogue between policy-makers and -implementers. (2) stakeholder involvement supports implementation particularly the role of clinical leadership and leadership through existing networks but also value in establishing new organisational structures to create a receptive context. (3) develop participation and collaboration through use of the patient voice which helped simplify the policy message and motivate change. (4) other resources help policy implementation and where these are evident then policy is implemented and where they are absent then implementation is not embedded. Lack of evidence was a particular area of constraint. (5) NPT has shown that social context is important, and provides for this. But in addition there is evidence that historical perspectives and previous experience are also important influence on receptivity to implementation.

This research contributes to the development of theory and practice in the area of implementation science. The exploration of the policy implementation has revealed the action and work which policy-makers and -implementers are engaged in while implementing policy. It has tested the utility of NPT in a real-life setting using all four mechanisms.