Evaluating and implementing new services

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Abstract
Changing the organisation of services Implementing organisational change in health services requires substantial effort and typically needs to be driven by enthusiastic groups and individuals. There are many examples of delays in getting existing evidence into practice. The slow pace of organisational change is often seen as problematic in the drive towards an evidence based health service. However, sometimes the converse is true. Too much momentum may lead to inappropriate implementation of change before evaluation is complete. Managing this momentum offers the key to rational evaluation and implementation of changes in service organisation and delivery. The drive for change in the way services are delivered can spring from various sources, including political imperatives, policy drivers, and enthusiasm from clinicians. Enthusiasm for improved services is desirable but can blind enthusiasts to the possible downsides of an intervention. Evidence based care may mean delaying the introduction of new treatments until robust evidence exists of their effectiveness. This approach is well suited to simple interventions aimed at individual patients, such as drugs. Here, momentum is often driven primarily by commercial imperatives. Although political and professional influences are brought to bear in the introduction of new drugs, as shown by recent controversies over treatments for Alzheimer's disease and multiple sclerosis, current regulatory frameworks attempt to ensure that new drugs cannot be prescribed before they have been thoroughly evaluated. Would this service exist if it had been evaluated first? Credit: ITV/REX When an existing device or operative technique is modified for a new purpose, intervention is more complex. But even here, a framework of regulation helps to curb the enthusiasm of pioneers and ensure that use of the new technique is based on evidence as well as passion and commitment. Since 2003, The National Institute for Health and Clinical Excellence (NICE) interventional procedures programme and the Review Body for Interventional Procedures have been assessing the safety and efficacy of new procedures. They gather evidence by systematic review and formulate guidelines. Use of a new procedure may be restricted to certain circumstances or to specific healthcare facilities. This review process has attracted criticism from some people who believe it will stifle change and innovation. Achieving a balance between controlling the momentum for change and maintaining enthusiasm is more difficult for complex innovations such as new clinical services. We have selected three examples which show the importance of managing momentum as part of a planned framework for the development, implementation, and evaluation of new clinical services. In the first two, the pace of implementation outstrips the emergence of evidence. Both are top-down innovations, one driven by professional bodies and one by policy makers. The third is a bottom-up approach, where the pace of implementation and evidence are more evenly matched.