Health and Social Care in the Community

11

(3) 219ndash228

copy 2003 Blackwell Publishing Ltd

219

Abstract

The objectives of the present paper are to describe selected findings from a research project on the diffusion and adoption of innovations in primary-care settings The project design was a comparative case study design exploring four innovations in different settings The findings are used to explore the influence of evidence on clinical behaviour particularly how clinical professionals judge credible evidence and take decisions The article goes on to explore other influences on behaviour and the role of context in shaping processes and behaviour Finally the concluding section draws out the relevance of these data for the current changes being implemented in primary care and raises questions about the implementation of clinical governance and quality improvements

Keywords

behaviour change context innovation primary care professionals

Accepted for publication

3 December 2002

Blackwell Publishing Ltd

Innovation in healthcare how does credible evidence influence professionals

Louise Fitzgerald

PhD BA(Econ)Hons DipPM

1

Ewan Ferlie

BA Hons MSc PhD

2

and Christine Hawkins

MA

3

1

Department of Human Resource Development Leicester Business School De Montfort University Leicester UK

2

The Management School Imperial College London and

3

Centre for Creativity Strategy and Change Warwick Business School

University of Warwick Warwick UK

Correspondence

Louise FitzgeraldProfessor of Human Resource

DevelopmentDepartment of Human Resource

DevelopmentLeicester Business SchoolDe Montfort UniversityThe GatewayLeicester LE1 9BHUKE-mail lfhumdmuacuk

Introduction

An agenda of radical change for the health service andfor the primary care sector in particular has been setout in government policy (Cmnd 3807 1997) challeng-ing the current variability in provision and per-formance (Department of Health 1998) This qualityagenda is pursued further and by new centralisedinstitutions such as the National Institute for ClinicalExcellence (NICE) and the Commission for HealthImprovement (CHI) To succeed these institutions needto address the question of whether they can achieve lsquotop-downrsquo change and how to successfully influence profes-sionals in primary care Finally

The NHS Plan ndash A Planfor Investment a Plan for Reform

(Department of Health2000) defined itself as a lsquoplan for reformrsquo and extendedthe reforms to the interactions between health andsocial care The requirement for inter-organisationalcollaboration places novel demands on professionals inthe primary care sector

These external pressures are reinforced by an internalclinically led pressure to move towards evidence-basedmedicine (EBM) within clinical practice (Cochrane 1972)

Historically there have been many studies on innova-tion and the diffusion of innovation Whilst much of the

research has been in the private sector some work hasfocused on healthcare including the seminal study byColeman

et al

(1966) Williamson (1992) usefully detailedthe lsquoknowledge-drivenrsquo and lsquoproblem-solvingrsquo modelsof knowledge production and use The former is basedon the assumption that the sheer fact that knowledgeexists presses towards its use The latter model suggeststhat research provides evidence and conclusions whichhelp to solve problems Williams amp Gibson (1990) elab-orated the knowledge lsquopushrsquo and problem lsquopullrsquo modelsof dissemination They detailed four models (1) theappropriability model (a lsquopushrsquo model) (2) the dissem-ination model (3) the knowledge-utilisation model(a lsquopullrsquo model) and (4) most complex of all the com-munication and feedback model These models suggestthat more than sound science may be necessary forsuccessful diffusion

Whilst the work of Rogers (1995) provided valuableinsights especially into the characteristics of adoptersit offered a mainly linear model of diffusion and sug-gested a lsquostage likersquo approach to the adoption processVarious criticisms have been made of such linear models(Fitzgerald

et al

2002) but one central concern here isthe impact of complex contexts and inter-professionalboundaries Some researchers both in the private sector

L Fitzgerald

et al

220

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

and in healthcare have sought to develop non-linearmodels Kimberly (1981) argued that the career ofmanagerial innovations is strongly shaped by the internalchange capacity of the receiving organisation and itsexternal context which includes government Actor net-work theory (Latour 1987 Callon

et al

1992) stressesthe support building or so-called lsquotranslational andenrolment strategiesrsquo performed by scientists as criticalto the diffusion of new knowledge Networks andcommunities of knowledge are key to the acquiring ofscientific acceptance The work of these authors servesto underline the complex and interactive processesapparent in the diffusion and adoption of innovationsA more recent study by Van de Ven

et al

(1999) iden-tified the messy processes involved and the fluidand spasmodic participation by different individualsand groups during the process of innovation creation andadoption

Rich (1997) reviewed the issues in developingmeasures of knowledge utilisation and suggestedthat variance in knowledge utilisation can be explainedby differences in types of information as well as bydifferences in the needs of users

Building on this foundation early results fromresearch in the healthcare sector in the UK (Fairhurst ampHuby 1998 Dopson

et al

1999 Fitzgerald

et al

1999aFerlie

et al

2000) raise critical questions about theproblematic nature of EBM and effective processesfor implementing change in professionalised organisa-tions This research seeks to extend this debate to theprimary-care sector

Subjects and methods

The present paper reports the results of a qualitativestudy of innovation diffusion within primary health-care in the UK that was carried out between 1997 and1999 (Fitzgerald

et al

1999b) The selected method-ology was comparative longitudinal case studies(Pettigrew 1990 Fitzgerald 1999) of innovation careerswith purposeful case selection Case studies are indi-cated within complex and dynamic contexts where itis difficult to isolate variables or where there are stronginteractions between variables (Yin 1994) The casestudy can generate hypotheses from exploratory datawhich can then be tested on wider samples using differ-ent methods Such interpretative methods are indicatedwhere the prime task is the description interpretationand explanation of a phenomenon (Lee 1999) ratherthan estimation of prevalence They address questionsof process as opposed to the inputndashoutput model ofmuch quantitative research Qualitative research con-tains many variants but the present authorsrsquo overallstance was that of process researchers (Pettigrew 1990

1997) a method which builds on ethnography Processresearch is the dynamic study of behaviour withinorganisations focusing on organisational context activ-ity and actions which unfold over time (Pettigrew 1990)The comparative design adopted in the present studyfacilitates pattern recognition across the cases in orderto generate generic as well as issue-specific learning

The aims of the project were to address the questionWhat makes a clinical professional decide to adopt aninnovation and use it in their clinical practice

The objectives of this research were

bull

to trace the relative uptakeimpact of four innovations across the West Midlands region and to establish the pattern of diffusion

bull

to examine the impact of these innovations on the practices of different professional groups involved in the delivery of primary healthcare and

bull

to identify other social organisational and managerial factors which affect this diffusion process

Case studies were built around four innovationswhich were purposefully selected against specifiedcriteria The first criterion was the strength of the scien-tific evidence base supporting the efficacy of the inno-vation Two innovations with strong scientific bases asevidenced in the literature and confirmed by the pro-fessional opinion of a steering committee were selectedto compare with two innovations which had weaker ornegligible evidence of effectiveness A second criterionwas whether the innovation required uni-professionalor multi-professional involvement for the delivery ofcare This criterion was adopted to explore the impactof multi-professional involvement on diffusion and toquestion whether this increased the complexity ofdiffusion

Four health authority (HA) areas were chosen toreflect the demographic and geographical diversity ofthe West Midlands region as accurately as possibleThese areas were categorised as urban mixed urbanand rural rural and inner city with areas of severedeprivation Within the constraints of the projectbudget it was judged that focusing on these four areasenabled the researchers to gather data which wouldprovide findings which were representative of theWest Midlands region but allow a depth of analysisof the micro-processes of the diffusion of innovations(Table 1)

The data collection consisted of two phases a macro-stage and a micro-stage In the macro-phase interviewswere conducted across the four HA areas on the diffu-sion of innovation in primary care in general with addi-tional innovation-specific questions Data collectioncommenced with opinion leaders in key professional

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

221

groups (eg chief executive public health director andprimary care lead) in the health authorities and used asnowball technique to identify other informants Inaddition general practitioners (GPs) were selected atrandom from the GP lists Tables 2 and 3 provides abreakdown of the interviewees

The micro-phase concentrated on the micro-processes of the diffusion of a single innovation in aspecific clinical setting In-depth interviews about eachinnovation were conducted with a range of involvedGPs within one core practice in each HA area Corepractices were picked at random from GP lists suppliedby the HAs The sole criterion for selection was that thepractice had to have staff involved in delivering thespecified careintervention in order for the researcherto be able to study the detailed processes of innovationTables 4 and 5 provides a breakdown of the inter-viewees in the micro-phase

All interviews used a semi-structured questionnairelasting between 50 and 90 minutes with a commonspine of questions followed by innovation-specificquestions The questionnaires were designed for thepresent study and piloted before use Intervieweeswere approached individually by letter for agreementNone of the interviewees were previously known to theresearchers and confidentiality was guaranteed All theinterviews were one-to-one and conducted at a time

and place chosen by the informant Two experiencedinterviewers conducted the interviews which weretape-recorded and transcribed In total 113 interviewswere conducted

Content analysis (Glaser amp Strauss 1967 Eisenhardt1989 Langley 1999) was conducted on the macro-phase

Table 1 Innovations in the two-by-two cell design (HRT) hormone replacement therapy and (GP) general practitioner

Strong scientific evidence Weaker scientific evidence

Largely uni-professional Use of aspirin for prevention of secondarycardiac incidents

Use of HRT for prevention of osteoporosis

Multi-professional Treatment of diabetes following the St VincentDeclaration

Direct employment of physiotherapistsin GP practices

Table 2 Macro-phase interview breakdown

Interviews Number

General interviewsHealth authority area

1 92 93 104 10

Sub-total 38

Interviews with questions by innovationAspirin 7Diabetes 11Hormone replacement therapy 7Physiotherapy 10Sub-total 35

Final total 73

Table 3 Respondents by occupational background

Primary care occupationalbackground Number

Clinical academic 4Medical Manager 8Non-medical manager 8General practitioner (GP) 36Nursing 2Chief executive officer 4GPcommissioner 5Director of public health 3Physiotherapist 3Total 73

Table 4 Micro-phase interview breakdown

Interviews with questionsby innovation Number

Aspirin 12Diabetes 4Hormone replacement therapy 13Physiotherapy 11Final total 40

Interviews for this innovation were incomplete because of difficulties of access within this health authority

Table 5 Respondents by occupational background

Primary care occupationalbackground Number

General practitioner 20Nursing (community) 10Physiotherapist 6Non-medical manager 4Total 40

L Fitzgerald

et al

222

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

data initially and then reviewed and revised when themicro-phase interviews were completed Transcriptswere exchanged for double-blind analysis

Results

Emerging themes How does credible evidence influence professional behaviour in primary care

This section explores a number of the key themesemerging from this study

Concepts of credible evidence and evidence-based medicine

The data illustrate that EBM is widely acknowledged asa positive force for improvement by professionals inprimary care

However the first theme to emerge is that lsquocredibleevidencersquo has no clear-cut agreed definition The viewsexpressed by professionals in primary care as to whatconstitutes credible evidence illustrate substantial dif-ferences from those of their colleagues in the acutesector (see Ferlie

et al

2000) In the acute sector manydoctors consider that there is a hierarchy of evidencewith randomised controlled trials (RCTs) at the pinnacleas the most robust form of evidence The value of RCTsand their appropriateness to the primary-care sectorwere more widely questioned by doctors in primarycare One reason for this is that many RCTs haveselected patients carefully and trials may exclude olderpatients or those with complex medical histories There-fore GPs are cautious of translating findings fromsamples of patients in RCTs in the acute sector directlyto different populations of patients in primary careAs one GP labelled himself lsquoI am a patient waiterrsquoA second reason is the fact that many GPs are highlycritical of the lack of clinical and other research evidencerelevant to primary care

hellip That is the one big problem with primary-care evidence-based medicine at the moment that is that most of the evi-dence we are encouraging GPs to change their behaviour onis actually very much secondary care based (GPmedicaladvisor)

A growing accumulation of research data illustratesvariability of views across different professional groups(Ferlie

et al

2001)The credibility of evidence is only partially depend-

ent on the quality of the research and is influenced byother factors such as the source of the evidence profes-sional networks and trust

As long as I have respect for the people who are actuallyproducing them [guidelines] then we weigh it up (GP)

Professionals establish the credibility of the evidencethat is presented to them by employing a number of mech-anisms For example one key mechanism is throughdebate and interaction with peers A frequently mentionedinteractive forum for validating information is the post-graduate education meeting that many GPs attend

Some practitioners mainly doctors wished to estab-lish the credibility of evidence directly from sourceOther professions within the primary health teamparticularly nurses demonstrated less willingness toengage directly in updating and tended to receive infor-mation from the doctors Nurses had less involvementin professional groups either locally or regionally Manyof the other professionals such as physiotherapistswere quite isolated when working in primary carealthough they related to their own professions at thenationalregional level In accessing information fromsource professional journals were the key source butthere was minimal evidence of crossover reading

Trust is an issue in the establishment of credibilityRelationships formed by individuals were productivein the clinical sense Doctors stated that the peoplewhom they go to for information and verification arethose whom they know personally ie consultants atlocal hospitals their immediate colleagues or otherdoctors whom they had known for a long time Alliedhealth professionals and members of the nursing pro-fession were more likely to consult someone in theirown profession for verification of evidence

Weighted adoption decisions

Decisions about whether to adopt and use an innovationare made by individual professionals and local groupsof practitioners often following a period of debate Foran innovation to diffuse in any setting there are mul-tiple adoption decisions rather than a single decision

Scientific evidence is important but is not sufficientin itself to ensure that an innovation diffuses into prac-tice Box 1 provides a comparison of diffusion of theinnovations studied with those underpinned by robustevidence shown in bold To produce this analysis acrossthe interviewees three indicators of spread were com-bined (1) geographical spread across a range of sites(2) spread beyond early change champions to a widerpopulation of adopters and (3) spread across organisa-tional occupational or sectoral boundaries (eg fromsecondary to primary care)

The results show that none of the innovations dif-fused in an unproblematic manner there was variablespread of innovations with only one innovation show-ing positive results on all three indicators and diffusingwidely The data illustrate that professionals reviewedand weighed a range of factors one of which was the

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

223

robustness of the evidence The full range of factorsmentioned were

bull

There is robust scientific evidence to support the innovation

bull

The innovation is applicable to many patients

or

without the intervention patients will suffer severely adverse outcomes

bull

There are neutral cost implications or savings

bull

The new intervention or treatment is not so complicated as to produce non-compliance in patients

bull

The new intervention raises patient satisfaction levels

These selective quotes offer some examples of the wayfactors were weighed in a professionalrsquos decision making

There is no doubt that if you offer pecuniary advantages toGPs it seems to influence their behaviour quite a bit (Consult-ant in public health)

Whilst we are independent contractors and not salariedchange in practice is likely to be affected by what we are paidfor doing or not doing (GP)

I am also influenced by my patients more than anything I thinkIf my patients come back and tell me this is useful that is veryimportant to me And that is why I use a lot of SSRIs [selectiveserotonin release inhibitors] hellip (GP)

Innovations were more readily adopted if a numberof the above key factors were favourable

The present data suggest that there are few innova-tions where all these factors are favourable The use ofaspirin for the prevention of secondary cardiac events isan unusual example of an intervention with many pos-itive features These data reinforce and explain previousresearch findings (Anglia amp Oxford 1994 Fairhurst ampHuby 1998 Dopson

et al

1999 Thomson OrsquoBrien

et al

1999 Locock

et al

2001) which indicate that in manycases there is a balance of unfavourable and favourablefactors which have to be weighted and judged

Context of innovation understanding the nature of the organisational forms in primary care

The data from the present study and from comparisonswith other similar research (Anglia amp Oxford 1994 Dopson

et al

1999 Ferlie

et al

2000) suggest that many aspects ofthe variability in patterns and speed of diffusion can beaccounted for by the influence of the local context

Organisations within the healthcare sector can bebest understood as occupying an extreme of a contin-uum of service organisations with standardised organ-isations at one extreme and individualised customisedservices at the other (Mintzberg 1983 Handy 1986)Healthcare organisations also have to be understood asprofessionalised organisations with unique features(Brock

et al

1999)The primary-care sector can be seen as a context that

has further distinctive features which are different fromthe acute sector and these are critically important to ourunderstanding of the way innovation (and information)diffuses The primary-care sector (and now primarycare trusts PCTs) can be characterised as complex struc-tures which are not hierarchies but loose networksNetworks as a form of organisation have been demon-strated to operate in different ways from hierarchies (Lea

et al

1995 Ferlie amp Pettigrew 1996 Pettigrew amp Fenton2000) General practices are independent partnership-based organisations and financial levers may inhibitor facilitate diffusion Partnership-based organisa-tions operate in a consensual non-hierarchical wayat the top (although this does not imply that thereare no differences of status between partners) whilstwithin the practice there are distinct hierarchies be-tween the professions Within an individual generalpractice practice nurses and receptionists frequently donot have a direct reporting relationship to a partnerwho supervises their work One key characteristic of anetwork is that it requires the definition and deliveryof tasks through collaborative effort based on consen-sus Within the primary-care sector service deliveryinvolves the coordination of staff employed by differentorganisations and the sector is characterised by infor-mational complexity in terms of the variety of sourcesand volume of information In total this sector has avery different profile from the acute sector and there-fore issues relating to the organisation of servicescontrol and clinical governance need to be handleddifferently in primary care

Translation

The present research evidence suggests that the processof the diffusion of innovations is more interactive thanpreviously conceived lsquoAdoptersrsquo are not passive they

Box 1 Overall comparison of diffusion by innovation

Pilotonly Pockets Debated

Variablepace Widespread

Primary Direct employment of physiotherapists Primary Treatment of diabetes Primary Use of aspirinPrimary Hormone replacement therapy for osteoporosis

L Fitzgerald

et al

224

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

do not receive information from others and decidewhether to use it Rather they engage in seeking infor-mation in debating that information and frequently inusing their professional networks to seek corroborationof the value and relevance of information Typicallyone GP who led innovation in the use of hormonereplacement therapy (HRT) had a background of familyplanning training and had been a family planninginstructing doctor

So naturally I have been quite interested in womenrsquos healthand all aspects of womenrsquos health

She instigated changes and shared them with herpartners lsquoEverything I did they now dorsquo

Over the years she sought and brought in lsquoquite a lotof external input reallyrsquo

In this practice the nurses stated that

Information would be filtered down to them by the doctorsbut having said that we get regular practice nurse newslettersfrom the facilitators

There is also evidence to illustrate that innovationsare changed or lsquotranslatedrsquo during this process so thatwhat is finally enacted may be an adapted version of theinnovation Therefore group debate with those in thecommunity of practice is a key stage in the spread of aninnovation

Information sharing communication and debate

The research data illustrates that the primary-caresector may be characterised as a network organisationdrowning in information overload

There are endless pamphlets in the post I donrsquot think anybody can complain of lack of information these days Drugcompanies various guidelines publications on HRT daycourses run on it I donrsquot really think there is any shortage ofinformation (GP)

Because GPs are dealing with such a diverse range ofconditions and patients updating and developing newknowledge is a daunting challenge Many proactiveGPs choose to specialise in some conditions more thanothers and practice partners seek to negotiate sharingand complementary tasks

The data demonstrate that the foundation forimprovement and innovation is a set of good or atleast satisfactory relationships between the partnersthe employed GPs and the remaining professional andadministrative staff Where relationships are dysfunc-tional or conflicts persist there is a low probability ofpromoting improvements and change

Whilst there are differences in the quality of relation-ships and communication in each general practice the

present data show that there is a high level of informalone-to-one information sharing in many practices Thisoccurs between doctors and between doctors andmembers of other professions and inter-professionalcommunication appears more widespread and frequentthan in the acute sector of healthcare However inmany locations this communication is restricted toinformal contacts and there was limited evidence ofsystematic mechanisms of communication In manygeneral practices routine organised meetings arelimited to doctors (and sometimes include practicemanagers) The research illustrates that the forums forthe sharing and debate of evidence between the profes-sions involved in the delivery of care are limited andseverely underdeveloped in primary care As a GPcommented in one innovative general practice

I think we are very team-orientated and I think we recognisethe other members of the team far more than other placesdo and encourage them to develop their own skills andinterests hellip

Nevertheless it is apparent that many innovationswill require inter-professional collaboration

Within practices the regular use of audit as amechanism for checking on the quality of care and fordevising improvements was very limited The majority ofinterviewees were apologetic about this acknowledg-ing that more activity was required Nevertheless therewere many inhibiting factors which were quotedincluding resources appropriate skills time and patientconfidentiality

Collectively there is little history of inter-practicecollaboration and sharing of knowledge between prac-tices However the creation of PCTs requires collectiveaction not only between doctors but also betweendoctors nurses allied health and social services profes-sionals It is heartening to note that with the advent offundholding (now defunct) a range of positive colla-borative networks were observed to emerge as anunintended by-product of other changes Through theestablishment of a multi-fund one GP described one ofthe ensuing innovations

One of the other ways in which it has worked is it has broughttogether the community trust social services and the HA todevelop a varicose vein leg ulcer clinic for our area hellip (GP)

Similarly the formation of the new lsquoout of hoursrsquo co-operative networks resulted in new groupings and theinformal exchange of information The prime purposeof these systems has been the control of workload andthe reduction of stress As well as providing good medicalcover the systems have improved informal commun-ication ie networking and this has a direct benefit onthe quality of care for patients Traditionally GPs have

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

L Fitzgerald

et al

220

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

and in healthcare have sought to develop non-linearmodels Kimberly (1981) argued that the career ofmanagerial innovations is strongly shaped by the internalchange capacity of the receiving organisation and itsexternal context which includes government Actor net-work theory (Latour 1987 Callon

et al

1992) stressesthe support building or so-called lsquotranslational andenrolment strategiesrsquo performed by scientists as criticalto the diffusion of new knowledge Networks andcommunities of knowledge are key to the acquiring ofscientific acceptance The work of these authors servesto underline the complex and interactive processesapparent in the diffusion and adoption of innovationsA more recent study by Van de Ven

et al

(1999) iden-tified the messy processes involved and the fluidand spasmodic participation by different individualsand groups during the process of innovation creation andadoption

Rich (1997) reviewed the issues in developingmeasures of knowledge utilisation and suggestedthat variance in knowledge utilisation can be explainedby differences in types of information as well as bydifferences in the needs of users

Building on this foundation early results fromresearch in the healthcare sector in the UK (Fairhurst ampHuby 1998 Dopson

et al

1999 Fitzgerald

et al

1999aFerlie

et al

2000) raise critical questions about theproblematic nature of EBM and effective processesfor implementing change in professionalised organisa-tions This research seeks to extend this debate to theprimary-care sector

Subjects and methods

The present paper reports the results of a qualitativestudy of innovation diffusion within primary health-care in the UK that was carried out between 1997 and1999 (Fitzgerald

et al

1999b) The selected method-ology was comparative longitudinal case studies(Pettigrew 1990 Fitzgerald 1999) of innovation careerswith purposeful case selection Case studies are indi-cated within complex and dynamic contexts where itis difficult to isolate variables or where there are stronginteractions between variables (Yin 1994) The casestudy can generate hypotheses from exploratory datawhich can then be tested on wider samples using differ-ent methods Such interpretative methods are indicatedwhere the prime task is the description interpretationand explanation of a phenomenon (Lee 1999) ratherthan estimation of prevalence They address questionsof process as opposed to the inputndashoutput model ofmuch quantitative research Qualitative research con-tains many variants but the present authorsrsquo overallstance was that of process researchers (Pettigrew 1990

1997) a method which builds on ethnography Processresearch is the dynamic study of behaviour withinorganisations focusing on organisational context activ-ity and actions which unfold over time (Pettigrew 1990)The comparative design adopted in the present studyfacilitates pattern recognition across the cases in orderto generate generic as well as issue-specific learning

The aims of the project were to address the questionWhat makes a clinical professional decide to adopt aninnovation and use it in their clinical practice

The objectives of this research were

bull

to trace the relative uptakeimpact of four innovations across the West Midlands region and to establish the pattern of diffusion

bull

to examine the impact of these innovations on the practices of different professional groups involved in the delivery of primary healthcare and

bull

to identify other social organisational and managerial factors which affect this diffusion process

Case studies were built around four innovationswhich were purposefully selected against specifiedcriteria The first criterion was the strength of the scien-tific evidence base supporting the efficacy of the inno-vation Two innovations with strong scientific bases asevidenced in the literature and confirmed by the pro-fessional opinion of a steering committee were selectedto compare with two innovations which had weaker ornegligible evidence of effectiveness A second criterionwas whether the innovation required uni-professionalor multi-professional involvement for the delivery ofcare This criterion was adopted to explore the impactof multi-professional involvement on diffusion and toquestion whether this increased the complexity ofdiffusion

Four health authority (HA) areas were chosen toreflect the demographic and geographical diversity ofthe West Midlands region as accurately as possibleThese areas were categorised as urban mixed urbanand rural rural and inner city with areas of severedeprivation Within the constraints of the projectbudget it was judged that focusing on these four areasenabled the researchers to gather data which wouldprovide findings which were representative of theWest Midlands region but allow a depth of analysisof the micro-processes of the diffusion of innovations(Table 1)

The data collection consisted of two phases a macro-stage and a micro-stage In the macro-phase interviewswere conducted across the four HA areas on the diffu-sion of innovation in primary care in general with addi-tional innovation-specific questions Data collectioncommenced with opinion leaders in key professional

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

221

groups (eg chief executive public health director andprimary care lead) in the health authorities and used asnowball technique to identify other informants Inaddition general practitioners (GPs) were selected atrandom from the GP lists Tables 2 and 3 provides abreakdown of the interviewees

The micro-phase concentrated on the micro-processes of the diffusion of a single innovation in aspecific clinical setting In-depth interviews about eachinnovation were conducted with a range of involvedGPs within one core practice in each HA area Corepractices were picked at random from GP lists suppliedby the HAs The sole criterion for selection was that thepractice had to have staff involved in delivering thespecified careintervention in order for the researcherto be able to study the detailed processes of innovationTables 4 and 5 provides a breakdown of the inter-viewees in the micro-phase

All interviews used a semi-structured questionnairelasting between 50 and 90 minutes with a commonspine of questions followed by innovation-specificquestions The questionnaires were designed for thepresent study and piloted before use Intervieweeswere approached individually by letter for agreementNone of the interviewees were previously known to theresearchers and confidentiality was guaranteed All theinterviews were one-to-one and conducted at a time

and place chosen by the informant Two experiencedinterviewers conducted the interviews which weretape-recorded and transcribed In total 113 interviewswere conducted

Content analysis (Glaser amp Strauss 1967 Eisenhardt1989 Langley 1999) was conducted on the macro-phase

Table 1 Innovations in the two-by-two cell design (HRT) hormone replacement therapy and (GP) general practitioner

Strong scientific evidence Weaker scientific evidence

Largely uni-professional Use of aspirin for prevention of secondarycardiac incidents

Use of HRT for prevention of osteoporosis

Multi-professional Treatment of diabetes following the St VincentDeclaration

Direct employment of physiotherapistsin GP practices

Table 2 Macro-phase interview breakdown

Interviews Number

General interviewsHealth authority area

1 92 93 104 10

Sub-total 38

Interviews with questions by innovationAspirin 7Diabetes 11Hormone replacement therapy 7Physiotherapy 10Sub-total 35

Final total 73

Table 3 Respondents by occupational background

Primary care occupationalbackground Number

Clinical academic 4Medical Manager 8Non-medical manager 8General practitioner (GP) 36Nursing 2Chief executive officer 4GPcommissioner 5Director of public health 3Physiotherapist 3Total 73

Table 4 Micro-phase interview breakdown

Interviews with questionsby innovation Number

Aspirin 12Diabetes 4Hormone replacement therapy 13Physiotherapy 11Final total 40

Interviews for this innovation were incomplete because of difficulties of access within this health authority

Table 5 Respondents by occupational background

Primary care occupationalbackground Number

General practitioner 20Nursing (community) 10Physiotherapist 6Non-medical manager 4Total 40

L Fitzgerald

et al

222

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

data initially and then reviewed and revised when themicro-phase interviews were completed Transcriptswere exchanged for double-blind analysis

Results

Emerging themes How does credible evidence influence professional behaviour in primary care

This section explores a number of the key themesemerging from this study

Concepts of credible evidence and evidence-based medicine

The data illustrate that EBM is widely acknowledged asa positive force for improvement by professionals inprimary care

However the first theme to emerge is that lsquocredibleevidencersquo has no clear-cut agreed definition The viewsexpressed by professionals in primary care as to whatconstitutes credible evidence illustrate substantial dif-ferences from those of their colleagues in the acutesector (see Ferlie

et al

2000) In the acute sector manydoctors consider that there is a hierarchy of evidencewith randomised controlled trials (RCTs) at the pinnacleas the most robust form of evidence The value of RCTsand their appropriateness to the primary-care sectorwere more widely questioned by doctors in primarycare One reason for this is that many RCTs haveselected patients carefully and trials may exclude olderpatients or those with complex medical histories There-fore GPs are cautious of translating findings fromsamples of patients in RCTs in the acute sector directlyto different populations of patients in primary careAs one GP labelled himself lsquoI am a patient waiterrsquoA second reason is the fact that many GPs are highlycritical of the lack of clinical and other research evidencerelevant to primary care

hellip That is the one big problem with primary-care evidence-based medicine at the moment that is that most of the evi-dence we are encouraging GPs to change their behaviour onis actually very much secondary care based (GPmedicaladvisor)

A growing accumulation of research data illustratesvariability of views across different professional groups(Ferlie

et al

2001)The credibility of evidence is only partially depend-

ent on the quality of the research and is influenced byother factors such as the source of the evidence profes-sional networks and trust

As long as I have respect for the people who are actuallyproducing them [guidelines] then we weigh it up (GP)

Professionals establish the credibility of the evidencethat is presented to them by employing a number of mech-anisms For example one key mechanism is throughdebate and interaction with peers A frequently mentionedinteractive forum for validating information is the post-graduate education meeting that many GPs attend

Some practitioners mainly doctors wished to estab-lish the credibility of evidence directly from sourceOther professions within the primary health teamparticularly nurses demonstrated less willingness toengage directly in updating and tended to receive infor-mation from the doctors Nurses had less involvementin professional groups either locally or regionally Manyof the other professionals such as physiotherapistswere quite isolated when working in primary carealthough they related to their own professions at thenationalregional level In accessing information fromsource professional journals were the key source butthere was minimal evidence of crossover reading

Trust is an issue in the establishment of credibilityRelationships formed by individuals were productivein the clinical sense Doctors stated that the peoplewhom they go to for information and verification arethose whom they know personally ie consultants atlocal hospitals their immediate colleagues or otherdoctors whom they had known for a long time Alliedhealth professionals and members of the nursing pro-fession were more likely to consult someone in theirown profession for verification of evidence

Weighted adoption decisions

Decisions about whether to adopt and use an innovationare made by individual professionals and local groupsof practitioners often following a period of debate Foran innovation to diffuse in any setting there are mul-tiple adoption decisions rather than a single decision

Scientific evidence is important but is not sufficientin itself to ensure that an innovation diffuses into prac-tice Box 1 provides a comparison of diffusion of theinnovations studied with those underpinned by robustevidence shown in bold To produce this analysis acrossthe interviewees three indicators of spread were com-bined (1) geographical spread across a range of sites(2) spread beyond early change champions to a widerpopulation of adopters and (3) spread across organisa-tional occupational or sectoral boundaries (eg fromsecondary to primary care)

The results show that none of the innovations dif-fused in an unproblematic manner there was variablespread of innovations with only one innovation show-ing positive results on all three indicators and diffusingwidely The data illustrate that professionals reviewedand weighed a range of factors one of which was the

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

223

robustness of the evidence The full range of factorsmentioned were

bull

There is robust scientific evidence to support the innovation

bull

The innovation is applicable to many patients

or

without the intervention patients will suffer severely adverse outcomes

bull

There are neutral cost implications or savings

bull

The new intervention or treatment is not so complicated as to produce non-compliance in patients

bull

The new intervention raises patient satisfaction levels

These selective quotes offer some examples of the wayfactors were weighed in a professionalrsquos decision making

There is no doubt that if you offer pecuniary advantages toGPs it seems to influence their behaviour quite a bit (Consult-ant in public health)

Whilst we are independent contractors and not salariedchange in practice is likely to be affected by what we are paidfor doing or not doing (GP)

I am also influenced by my patients more than anything I thinkIf my patients come back and tell me this is useful that is veryimportant to me And that is why I use a lot of SSRIs [selectiveserotonin release inhibitors] hellip (GP)

Innovations were more readily adopted if a numberof the above key factors were favourable

The present data suggest that there are few innova-tions where all these factors are favourable The use ofaspirin for the prevention of secondary cardiac events isan unusual example of an intervention with many pos-itive features These data reinforce and explain previousresearch findings (Anglia amp Oxford 1994 Fairhurst ampHuby 1998 Dopson

et al

1999 Thomson OrsquoBrien

et al

1999 Locock

et al

2001) which indicate that in manycases there is a balance of unfavourable and favourablefactors which have to be weighted and judged

Context of innovation understanding the nature of the organisational forms in primary care

The data from the present study and from comparisonswith other similar research (Anglia amp Oxford 1994 Dopson

et al

1999 Ferlie

et al

2000) suggest that many aspects ofthe variability in patterns and speed of diffusion can beaccounted for by the influence of the local context

Organisations within the healthcare sector can bebest understood as occupying an extreme of a contin-uum of service organisations with standardised organ-isations at one extreme and individualised customisedservices at the other (Mintzberg 1983 Handy 1986)Healthcare organisations also have to be understood asprofessionalised organisations with unique features(Brock

et al

1999)The primary-care sector can be seen as a context that

has further distinctive features which are different fromthe acute sector and these are critically important to ourunderstanding of the way innovation (and information)diffuses The primary-care sector (and now primarycare trusts PCTs) can be characterised as complex struc-tures which are not hierarchies but loose networksNetworks as a form of organisation have been demon-strated to operate in different ways from hierarchies (Lea

et al

1995 Ferlie amp Pettigrew 1996 Pettigrew amp Fenton2000) General practices are independent partnership-based organisations and financial levers may inhibitor facilitate diffusion Partnership-based organisa-tions operate in a consensual non-hierarchical wayat the top (although this does not imply that thereare no differences of status between partners) whilstwithin the practice there are distinct hierarchies be-tween the professions Within an individual generalpractice practice nurses and receptionists frequently donot have a direct reporting relationship to a partnerwho supervises their work One key characteristic of anetwork is that it requires the definition and deliveryof tasks through collaborative effort based on consen-sus Within the primary-care sector service deliveryinvolves the coordination of staff employed by differentorganisations and the sector is characterised by infor-mational complexity in terms of the variety of sourcesand volume of information In total this sector has avery different profile from the acute sector and there-fore issues relating to the organisation of servicescontrol and clinical governance need to be handleddifferently in primary care

Translation

The present research evidence suggests that the processof the diffusion of innovations is more interactive thanpreviously conceived lsquoAdoptersrsquo are not passive they

Box 1 Overall comparison of diffusion by innovation

Pilotonly Pockets Debated

Variablepace Widespread

Primary Direct employment of physiotherapists Primary Treatment of diabetes Primary Use of aspirinPrimary Hormone replacement therapy for osteoporosis

L Fitzgerald

et al

224

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

do not receive information from others and decidewhether to use it Rather they engage in seeking infor-mation in debating that information and frequently inusing their professional networks to seek corroborationof the value and relevance of information Typicallyone GP who led innovation in the use of hormonereplacement therapy (HRT) had a background of familyplanning training and had been a family planninginstructing doctor

So naturally I have been quite interested in womenrsquos healthand all aspects of womenrsquos health

She instigated changes and shared them with herpartners lsquoEverything I did they now dorsquo

Over the years she sought and brought in lsquoquite a lotof external input reallyrsquo

In this practice the nurses stated that

Information would be filtered down to them by the doctorsbut having said that we get regular practice nurse newslettersfrom the facilitators

There is also evidence to illustrate that innovationsare changed or lsquotranslatedrsquo during this process so thatwhat is finally enacted may be an adapted version of theinnovation Therefore group debate with those in thecommunity of practice is a key stage in the spread of aninnovation

Information sharing communication and debate

The research data illustrates that the primary-caresector may be characterised as a network organisationdrowning in information overload

There are endless pamphlets in the post I donrsquot think anybody can complain of lack of information these days Drugcompanies various guidelines publications on HRT daycourses run on it I donrsquot really think there is any shortage ofinformation (GP)

Because GPs are dealing with such a diverse range ofconditions and patients updating and developing newknowledge is a daunting challenge Many proactiveGPs choose to specialise in some conditions more thanothers and practice partners seek to negotiate sharingand complementary tasks

The data demonstrate that the foundation forimprovement and innovation is a set of good or atleast satisfactory relationships between the partnersthe employed GPs and the remaining professional andadministrative staff Where relationships are dysfunc-tional or conflicts persist there is a low probability ofpromoting improvements and change

Whilst there are differences in the quality of relation-ships and communication in each general practice the

present data show that there is a high level of informalone-to-one information sharing in many practices Thisoccurs between doctors and between doctors andmembers of other professions and inter-professionalcommunication appears more widespread and frequentthan in the acute sector of healthcare However inmany locations this communication is restricted toinformal contacts and there was limited evidence ofsystematic mechanisms of communication In manygeneral practices routine organised meetings arelimited to doctors (and sometimes include practicemanagers) The research illustrates that the forums forthe sharing and debate of evidence between the profes-sions involved in the delivery of care are limited andseverely underdeveloped in primary care As a GPcommented in one innovative general practice

I think we are very team-orientated and I think we recognisethe other members of the team far more than other placesdo and encourage them to develop their own skills andinterests hellip

Nevertheless it is apparent that many innovationswill require inter-professional collaboration

Within practices the regular use of audit as amechanism for checking on the quality of care and fordevising improvements was very limited The majority ofinterviewees were apologetic about this acknowledg-ing that more activity was required Nevertheless therewere many inhibiting factors which were quotedincluding resources appropriate skills time and patientconfidentiality

Collectively there is little history of inter-practicecollaboration and sharing of knowledge between prac-tices However the creation of PCTs requires collectiveaction not only between doctors but also betweendoctors nurses allied health and social services profes-sionals It is heartening to note that with the advent offundholding (now defunct) a range of positive colla-borative networks were observed to emerge as anunintended by-product of other changes Through theestablishment of a multi-fund one GP described one ofthe ensuing innovations

One of the other ways in which it has worked is it has broughttogether the community trust social services and the HA todevelop a varicose vein leg ulcer clinic for our area hellip (GP)

Similarly the formation of the new lsquoout of hoursrsquo co-operative networks resulted in new groupings and theinformal exchange of information The prime purposeof these systems has been the control of workload andthe reduction of stress As well as providing good medicalcover the systems have improved informal commun-ication ie networking and this has a direct benefit onthe quality of care for patients Traditionally GPs have

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

221

groups (eg chief executive public health director andprimary care lead) in the health authorities and used asnowball technique to identify other informants Inaddition general practitioners (GPs) were selected atrandom from the GP lists Tables 2 and 3 provides abreakdown of the interviewees

The micro-phase concentrated on the micro-processes of the diffusion of a single innovation in aspecific clinical setting In-depth interviews about eachinnovation were conducted with a range of involvedGPs within one core practice in each HA area Corepractices were picked at random from GP lists suppliedby the HAs The sole criterion for selection was that thepractice had to have staff involved in delivering thespecified careintervention in order for the researcherto be able to study the detailed processes of innovationTables 4 and 5 provides a breakdown of the inter-viewees in the micro-phase

All interviews used a semi-structured questionnairelasting between 50 and 90 minutes with a commonspine of questions followed by innovation-specificquestions The questionnaires were designed for thepresent study and piloted before use Intervieweeswere approached individually by letter for agreementNone of the interviewees were previously known to theresearchers and confidentiality was guaranteed All theinterviews were one-to-one and conducted at a time

and place chosen by the informant Two experiencedinterviewers conducted the interviews which weretape-recorded and transcribed In total 113 interviewswere conducted

Content analysis (Glaser amp Strauss 1967 Eisenhardt1989 Langley 1999) was conducted on the macro-phase

Table 1 Innovations in the two-by-two cell design (HRT) hormone replacement therapy and (GP) general practitioner

Strong scientific evidence Weaker scientific evidence

Largely uni-professional Use of aspirin for prevention of secondarycardiac incidents

Use of HRT for prevention of osteoporosis

Multi-professional Treatment of diabetes following the St VincentDeclaration

Direct employment of physiotherapistsin GP practices

Table 2 Macro-phase interview breakdown

Interviews Number

General interviewsHealth authority area

1 92 93 104 10

Sub-total 38

Interviews with questions by innovationAspirin 7Diabetes 11Hormone replacement therapy 7Physiotherapy 10Sub-total 35

Final total 73

Table 3 Respondents by occupational background

Primary care occupationalbackground Number

Clinical academic 4Medical Manager 8Non-medical manager 8General practitioner (GP) 36Nursing 2Chief executive officer 4GPcommissioner 5Director of public health 3Physiotherapist 3Total 73

Table 4 Micro-phase interview breakdown

Interviews with questionsby innovation Number

Aspirin 12Diabetes 4Hormone replacement therapy 13Physiotherapy 11Final total 40

Interviews for this innovation were incomplete because of difficulties of access within this health authority

Table 5 Respondents by occupational background

Primary care occupationalbackground Number

General practitioner 20Nursing (community) 10Physiotherapist 6Non-medical manager 4Total 40

L Fitzgerald

et al

222

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

data initially and then reviewed and revised when themicro-phase interviews were completed Transcriptswere exchanged for double-blind analysis

Results

Emerging themes How does credible evidence influence professional behaviour in primary care

This section explores a number of the key themesemerging from this study

Concepts of credible evidence and evidence-based medicine

The data illustrate that EBM is widely acknowledged asa positive force for improvement by professionals inprimary care

However the first theme to emerge is that lsquocredibleevidencersquo has no clear-cut agreed definition The viewsexpressed by professionals in primary care as to whatconstitutes credible evidence illustrate substantial dif-ferences from those of their colleagues in the acutesector (see Ferlie

et al

2000) In the acute sector manydoctors consider that there is a hierarchy of evidencewith randomised controlled trials (RCTs) at the pinnacleas the most robust form of evidence The value of RCTsand their appropriateness to the primary-care sectorwere more widely questioned by doctors in primarycare One reason for this is that many RCTs haveselected patients carefully and trials may exclude olderpatients or those with complex medical histories There-fore GPs are cautious of translating findings fromsamples of patients in RCTs in the acute sector directlyto different populations of patients in primary careAs one GP labelled himself lsquoI am a patient waiterrsquoA second reason is the fact that many GPs are highlycritical of the lack of clinical and other research evidencerelevant to primary care

hellip That is the one big problem with primary-care evidence-based medicine at the moment that is that most of the evi-dence we are encouraging GPs to change their behaviour onis actually very much secondary care based (GPmedicaladvisor)

A growing accumulation of research data illustratesvariability of views across different professional groups(Ferlie

et al

2001)The credibility of evidence is only partially depend-

ent on the quality of the research and is influenced byother factors such as the source of the evidence profes-sional networks and trust

As long as I have respect for the people who are actuallyproducing them [guidelines] then we weigh it up (GP)

Professionals establish the credibility of the evidencethat is presented to them by employing a number of mech-anisms For example one key mechanism is throughdebate and interaction with peers A frequently mentionedinteractive forum for validating information is the post-graduate education meeting that many GPs attend

Some practitioners mainly doctors wished to estab-lish the credibility of evidence directly from sourceOther professions within the primary health teamparticularly nurses demonstrated less willingness toengage directly in updating and tended to receive infor-mation from the doctors Nurses had less involvementin professional groups either locally or regionally Manyof the other professionals such as physiotherapistswere quite isolated when working in primary carealthough they related to their own professions at thenationalregional level In accessing information fromsource professional journals were the key source butthere was minimal evidence of crossover reading

Trust is an issue in the establishment of credibilityRelationships formed by individuals were productivein the clinical sense Doctors stated that the peoplewhom they go to for information and verification arethose whom they know personally ie consultants atlocal hospitals their immediate colleagues or otherdoctors whom they had known for a long time Alliedhealth professionals and members of the nursing pro-fession were more likely to consult someone in theirown profession for verification of evidence

Weighted adoption decisions

Decisions about whether to adopt and use an innovationare made by individual professionals and local groupsof practitioners often following a period of debate Foran innovation to diffuse in any setting there are mul-tiple adoption decisions rather than a single decision

Scientific evidence is important but is not sufficientin itself to ensure that an innovation diffuses into prac-tice Box 1 provides a comparison of diffusion of theinnovations studied with those underpinned by robustevidence shown in bold To produce this analysis acrossthe interviewees three indicators of spread were com-bined (1) geographical spread across a range of sites(2) spread beyond early change champions to a widerpopulation of adopters and (3) spread across organisa-tional occupational or sectoral boundaries (eg fromsecondary to primary care)

The results show that none of the innovations dif-fused in an unproblematic manner there was variablespread of innovations with only one innovation show-ing positive results on all three indicators and diffusingwidely The data illustrate that professionals reviewedand weighed a range of factors one of which was the

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

223

robustness of the evidence The full range of factorsmentioned were

bull

There is robust scientific evidence to support the innovation

bull

The innovation is applicable to many patients

or

without the intervention patients will suffer severely adverse outcomes

bull

There are neutral cost implications or savings

bull

The new intervention or treatment is not so complicated as to produce non-compliance in patients

bull

The new intervention raises patient satisfaction levels

These selective quotes offer some examples of the wayfactors were weighed in a professionalrsquos decision making

There is no doubt that if you offer pecuniary advantages toGPs it seems to influence their behaviour quite a bit (Consult-ant in public health)

Whilst we are independent contractors and not salariedchange in practice is likely to be affected by what we are paidfor doing or not doing (GP)

I am also influenced by my patients more than anything I thinkIf my patients come back and tell me this is useful that is veryimportant to me And that is why I use a lot of SSRIs [selectiveserotonin release inhibitors] hellip (GP)

Innovations were more readily adopted if a numberof the above key factors were favourable

The present data suggest that there are few innova-tions where all these factors are favourable The use ofaspirin for the prevention of secondary cardiac events isan unusual example of an intervention with many pos-itive features These data reinforce and explain previousresearch findings (Anglia amp Oxford 1994 Fairhurst ampHuby 1998 Dopson

et al

1999 Thomson OrsquoBrien

et al

1999 Locock

et al

2001) which indicate that in manycases there is a balance of unfavourable and favourablefactors which have to be weighted and judged

Context of innovation understanding the nature of the organisational forms in primary care

The data from the present study and from comparisonswith other similar research (Anglia amp Oxford 1994 Dopson

et al

1999 Ferlie

et al

2000) suggest that many aspects ofthe variability in patterns and speed of diffusion can beaccounted for by the influence of the local context

Organisations within the healthcare sector can bebest understood as occupying an extreme of a contin-uum of service organisations with standardised organ-isations at one extreme and individualised customisedservices at the other (Mintzberg 1983 Handy 1986)Healthcare organisations also have to be understood asprofessionalised organisations with unique features(Brock

et al

1999)The primary-care sector can be seen as a context that

has further distinctive features which are different fromthe acute sector and these are critically important to ourunderstanding of the way innovation (and information)diffuses The primary-care sector (and now primarycare trusts PCTs) can be characterised as complex struc-tures which are not hierarchies but loose networksNetworks as a form of organisation have been demon-strated to operate in different ways from hierarchies (Lea

et al

1995 Ferlie amp Pettigrew 1996 Pettigrew amp Fenton2000) General practices are independent partnership-based organisations and financial levers may inhibitor facilitate diffusion Partnership-based organisa-tions operate in a consensual non-hierarchical wayat the top (although this does not imply that thereare no differences of status between partners) whilstwithin the practice there are distinct hierarchies be-tween the professions Within an individual generalpractice practice nurses and receptionists frequently donot have a direct reporting relationship to a partnerwho supervises their work One key characteristic of anetwork is that it requires the definition and deliveryof tasks through collaborative effort based on consen-sus Within the primary-care sector service deliveryinvolves the coordination of staff employed by differentorganisations and the sector is characterised by infor-mational complexity in terms of the variety of sourcesand volume of information In total this sector has avery different profile from the acute sector and there-fore issues relating to the organisation of servicescontrol and clinical governance need to be handleddifferently in primary care

Translation

The present research evidence suggests that the processof the diffusion of innovations is more interactive thanpreviously conceived lsquoAdoptersrsquo are not passive they

Box 1 Overall comparison of diffusion by innovation

Pilotonly Pockets Debated

Variablepace Widespread

Primary Direct employment of physiotherapists Primary Treatment of diabetes Primary Use of aspirinPrimary Hormone replacement therapy for osteoporosis

L Fitzgerald

et al

224

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

do not receive information from others and decidewhether to use it Rather they engage in seeking infor-mation in debating that information and frequently inusing their professional networks to seek corroborationof the value and relevance of information Typicallyone GP who led innovation in the use of hormonereplacement therapy (HRT) had a background of familyplanning training and had been a family planninginstructing doctor

So naturally I have been quite interested in womenrsquos healthand all aspects of womenrsquos health

She instigated changes and shared them with herpartners lsquoEverything I did they now dorsquo

Over the years she sought and brought in lsquoquite a lotof external input reallyrsquo

In this practice the nurses stated that

Information would be filtered down to them by the doctorsbut having said that we get regular practice nurse newslettersfrom the facilitators

There is also evidence to illustrate that innovationsare changed or lsquotranslatedrsquo during this process so thatwhat is finally enacted may be an adapted version of theinnovation Therefore group debate with those in thecommunity of practice is a key stage in the spread of aninnovation

Information sharing communication and debate

The research data illustrates that the primary-caresector may be characterised as a network organisationdrowning in information overload

There are endless pamphlets in the post I donrsquot think anybody can complain of lack of information these days Drugcompanies various guidelines publications on HRT daycourses run on it I donrsquot really think there is any shortage ofinformation (GP)

Because GPs are dealing with such a diverse range ofconditions and patients updating and developing newknowledge is a daunting challenge Many proactiveGPs choose to specialise in some conditions more thanothers and practice partners seek to negotiate sharingand complementary tasks

The data demonstrate that the foundation forimprovement and innovation is a set of good or atleast satisfactory relationships between the partnersthe employed GPs and the remaining professional andadministrative staff Where relationships are dysfunc-tional or conflicts persist there is a low probability ofpromoting improvements and change

Whilst there are differences in the quality of relation-ships and communication in each general practice the

present data show that there is a high level of informalone-to-one information sharing in many practices Thisoccurs between doctors and between doctors andmembers of other professions and inter-professionalcommunication appears more widespread and frequentthan in the acute sector of healthcare However inmany locations this communication is restricted toinformal contacts and there was limited evidence ofsystematic mechanisms of communication In manygeneral practices routine organised meetings arelimited to doctors (and sometimes include practicemanagers) The research illustrates that the forums forthe sharing and debate of evidence between the profes-sions involved in the delivery of care are limited andseverely underdeveloped in primary care As a GPcommented in one innovative general practice

I think we are very team-orientated and I think we recognisethe other members of the team far more than other placesdo and encourage them to develop their own skills andinterests hellip

Nevertheless it is apparent that many innovationswill require inter-professional collaboration

Within practices the regular use of audit as amechanism for checking on the quality of care and fordevising improvements was very limited The majority ofinterviewees were apologetic about this acknowledg-ing that more activity was required Nevertheless therewere many inhibiting factors which were quotedincluding resources appropriate skills time and patientconfidentiality

Collectively there is little history of inter-practicecollaboration and sharing of knowledge between prac-tices However the creation of PCTs requires collectiveaction not only between doctors but also betweendoctors nurses allied health and social services profes-sionals It is heartening to note that with the advent offundholding (now defunct) a range of positive colla-borative networks were observed to emerge as anunintended by-product of other changes Through theestablishment of a multi-fund one GP described one ofthe ensuing innovations

One of the other ways in which it has worked is it has broughttogether the community trust social services and the HA todevelop a varicose vein leg ulcer clinic for our area hellip (GP)

Similarly the formation of the new lsquoout of hoursrsquo co-operative networks resulted in new groupings and theinformal exchange of information The prime purposeof these systems has been the control of workload andthe reduction of stress As well as providing good medicalcover the systems have improved informal commun-ication ie networking and this has a direct benefit onthe quality of care for patients Traditionally GPs have

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

L Fitzgerald

et al

222

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

data initially and then reviewed and revised when themicro-phase interviews were completed Transcriptswere exchanged for double-blind analysis

Results

Emerging themes How does credible evidence influence professional behaviour in primary care

This section explores a number of the key themesemerging from this study

Concepts of credible evidence and evidence-based medicine

The data illustrate that EBM is widely acknowledged asa positive force for improvement by professionals inprimary care

However the first theme to emerge is that lsquocredibleevidencersquo has no clear-cut agreed definition The viewsexpressed by professionals in primary care as to whatconstitutes credible evidence illustrate substantial dif-ferences from those of their colleagues in the acutesector (see Ferlie

et al

2000) In the acute sector manydoctors consider that there is a hierarchy of evidencewith randomised controlled trials (RCTs) at the pinnacleas the most robust form of evidence The value of RCTsand their appropriateness to the primary-care sectorwere more widely questioned by doctors in primarycare One reason for this is that many RCTs haveselected patients carefully and trials may exclude olderpatients or those with complex medical histories There-fore GPs are cautious of translating findings fromsamples of patients in RCTs in the acute sector directlyto different populations of patients in primary careAs one GP labelled himself lsquoI am a patient waiterrsquoA second reason is the fact that many GPs are highlycritical of the lack of clinical and other research evidencerelevant to primary care

hellip That is the one big problem with primary-care evidence-based medicine at the moment that is that most of the evi-dence we are encouraging GPs to change their behaviour onis actually very much secondary care based (GPmedicaladvisor)

A growing accumulation of research data illustratesvariability of views across different professional groups(Ferlie

et al

2001)The credibility of evidence is only partially depend-

ent on the quality of the research and is influenced byother factors such as the source of the evidence profes-sional networks and trust

As long as I have respect for the people who are actuallyproducing them [guidelines] then we weigh it up (GP)

Professionals establish the credibility of the evidencethat is presented to them by employing a number of mech-anisms For example one key mechanism is throughdebate and interaction with peers A frequently mentionedinteractive forum for validating information is the post-graduate education meeting that many GPs attend

Some practitioners mainly doctors wished to estab-lish the credibility of evidence directly from sourceOther professions within the primary health teamparticularly nurses demonstrated less willingness toengage directly in updating and tended to receive infor-mation from the doctors Nurses had less involvementin professional groups either locally or regionally Manyof the other professionals such as physiotherapistswere quite isolated when working in primary carealthough they related to their own professions at thenationalregional level In accessing information fromsource professional journals were the key source butthere was minimal evidence of crossover reading

Trust is an issue in the establishment of credibilityRelationships formed by individuals were productivein the clinical sense Doctors stated that the peoplewhom they go to for information and verification arethose whom they know personally ie consultants atlocal hospitals their immediate colleagues or otherdoctors whom they had known for a long time Alliedhealth professionals and members of the nursing pro-fession were more likely to consult someone in theirown profession for verification of evidence

Weighted adoption decisions

Decisions about whether to adopt and use an innovationare made by individual professionals and local groupsof practitioners often following a period of debate Foran innovation to diffuse in any setting there are mul-tiple adoption decisions rather than a single decision

Scientific evidence is important but is not sufficientin itself to ensure that an innovation diffuses into prac-tice Box 1 provides a comparison of diffusion of theinnovations studied with those underpinned by robustevidence shown in bold To produce this analysis acrossthe interviewees three indicators of spread were com-bined (1) geographical spread across a range of sites(2) spread beyond early change champions to a widerpopulation of adopters and (3) spread across organisa-tional occupational or sectoral boundaries (eg fromsecondary to primary care)

The results show that none of the innovations dif-fused in an unproblematic manner there was variablespread of innovations with only one innovation show-ing positive results on all three indicators and diffusingwidely The data illustrate that professionals reviewedand weighed a range of factors one of which was the

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

223

robustness of the evidence The full range of factorsmentioned were

bull

There is robust scientific evidence to support the innovation

bull

The innovation is applicable to many patients

or

without the intervention patients will suffer severely adverse outcomes

bull

There are neutral cost implications or savings

bull

The new intervention or treatment is not so complicated as to produce non-compliance in patients

bull

The new intervention raises patient satisfaction levels

These selective quotes offer some examples of the wayfactors were weighed in a professionalrsquos decision making

There is no doubt that if you offer pecuniary advantages toGPs it seems to influence their behaviour quite a bit (Consult-ant in public health)

Whilst we are independent contractors and not salariedchange in practice is likely to be affected by what we are paidfor doing or not doing (GP)

I am also influenced by my patients more than anything I thinkIf my patients come back and tell me this is useful that is veryimportant to me And that is why I use a lot of SSRIs [selectiveserotonin release inhibitors] hellip (GP)

Innovations were more readily adopted if a numberof the above key factors were favourable

The present data suggest that there are few innova-tions where all these factors are favourable The use ofaspirin for the prevention of secondary cardiac events isan unusual example of an intervention with many pos-itive features These data reinforce and explain previousresearch findings (Anglia amp Oxford 1994 Fairhurst ampHuby 1998 Dopson

et al

1999 Thomson OrsquoBrien

et al

1999 Locock

et al

2001) which indicate that in manycases there is a balance of unfavourable and favourablefactors which have to be weighted and judged

Context of innovation understanding the nature of the organisational forms in primary care

The data from the present study and from comparisonswith other similar research (Anglia amp Oxford 1994 Dopson

et al

1999 Ferlie

et al

2000) suggest that many aspects ofthe variability in patterns and speed of diffusion can beaccounted for by the influence of the local context

Organisations within the healthcare sector can bebest understood as occupying an extreme of a contin-uum of service organisations with standardised organ-isations at one extreme and individualised customisedservices at the other (Mintzberg 1983 Handy 1986)Healthcare organisations also have to be understood asprofessionalised organisations with unique features(Brock

et al

1999)The primary-care sector can be seen as a context that

has further distinctive features which are different fromthe acute sector and these are critically important to ourunderstanding of the way innovation (and information)diffuses The primary-care sector (and now primarycare trusts PCTs) can be characterised as complex struc-tures which are not hierarchies but loose networksNetworks as a form of organisation have been demon-strated to operate in different ways from hierarchies (Lea

et al

1995 Ferlie amp Pettigrew 1996 Pettigrew amp Fenton2000) General practices are independent partnership-based organisations and financial levers may inhibitor facilitate diffusion Partnership-based organisa-tions operate in a consensual non-hierarchical wayat the top (although this does not imply that thereare no differences of status between partners) whilstwithin the practice there are distinct hierarchies be-tween the professions Within an individual generalpractice practice nurses and receptionists frequently donot have a direct reporting relationship to a partnerwho supervises their work One key characteristic of anetwork is that it requires the definition and deliveryof tasks through collaborative effort based on consen-sus Within the primary-care sector service deliveryinvolves the coordination of staff employed by differentorganisations and the sector is characterised by infor-mational complexity in terms of the variety of sourcesand volume of information In total this sector has avery different profile from the acute sector and there-fore issues relating to the organisation of servicescontrol and clinical governance need to be handleddifferently in primary care

Translation

The present research evidence suggests that the processof the diffusion of innovations is more interactive thanpreviously conceived lsquoAdoptersrsquo are not passive they

Box 1 Overall comparison of diffusion by innovation

Pilotonly Pockets Debated

Variablepace Widespread

Primary Direct employment of physiotherapists Primary Treatment of diabetes Primary Use of aspirinPrimary Hormone replacement therapy for osteoporosis

L Fitzgerald

et al

224

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

do not receive information from others and decidewhether to use it Rather they engage in seeking infor-mation in debating that information and frequently inusing their professional networks to seek corroborationof the value and relevance of information Typicallyone GP who led innovation in the use of hormonereplacement therapy (HRT) had a background of familyplanning training and had been a family planninginstructing doctor

So naturally I have been quite interested in womenrsquos healthand all aspects of womenrsquos health

She instigated changes and shared them with herpartners lsquoEverything I did they now dorsquo

Over the years she sought and brought in lsquoquite a lotof external input reallyrsquo

In this practice the nurses stated that

Information would be filtered down to them by the doctorsbut having said that we get regular practice nurse newslettersfrom the facilitators

There is also evidence to illustrate that innovationsare changed or lsquotranslatedrsquo during this process so thatwhat is finally enacted may be an adapted version of theinnovation Therefore group debate with those in thecommunity of practice is a key stage in the spread of aninnovation

Information sharing communication and debate

The research data illustrates that the primary-caresector may be characterised as a network organisationdrowning in information overload

There are endless pamphlets in the post I donrsquot think anybody can complain of lack of information these days Drugcompanies various guidelines publications on HRT daycourses run on it I donrsquot really think there is any shortage ofinformation (GP)

Because GPs are dealing with such a diverse range ofconditions and patients updating and developing newknowledge is a daunting challenge Many proactiveGPs choose to specialise in some conditions more thanothers and practice partners seek to negotiate sharingand complementary tasks

The data demonstrate that the foundation forimprovement and innovation is a set of good or atleast satisfactory relationships between the partnersthe employed GPs and the remaining professional andadministrative staff Where relationships are dysfunc-tional or conflicts persist there is a low probability ofpromoting improvements and change

Whilst there are differences in the quality of relation-ships and communication in each general practice the

present data show that there is a high level of informalone-to-one information sharing in many practices Thisoccurs between doctors and between doctors andmembers of other professions and inter-professionalcommunication appears more widespread and frequentthan in the acute sector of healthcare However inmany locations this communication is restricted toinformal contacts and there was limited evidence ofsystematic mechanisms of communication In manygeneral practices routine organised meetings arelimited to doctors (and sometimes include practicemanagers) The research illustrates that the forums forthe sharing and debate of evidence between the profes-sions involved in the delivery of care are limited andseverely underdeveloped in primary care As a GPcommented in one innovative general practice

I think we are very team-orientated and I think we recognisethe other members of the team far more than other placesdo and encourage them to develop their own skills andinterests hellip

Nevertheless it is apparent that many innovationswill require inter-professional collaboration

Within practices the regular use of audit as amechanism for checking on the quality of care and fordevising improvements was very limited The majority ofinterviewees were apologetic about this acknowledg-ing that more activity was required Nevertheless therewere many inhibiting factors which were quotedincluding resources appropriate skills time and patientconfidentiality

Collectively there is little history of inter-practicecollaboration and sharing of knowledge between prac-tices However the creation of PCTs requires collectiveaction not only between doctors but also betweendoctors nurses allied health and social services profes-sionals It is heartening to note that with the advent offundholding (now defunct) a range of positive colla-borative networks were observed to emerge as anunintended by-product of other changes Through theestablishment of a multi-fund one GP described one ofthe ensuing innovations

One of the other ways in which it has worked is it has broughttogether the community trust social services and the HA todevelop a varicose vein leg ulcer clinic for our area hellip (GP)

Similarly the formation of the new lsquoout of hoursrsquo co-operative networks resulted in new groupings and theinformal exchange of information The prime purposeof these systems has been the control of workload andthe reduction of stress As well as providing good medicalcover the systems have improved informal commun-ication ie networking and this has a direct benefit onthe quality of care for patients Traditionally GPs have

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

223

robustness of the evidence The full range of factorsmentioned were

bull

There is robust scientific evidence to support the innovation

bull

The innovation is applicable to many patients

or

without the intervention patients will suffer severely adverse outcomes

bull

There are neutral cost implications or savings

bull

The new intervention or treatment is not so complicated as to produce non-compliance in patients

bull

The new intervention raises patient satisfaction levels

These selective quotes offer some examples of the wayfactors were weighed in a professionalrsquos decision making

There is no doubt that if you offer pecuniary advantages toGPs it seems to influence their behaviour quite a bit (Consult-ant in public health)

Whilst we are independent contractors and not salariedchange in practice is likely to be affected by what we are paidfor doing or not doing (GP)

I am also influenced by my patients more than anything I thinkIf my patients come back and tell me this is useful that is veryimportant to me And that is why I use a lot of SSRIs [selectiveserotonin release inhibitors] hellip (GP)

Innovations were more readily adopted if a numberof the above key factors were favourable

The present data suggest that there are few innova-tions where all these factors are favourable The use ofaspirin for the prevention of secondary cardiac events isan unusual example of an intervention with many pos-itive features These data reinforce and explain previousresearch findings (Anglia amp Oxford 1994 Fairhurst ampHuby 1998 Dopson

et al

1999 Thomson OrsquoBrien

et al

1999 Locock

et al

2001) which indicate that in manycases there is a balance of unfavourable and favourablefactors which have to be weighted and judged

Context of innovation understanding the nature of the organisational forms in primary care

The data from the present study and from comparisonswith other similar research (Anglia amp Oxford 1994 Dopson

et al

1999 Ferlie

et al

2000) suggest that many aspects ofthe variability in patterns and speed of diffusion can beaccounted for by the influence of the local context

Organisations within the healthcare sector can bebest understood as occupying an extreme of a contin-uum of service organisations with standardised organ-isations at one extreme and individualised customisedservices at the other (Mintzberg 1983 Handy 1986)Healthcare organisations also have to be understood asprofessionalised organisations with unique features(Brock

et al

1999)The primary-care sector can be seen as a context that

has further distinctive features which are different fromthe acute sector and these are critically important to ourunderstanding of the way innovation (and information)diffuses The primary-care sector (and now primarycare trusts PCTs) can be characterised as complex struc-tures which are not hierarchies but loose networksNetworks as a form of organisation have been demon-strated to operate in different ways from hierarchies (Lea

et al

1995 Ferlie amp Pettigrew 1996 Pettigrew amp Fenton2000) General practices are independent partnership-based organisations and financial levers may inhibitor facilitate diffusion Partnership-based organisa-tions operate in a consensual non-hierarchical wayat the top (although this does not imply that thereare no differences of status between partners) whilstwithin the practice there are distinct hierarchies be-tween the professions Within an individual generalpractice practice nurses and receptionists frequently donot have a direct reporting relationship to a partnerwho supervises their work One key characteristic of anetwork is that it requires the definition and deliveryof tasks through collaborative effort based on consen-sus Within the primary-care sector service deliveryinvolves the coordination of staff employed by differentorganisations and the sector is characterised by infor-mational complexity in terms of the variety of sourcesand volume of information In total this sector has avery different profile from the acute sector and there-fore issues relating to the organisation of servicescontrol and clinical governance need to be handleddifferently in primary care

Translation

The present research evidence suggests that the processof the diffusion of innovations is more interactive thanpreviously conceived lsquoAdoptersrsquo are not passive they

Box 1 Overall comparison of diffusion by innovation

Pilotonly Pockets Debated

Variablepace Widespread

Primary Direct employment of physiotherapists Primary Treatment of diabetes Primary Use of aspirinPrimary Hormone replacement therapy for osteoporosis

L Fitzgerald

et al

224

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

do not receive information from others and decidewhether to use it Rather they engage in seeking infor-mation in debating that information and frequently inusing their professional networks to seek corroborationof the value and relevance of information Typicallyone GP who led innovation in the use of hormonereplacement therapy (HRT) had a background of familyplanning training and had been a family planninginstructing doctor

So naturally I have been quite interested in womenrsquos healthand all aspects of womenrsquos health

She instigated changes and shared them with herpartners lsquoEverything I did they now dorsquo

Over the years she sought and brought in lsquoquite a lotof external input reallyrsquo

In this practice the nurses stated that

Information would be filtered down to them by the doctorsbut having said that we get regular practice nurse newslettersfrom the facilitators

There is also evidence to illustrate that innovationsare changed or lsquotranslatedrsquo during this process so thatwhat is finally enacted may be an adapted version of theinnovation Therefore group debate with those in thecommunity of practice is a key stage in the spread of aninnovation

Information sharing communication and debate

The research data illustrates that the primary-caresector may be characterised as a network organisationdrowning in information overload

There are endless pamphlets in the post I donrsquot think anybody can complain of lack of information these days Drugcompanies various guidelines publications on HRT daycourses run on it I donrsquot really think there is any shortage ofinformation (GP)

Because GPs are dealing with such a diverse range ofconditions and patients updating and developing newknowledge is a daunting challenge Many proactiveGPs choose to specialise in some conditions more thanothers and practice partners seek to negotiate sharingand complementary tasks

The data demonstrate that the foundation forimprovement and innovation is a set of good or atleast satisfactory relationships between the partnersthe employed GPs and the remaining professional andadministrative staff Where relationships are dysfunc-tional or conflicts persist there is a low probability ofpromoting improvements and change

Whilst there are differences in the quality of relation-ships and communication in each general practice the

present data show that there is a high level of informalone-to-one information sharing in many practices Thisoccurs between doctors and between doctors andmembers of other professions and inter-professionalcommunication appears more widespread and frequentthan in the acute sector of healthcare However inmany locations this communication is restricted toinformal contacts and there was limited evidence ofsystematic mechanisms of communication In manygeneral practices routine organised meetings arelimited to doctors (and sometimes include practicemanagers) The research illustrates that the forums forthe sharing and debate of evidence between the profes-sions involved in the delivery of care are limited andseverely underdeveloped in primary care As a GPcommented in one innovative general practice

I think we are very team-orientated and I think we recognisethe other members of the team far more than other placesdo and encourage them to develop their own skills andinterests hellip

Nevertheless it is apparent that many innovationswill require inter-professional collaboration

Within practices the regular use of audit as amechanism for checking on the quality of care and fordevising improvements was very limited The majority ofinterviewees were apologetic about this acknowledg-ing that more activity was required Nevertheless therewere many inhibiting factors which were quotedincluding resources appropriate skills time and patientconfidentiality

Collectively there is little history of inter-practicecollaboration and sharing of knowledge between prac-tices However the creation of PCTs requires collectiveaction not only between doctors but also betweendoctors nurses allied health and social services profes-sionals It is heartening to note that with the advent offundholding (now defunct) a range of positive colla-borative networks were observed to emerge as anunintended by-product of other changes Through theestablishment of a multi-fund one GP described one ofthe ensuing innovations

One of the other ways in which it has worked is it has broughttogether the community trust social services and the HA todevelop a varicose vein leg ulcer clinic for our area hellip (GP)

Similarly the formation of the new lsquoout of hoursrsquo co-operative networks resulted in new groupings and theinformal exchange of information The prime purposeof these systems has been the control of workload andthe reduction of stress As well as providing good medicalcover the systems have improved informal commun-ication ie networking and this has a direct benefit onthe quality of care for patients Traditionally GPs have

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

L Fitzgerald

et al

224

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

do not receive information from others and decidewhether to use it Rather they engage in seeking infor-mation in debating that information and frequently inusing their professional networks to seek corroborationof the value and relevance of information Typicallyone GP who led innovation in the use of hormonereplacement therapy (HRT) had a background of familyplanning training and had been a family planninginstructing doctor

So naturally I have been quite interested in womenrsquos healthand all aspects of womenrsquos health

She instigated changes and shared them with herpartners lsquoEverything I did they now dorsquo

Over the years she sought and brought in lsquoquite a lotof external input reallyrsquo

In this practice the nurses stated that

Information would be filtered down to them by the doctorsbut having said that we get regular practice nurse newslettersfrom the facilitators

There is also evidence to illustrate that innovationsare changed or lsquotranslatedrsquo during this process so thatwhat is finally enacted may be an adapted version of theinnovation Therefore group debate with those in thecommunity of practice is a key stage in the spread of aninnovation

Information sharing communication and debate

The research data illustrates that the primary-caresector may be characterised as a network organisationdrowning in information overload

There are endless pamphlets in the post I donrsquot think anybody can complain of lack of information these days Drugcompanies various guidelines publications on HRT daycourses run on it I donrsquot really think there is any shortage ofinformation (GP)

Because GPs are dealing with such a diverse range ofconditions and patients updating and developing newknowledge is a daunting challenge Many proactiveGPs choose to specialise in some conditions more thanothers and practice partners seek to negotiate sharingand complementary tasks

The data demonstrate that the foundation forimprovement and innovation is a set of good or atleast satisfactory relationships between the partnersthe employed GPs and the remaining professional andadministrative staff Where relationships are dysfunc-tional or conflicts persist there is a low probability ofpromoting improvements and change

Whilst there are differences in the quality of relation-ships and communication in each general practice the

present data show that there is a high level of informalone-to-one information sharing in many practices Thisoccurs between doctors and between doctors andmembers of other professions and inter-professionalcommunication appears more widespread and frequentthan in the acute sector of healthcare However inmany locations this communication is restricted toinformal contacts and there was limited evidence ofsystematic mechanisms of communication In manygeneral practices routine organised meetings arelimited to doctors (and sometimes include practicemanagers) The research illustrates that the forums forthe sharing and debate of evidence between the profes-sions involved in the delivery of care are limited andseverely underdeveloped in primary care As a GPcommented in one innovative general practice

I think we are very team-orientated and I think we recognisethe other members of the team far more than other placesdo and encourage them to develop their own skills andinterests hellip

Nevertheless it is apparent that many innovationswill require inter-professional collaboration

Within practices the regular use of audit as amechanism for checking on the quality of care and fordevising improvements was very limited The majority ofinterviewees were apologetic about this acknowledg-ing that more activity was required Nevertheless therewere many inhibiting factors which were quotedincluding resources appropriate skills time and patientconfidentiality

Collectively there is little history of inter-practicecollaboration and sharing of knowledge between prac-tices However the creation of PCTs requires collectiveaction not only between doctors but also betweendoctors nurses allied health and social services profes-sionals It is heartening to note that with the advent offundholding (now defunct) a range of positive colla-borative networks were observed to emerge as anunintended by-product of other changes Through theestablishment of a multi-fund one GP described one ofthe ensuing innovations

One of the other ways in which it has worked is it has broughttogether the community trust social services and the HA todevelop a varicose vein leg ulcer clinic for our area hellip (GP)

Similarly the formation of the new lsquoout of hoursrsquo co-operative networks resulted in new groupings and theinformal exchange of information The prime purposeof these systems has been the control of workload andthe reduction of stress As well as providing good medicalcover the systems have improved informal commun-ication ie networking and this has a direct benefit onthe quality of care for patients Traditionally GPs have

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

225

worked in isolation from each other and whilst this inde-pendence has been valued it has adversely affected thedissemination of information and innovation

Historically one of the most significant policy-ledchanges affecting the diffusion of innovations wasthe establishment of commissioning groups or strategygroups at the HA level In one study area the HAhad established commissioning groups consisting ofrepresentatives of all the GPs both fundholding andnon-fundholding This body played a critical role indrawing the GPs into strategic decision-making andin setting district-wide priorities for care In anotherexample the GPs formed a smaller-scale locality com-missioning group as an antagonistic reaction to govern-ment policy

We set up a group called the X Locality CommissioningGroup which is a group that has been open to all practiceswithin the area which included fundholders and non-fundholders The fundholders have been welcome but notso inspirational hellip I think it came into being because of fund-holding We decided ndash well a number of practices decidedthat they did not want to become fundholders and I would liketo think of ourselves as first wave non-fundholders becauseof a number of reasons The main one was that the generalphilosophy was to isolate general practices and to strengthentheir independent fortification which was something we didnot want to adhere to hellip (GP)

This locality group subsequently proposed improve-ments to local services which they negotiated with theHA

Networks of other professions were less easy todefine especially for those groups who are generallycontracted into general practice ie physiotherapistsThere was some recognition that other professionscould have a key influence on changing practice but theevidence suggests that outside medicine there are lessdeveloped local forums for learning and informationexchange

Opinion leaders as facilitators or inhibitors of change

The present findings mirror those of other researchers(Locock

et al

2001) who showed that lsquoopinion leadersrsquocan play a range of positive roles in facilitating theacceptance of an innovation at a local level (Opinionleaders can also inhibit innovation) In many areas ofprimary care the present authors found that leadershipfor developments in the care of a particular conditionwas provided informally by a credible local profes-sional Such individuals might become local lsquotechnicalrsquoexperts whose advice was regularly sought by othersor they might be lsquoeducatorsrsquo who held a role within thepostgraduate education system but who were alsoinfluential in encouraging and supporting innovations

Discussion

Overview of findings

In this section the present authors return to the objec-tives of this project The data illustrate that even for thoseinnovations supported by robust scientific evidencediffusion is a complex and problematic process Thefirst objective was to trace the relative uptake of thefour innovations The authors have demonstrated thatthe diffusion of an innovation and its rate and breadthof spread within and across organisations is influencedby a range of factors They have illustrated this variablepattern of diffusion and highlighted that the credibilityof lsquoevidencersquo is in itself a debatable concept There wasno such thing as lsquothe evidencersquo just competing bodies ofevidence

Interestingly these data provide stronger supportfor the view that clinical professionals base their prac-tice on the most robust evidence than the results ofa similar study in the acute sector (Wood

et al

1998Ferlie

et al

2000) However such a comparison has tobe treated with considerable caution since the numbersinvolved in both studies was relatively small As withall qualitative research there are issues of generalis-ability The face validity of the present findings to othersites was confirmed by clinical professionals at confer-ence presentations (Fitzgerald

et al

1998 1999c)The second and third objectives related to examin-

ing the impact of the innovations and identifyingsocial organisational and managerial factors whichinfluenced diffusion The present data suggest thatweighted adoption decisions are not made in isolationby individual clinicians but frequently through aprocess of debate within local communities of practiceThese local communities of practice are highly influen-tial and in the majority of cases in primary care uni-professional In terms of the impact of an innovationthe operation of local communities of practice accountsfor the variable impact of innovations geographicallyand more especially inter-professionally

The evidence from the present research study illus-trates and develops the critical role of context to ourunderstanding of the processes of diffusion (Kimberlyamp Evanisko 1981) The primary-care sector has uniquehistorical and current characteristics For example itconsists of small units which are geographically spreadand historically fragmented These characteristicsimpact pragmatically on the ability to diffuse becauseof distance and introduce social and cultural inhibitorscaused by organisational boundaries which mean thatthere are few well-established collective forums fordebate Autonomy has been and remains valued Thecomplexities of assessing credible evidence and the

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

L Fitzgerald

et al

226

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

broad nature of the role in primary-care medicine theprocesses of the translation of evidence to local situ-ations and the processes of information sharing arecritical

Policy implications

The present research has widespread implications forthe effective management of change in primary careand for the ability of the policy makers to implementpolicy lsquoon the groundrsquo Previous research in healthcarehas illustrated that one continuing problem for anygovernment seeking to implement reforms has been thegap between strategic intent and operational manage-ment and action (Pettigrew

et al

1992)

Organisational form and structures

The present data demonstrate that primary care mustbe conceived of as an organisational form that has dra-matically different characteristics to those of the acutesector This requires different approaches to be adoptedtowards the implementation of EBM since innovationswill not diffuse in a similar way Understanding thenature of the primary-care context also has implicationsfor the effective management of change

Some of the key factors to emerge are

bull

History ndash it is important to acknowledge and employ the distinct and different history of the primary-care sector All the evidence to date emphasises that innovation processes are context-sensitive and therefore actions need to be lsquocustomisedrsquo to the context For example primary care has little history of collective inter-practice collaboration

bull

The partnership form of organisation as seen in a general practice could be both an asset and a liability Partnerships have to operate through consensus and persuasion rather than through hierarchy and power This means that many partners learn to develop these persuasive skills and to maintain sound relationships over prolonged periods of time Good-quality relationships are the foundation for improvement and change However partnerships also exclude others who are non-partners To date it is uncommon for the members of other professions or practice managers to be accepted as partners

bull

Networks do not operate like hierarchies If we are to realise some of the novel advantages of PCTs as collectivities of general practices and develop inter-organisational collaboration between health and social care there is an urgent need for professionals and managers to utilise the knowledge that we have

concerning network organisations and inter-organisational networks (Huxham amp Vangen 2000 Pettigrew amp Fenton 2000)

bull

Managing a small partnership requires minimal strategic management skills The management demands of PCTs are not solely those deriving from the increased scale of the organisation but the need for different strategic skills

Effective implementation of change

At a generic level the research data raise questionsabout the effective implementation of change in primary-care settings Can top-down change work How canone precipitate change in primary care when GP prac-tices are independent organisations and the PCT (andits board) has limited direct power and has to workthrough influence and persuasion

There is clear and strong evidence to demonstratethat much of the currently available scientific researchevidence will need to be lsquotranslatedrsquo to suit local con-texts and situations in primary care How can this trans-lation best be achieved

The present research data have produced a range ofpotentially useful ideas for making this form of influ-ence effective including

bull

acknowledgement that the managerial process requires a facilitative negotiative approach

bull

focusing management and leadership attention on building collaborative relationships which will require consistent effort over time in order to earn trust and possibly including this in managerial performance targets

bull

actively employing opinion leaders from within primary care as change leaders to lead targeted improvements in selected areas of care

bull

ensuring that change targets engage with the values of the professionals involved and targeting outcomes desired by them

bull

building on good informal relations and encouraging and facilitating the inter-professional sharing of evidence and open debate without too much interference from hierarchy (this may mean that forums require some initial financial or administrative support)

bull

using data and evidence to persuade and inform

bull

using the lsquoeverydayrsquo ie things which have to be done anyway but devising processes which include collective collaboration (eg project-planning teams to carry out work which are deliberately multi-professional and cross-boundary) and

bull

offering meaningful levers for change (eg study leave as a reward)

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

Innovation in healthcare

copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community

11

(3) 219ndash228

227

On the basis of our prior knowledge of the effectiveimplementation of change in professionalised organ-isations it is evident that the substantial changes nowoccurring in primary care are likely to require skilledfacilitation active support systems during the transi-tion period considerable time and the development ofnew senior management skills

References

Anglia and Oxford Regional Health Authority (1994) GettingResearch into Practice and Purchasing (GRIPP) Four CountiesApproach Resource Pack Anglia and Oxford Regional HealthAuthority Oxford

Brock D Powell M amp Hinings CR (1999) Restructuring theProfessional Organisation Routledge London

Callon M Laredo P Rabehariosoa V Gonadr T amp Leray T(1992) The management and evaluation of technologicalprograms and the dynamics of techno-economic networksthe case of the AFME Research Policy 21 215ndash236

Cmnd 3807 (1997) The New NHS Modern Dependable TheStationery Office London

Cochrane A (1972) Effectiveness and Efficiency Random Reflec-tions on Health Services Nuffield Provincial Hospitals TrustLondon

Coleman J Katz E amp Menzel H (1966) Medical Innovation ADiffusion Study Bobs Merill New York NY

Department of Health (1998) A First Class Service Quality in theNew NHS The Stationery Office London

Department of Health (2000) The NHS Plan ndash A Plan for Invest-ment a Plan for Reform The Stationery Office London

Dopson S Miller R Dawson S amp Sutherland K (1999)Influences on clinical practice Quality in Health Care 8 108ndash118

Eisenhardt K (1989) Building theories from case researchAcademy of Management Review 14 532ndash550

Fairhurst K amp Huby G (1998) From trial data to practicalknowledge a qualitative study of how general practitionershave accessed and used evidence about statin drugs in theirmanagement of hypercholesterolaemia British Medical Jour-nal 317 1130ndash1134

Ferlie E Fitzgerald L amp Wood M (2000) Getting evidenceinto clinical practice An organisational behaviour per-spective Journal of Health Services Research and Policy 5 96ndash102

Ferlie E Fitzgerald L Wood M amp Hawkins C (2001) Thenon-spread of innovations the mediating role of profession-als Paper presented at the Academy of Management Wash-ington DC 5ndash8 August 2001

Ferlie E amp Pettigrew AM (1996) Managing through net-works some issues and implications for the NHS BritishJournal of Management 7 81ndash99

Fitzgerald L (1999) Case studies as a research tool Quality inHealth Care 8 75

Fitzgerald L Ferlie E Wood M amp Hawkins C (1999a)Evidence into practice An exploratory analysis of theinterpretation of evidence In A Marks amp S Dopson (Eds)Organisational Behaviour in Health Care pp 189ndash206 Mac-millan London

Fitzgerald L Ferlie E Wood M amp Hawkins C (2002) Inter-locking interactions the diffusion of innovations in healthcare Human Relations 55 1ndash21

Fitzgerald L Hawkins C amp Ferlie E (1998) Understandingchange in primary care practice Paper presented at theRoyal College of General Practitionersrsquo Research Sympo-sium Regents College London 21 May 1998

Fitzgerald L Hawkins C amp Ferlie E (1999b) Understand-ing Change in Primary Health Care Practice BehaviouralOrganisational and Scientific Processes Final report to W Mid-lands RampD Directorate [WWW document] URL httpwwwdohgovukresearchwmro

Fitzgerald L Hawkins C amp Ferlie E (1999c) Interpretation ofevidence from primary care research Paper presented at the2nd Annual Conference of the Federation of Primary CareResearch Networks London 7 October 1999

Glaser B amp Strauss A (1967) The Discovery of Grounded TheoryAldine Chicago IL

Handy C (1986) Understanding Organisations PenguinHarmondsworth

Huxham C amp Vangen S (2000) Leadership in the shaping andimplementation of collaborative agendas how things hap-pen in a (not-quite) joined up world Academy of ManagementJournal 43 1159ndash1176

Kimberly JR (1981) Managerial innovation In P Nystrom ampW Starbuck (Eds) Handbook of Organisational Design Vol 1pp 84ndash104 Oxford University Press Oxford

Kimberly JR amp Evanisko MJ (1981) Organisational innova-tion the influence of individual organisational and contex-tual factors on hospital adoption of technological andadministrative innovations Academy of Management Journal24 689ndash713

Langley A (1999) Strategies for theorizing from process dataAcademy of Management Review 24 691ndash710

Latour B (1987) Science in Action Harvard University PressCambridge MA

Lea M OrsquoShea K amp Fung P (1995) Constructing the networkedorganization content and context in the development ofelectronic communications Organization Science 6 462ndash478

Lee TW (1999) Using Qualitative Methods in OrganizationalResearch Sage Thousand Oaks CA

Locock L Dopson S Chambers D amp Gabbay J (2001) Under-standing opinion leadersrsquo roles Social Science and Medicine53 745ndash757

Mintzberg H (1983) Structure in Fives Designing EffectiveOrganizations Prentice Hall Englewood Cliffs NJ

Pettigrew A (1990) Longitudinal field research on changetheory and practice Organization Science 1 267ndash292

Pettigrew A (1997) What is processual analysis ScandinavianJournal of Management 13 337ndash348

Pettigrew AM Ferlie E amp McKee L (1992) Shaping StrategicChange the Case of the NHS Sage Thousand Oaks CA

Pettigrew AM amp Fenton E (Eds) (2000) The Innovating Organ-isation Sage Thousand Oaks CA

Rich RF (1997) Measuring knowledge utilization processesand outcomes Knowledge and Policy the International Journalof Knowledge Transfer and Utilization 10 11ndash24

Rogers E (1995) The Diffusion of Innovations 4th edn FreePress New York NY

Thomson OrsquoBrien MA Oxman AD Haynes RB Davis DAFreemantle N amp Harvey EL (1999) Local Opinion Leaderseffects on professional practice and health care outcomes(Cochrane Review) In The Cochrane Library Issue 3 UpdateSoftware Oxford

Van de Ven A Polley DE Garud R amp Venkataraman S(1999) The Innovation Journey Oxford University PressOxford

L Fitzgerald et al

228 copy 2003 Blackwell Publishing Ltd Health and Social Care in the Community 11(3) 219ndash228

Williamson P (1992) From dissemination to use managementand organisational barriers to the application of healthservices research findings Health Bulletin 50 78ndash86

Williams F amp Gibson DV (1990) Technology Transfer ndash ACommunications Perspective Sage Thousand Oaks CA

Wood M Ferlie E amp Fitzgerald L (1998) Achieving clinicalbehaviour change a case of becoming indeterminate SocialScience and Medicine 47 1729ndash1738

Yin RRK (1994) Case Study Research Design and Method2nd edn Sage Thousand Oaks CA