It is reported that it takes around 15 to 20 years for research evidence to become part of routine practice in healthcare, a timescale that appears to have changed very little in decades. It is clearly the aspiration of patients, policymakers, commissioners, clinicians and practitioners that care is evidence-based and can deliver the best possible outcomes, efficiencies and experience for service users. However, the reality is that implementation is complex, messy and difficult, especially in the highly variable and fast changing context of health and care delivery.
There is a renewed focus on supporting effective implementation of research findings in the current economic climate; research evidence is seen as key to providing solutions to the challenge of improving quality while simultaneously supporting efficiencies across the NHS. Managers responsible for quality improvement and change management may find it hard to keep up with and critically appraise research outputs, and will be aware of the difficulties in getting evidence-based interventions into day-to-day frontline practice. Even when one clinician, one provider, or one health system successfully implements an evidence-based intervention, it is rarely spread or scaled to neighbouring health economies or organisations.
The academic study of implementation science is a growing field, which seeks to provide answers to this conundrum. The National Institute of Health and Care Research (NIHR) recognised the need to understand the “implementation gap” better, and in 2020 established seven Implementation Priority Networks, which are led and delivered by the Applied Research Collaborations (ARCs). The aim of these networks is to “develop evidence to inform decision making, enable effective implementation, and change practice” (nihr.ac.uk).
The priority networks are academic structures and programmes, whose purpose is to facilitate and study implementation. They are not themselves delivery structures, and it is the health and care partners who are responsible for carrying out the implementation. Therefore, there was potential for some misalignment between an academic focus of a programme, and what the practitioners believe that they need to deliver for their patients in the here and now. Challenges could include, for example, overcoming the lack of familiarity with organisational and practice cultures, approaches, and language, which can contribute to gaps in understanding.
The Mental Health Implementation Network (MHIN) is one of the national priority areas, funded to deliver ‘real world’ impact, i.e. to improve mental health across the life course by facilitating the implementation and evaluation of high impact interventions across England. At an early stage, a broad range of stakeholders participated in shaping and prioritising the programme’s work, including experts by experience, local communities, health and social care providers, commissioners, professional bodies, local and national voluntary sector organisations.
The three projects MHIN worked on with local ARC partners were:
The MHIN leadership comprised applied health researchers, patient public involvement and engagement leads and implementation science experts. However, there was a recognition that MHIN would need to draw on specific expertise and knowledge around real-world change management, and service delivery in the context of the new health and care landscape, and hence an “Implementation Workstream” was established. The implementation workstream team brought practical hands-on expertise into the MHIN, being subject matter experts with regard to leading national implementation projects, rather than academics in the field of implementation science.
The implementation team consisted of Zoe Lelliott, a joint deputy director of ARC South London (and previous interim CEO of Health Innovation Network South London), Sarah Robinson, the implementation lead for ARC East of England (and Director of Delivery for Health Innovation East) and Afra Kelsall, a senior advisor from Health Innovation East (with previous experience at the Care Quality Commission and NHS England), hereafter referred to as ‘we’.
Over a three-year period in the first funding phase of the programme the Implementation Workstream helped to shape and influence the overall MHIN programme in many ways. This included implementation of the selected interventions, but more generally advising across the programme. We supported the MHIN team with complex programme design and delivery, and assisted with stakeholder engagement and dissemination. We believe that our views, perspectives and advice have contributed significantly to the impact that MHIN has been able to achieve, working closely in partnership with the central MHIN programme team and the implementing teams around the country.
We are keen to share our insights and learning and some of the challenges that we faced with others who may be on an implementation journey. We want to share our experiences and views more widely with implementers (and would-be implementers) of research evidence everywhere, from our unique perspective.
We found that the skills and experience we had developed whilst leading other complex projects and national programmes were particularly valuable for MHIN. At times our approach to agile problem solving helped to maintain pace and ensure delivery of milestones and timelines. Despite some initial tensions due to our different approaches, we developed as an effective team and found that the different perspectives helped us to better understand the complex (and messy) process of implementation, with the shared aim of more effectively getting research evidence into practice.
A detailed prioritization process determined the areas of highest need for improvement within mental health, providing the focus for MHIN’s three projects. The Implementation Workstream Team’s had input into the selection of evidence-based interventions for each of the 3 projects, and the contextual factors that affected implementation of these interventions. We were also able to explore MHIN’s process for selecting partner ARCs and implementing sites.
We set up and convened MHIN’s first Community of Practice (CoP) for ‘Alcohol Assertive Outreach’, drawing on the literature and theory of CoPs in the true sense. We describe our journey setting up MHIN’s first Community of Practice for Alcohol Assertive Outreach, which gave those involved an opportunity to share the challenges and lessons from implementing AAOT. We include tips and advice for anyone thinking about setting up and convening their own community. Read a blog introducing this report.
Each type of implementation strategy has challenges and issues, which impact on the sustainability of intervention delivery. Teams on the ground can be advised and supported by practical implementation experts on use of strategies. This can help them to translate implementation science ideas and concepts into practical strategies and actions, thus maximising the potential for impact of evidence-based interventions.
Each of the Implementation Leads from the seven NIHR priority network has contributed a summary of their initial learning from their individual programmes. We hope to provide a summary of these, together with a commentary and simple analysis of the themes and proposing some initial recommendations.
We strongly believe that if the programme’s academic findings are considered together with our ‘real world’ implementation workstream observations and insights, this will enable a greater depth of understanding of the issues affecting implementation.
We hope that our reflections will be of value to those who are planning the implementation of evidence-based interventions, and that they will help to facilitate the achievement of positive health and care impacts.
Zoe Lelliott is joint deputy director of ARC South London, director of King's Improvement Science (and previous interim CEO of Health Innovation Network South London), Sarah Robinson is the implementation lead for ARC East of England (and director of delivery for Health Innovation East) and Afra Kelsall is a senior advisor from Health Innovation East (with previous experience at the Care Quality Commission and NHS England).