Theory of Change
If you want to improve care at the front line against a standard (e.g. kindness to clients, implementing cancer treatment, etc.) then you have to intervene at the service level. The development of service interventions is stock in trade for service managers/clinicians; they are doing so all the time. But how should an intervention be developed? As you might expect this subject of how is an immense one, but there is broad agreement on the process, recently described by Wight et al., and detailed below.
- Define and understand the problem.
- Identify things that might change.
- Come up with a causal change mechanism/theory of change.
- Identify how to deliver the change.
- Test and refine on a small scale.
- Roll out and evaluate (summative evaluation).
Well that’s pretty basic and fits well with the Medical Research Council guidance referred to in a previous CLAHRC West Midlands News Blog. 
For a much more extensive discussion see a recent paper by Alicia O’Cathain, which discusses different approaches. In fact the approaches are not hermetically sealed from each other and many have overlapping constraints. The emphasis, of course, varies. Few do not highlight the importance of involving service users in the development and design. No one thinks that an intervention should not be preceded by “diagnosis of the causes of a developed problem.” Piloting before widespread application is widely supported if not always adhered to. Some (intervention mapping for example) are more elaborate and formulaic than that. However, it is hard to insist a one-size-fits-all approach. Having an explicit theory does not increase the probability of success, but it does make it easier to explain the intervention to others.
One way to obtain change is to mandate certain behaviours and to enforce compliance. Such coercion is often justified, but in the grey area of healthcare in general, and medical care in particular, few activities are governed by hard rules. Mandating correct clinical diagnosis, for example, does not make a lot of sense. So we are into more subtle methods to change behaviour.
Some interventions are truly straightforward and do not require conscious behaviour change- certain engineering solutions, such as forced function to prevent misconnecting anaesthetic gas pipes, for example. But most require those annoying creatures, human beings, to change their behaviours in some way. Perhaps the greatest single greatest contribution to providing a framework comes from the development of the trans-theoretical model  and its further distillation in the form of the COM-B model. These models are built up from analysis and categorisation of the myriad preceding psychological theories that seek to explicate behaviour change. Of course, one way to obtain change is to mandate certain behaviours and to enforce compliance. Such coercion is often justified, but in the grey area of healthcare in general, and medical care in particular, few activities are governed by hard rules. Mandating correct clinical diagnosis, for example, does not make a lot of sense. So we are in to more subtle methods to change behaviour.
Thoughts from ARC WM
A recent article published by the Council for Allied Health Professions Research highlights Krysia Dziedzic’s top tips for implementation. Krysia is part of our Long-term conditions theme and directs the Impact Accelerator Unit in the School of Primary, Community and Social Care at Keele University. Here I give my own tips for service change.
Some Frequently Flouted ‘Rules’ of Behaviour Change When Service Intervention are Designed and Implemented
|Incentives (expectancy theory)||Never use an incentive, positive or negative, when the people at whom it is targeted do not believe they can achieve it under their own volition. |
|Even if an intervention is targeted at the frontline of operations, intervene also at ‘higher’ levels||In general, when intervening at the operational level, also activate higher levels, not only to liberate resource but also to create the right social environment in line with Social Expectancy Theory. |
|Political work||Do not intervene when people are not expecting it and when it may change patterns of work, without first doing political work to ‘win hearts and minds’. People might not oppose what you are attempting, but you need active support. I think it is worth considering compensating the first generation of losers after Aneurin Bevan’s “I stuffed their mouths with gold” dictum.|
|Be persistent, but also patient||Expect prolonged resistance if skill substitution or material disruption of work is involved. Elinor Ostrom’s emphasis on developing personal relations and providing lots of time for dialogue – cheap talk. It also takes time for people in different roles to share the same intellectual map or ‘logics’.|
|Piloting||Whenever possible pilot interventions to iron out problems. If possible, alpha test them before they are rolled out. Incremental change is generally better than re-engineering business process, which involves greater risk than more incremental approaches.|
|Involve service users in the design of interventions at all stages||Co-design not only makes sense, but is supported by experimental evidence.  The ARC WM approach is to involve public contributors simultaneously in intervention design and evaluations.|
|Address multiple barriers to implementation||Interventions are more likely to succeed if all material barriers are identified and addressed. Frameworks, such as COM-B / trans-theoretical model can help identify ‘lurking’ barriers.|
|Seek risk-sharing agreements when purchasing equipment||Equipment often fails and repair can be very expensive because the vendor is in a monopoly position. Build in service contracts or even re-imbursement by hours of trouble-free service.|
|Do not overload the intervention description||Be parsimonious by describing the essential features of a service intervention. Consider ‘essential’ and optional elements. Remember, if a compound intervention has n components, and the probability of successful implementation of each is p, then only pn will get the complete bundle.|
|Encourage innovation||Mentor front-line staff to be the architects of their own destiny, rather than prescribe solutions – try to be an ‘invisible leader’.|
|Always read the previous literature concerning the proposed intervention||Failure to do so is scientific and management malpractice. Yes, contexts vary, but not to the degree that systematic analysis of previous experience can be jettisoned.|
|Evaluations||Conduct (and distinguish between) intra-mural (formative) and extra-mural (summative) evaluations. The former are necessary to identify unanticipated problems and probe the limits of what may be achieved.  Intra-mural evaluations are an integral part of Plan-Do-Study-Act (PDSA) cycles, Total Quality Management (TQM), and so on.|
Richard Lilford, ARC WM Director; Krysia Dziedzic, Director of the Impact Accelerator Unit
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