Implementing change in primary care practice: lessons from a mixed-methods evaluation of a frailty initiative

BACKGROUND: The NHS is facing increasing needs from an aging population, which is acutely visible in the emerging problem of frailty. There is growing evidence describing new models of care for people living with frailty, but a lack of evidence on successful implementation of these complex interventions at the practice level. AIM: This study aimed to determine what factors enable or prevent implementation of a whole-system, complex intervention for managing frailty (the PACT initiative) in the UK primary care setting. DESIGN & SETTING: A mixed-methods evaluation study undertaken within a large clinical commissioning group (CCG). Design and analysis was informed by normalisation process theory (NPT). METHOD: Data collection from six sites included: observation of delivery, interviews with staff, and an online survey. NPT-informed analysis sought to identify enablers and barriers to implementation of change. RESULTS: Seven themes were identified. PACT was valued by professionals and patients but a lack of clarity on its aims was identified as a barrier to implementation. Successful implementation relied on champions pushing the work forward, and dealing with unanticipated resistance. Contracts focused on delivery of service outcomes, but these were sometimes at odds with professional priorities. Implementation followed evidence-informed rather than evidence-based practice, requiring redesign of the intervention and potentially created a new body of knowledge on managing frailty. CONCLUSION: Successful implementation of complex interventions in primary care need inbuilt capacity for flexibility and adaptability, requiring expertise as well as evidence. Professionals need to be supported to translate innovative practice into practice-based evidence.