Intended for healthcare professionals

Analysis And Comment Health policy

Evaluating and implementing new services

BMJ 2006; 332 doi: (Published 12 January 2006) Cite this as: BMJ 2006;332:109
  1. Ann McDonnell, lecturer in nursing (,
  2. Richard Wilson, research fellow2,
  3. Steve Goodacre, senior clinical lecturer in emergency medicine2
  1. 1 School of Nursing and Midwifery, University of Sheffield, Sheffield S1 4DA
  2. 2 School of Health and Related Research, University of Sheffield
  1. Correspondence to: A McDonnell
  • Accepted 17 November 2005

Evidence based health care should apply to the way that services are delivered as much as it does to treatments

Changes to the delivery and organisation of health services should be evaluated before they are widely implemented. Evaluation should be sequential, moving from theory to modelling, explanatory trials, pragmatic trails, and ultimately long term implementation. 1 However, this sequence is rarely followed. New services are often implemented, or existing services are changed, before evaluation can take place. Any subsequent evaluation will have to use unreliable methods (such as an uncontrolled, before and after design) and is, of course, too late to influence implementation. We use three examples from the NHS to show how enthusiasm can overtake evidence and the benefits of a more considered approach.

Changing the organisation of services

Implementing organisational change in health services requires substantial effort and typically needs to be driven by enthusiastic groups and individuals. There are many examples of delays in getting existing evidence into practice. The slow pace of organisational change is often seen as problematic in the drive towards an evidence based health service. However, sometimes the converse is true. Too much momentum may lead to inappropriate implementation of change before evaluation is complete. Managing this momentum offers the key to rational evaluation and implementation of changes in service organisation and delivery.

The drive for change in the way services are delivered can spring from various sources, including political imperatives, policy drivers, and enthusiasm from clinicians. Enthusiasm for improved services is desirable but can blind enthusiasts to the possible downsides of an intervention. Evidence based care may mean delaying the introduction of new treatments until robust evidence exists of their effectiveness. This approach is well suited to simple interventions aimed at individual patients, such as drugs. Here, momentum is often driven primarily by commercial imperatives. Although political …

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