Abstract

Background: Increasing access to high-quality social care under substantial financial and political pressures is a great challenge for most governments. In England, the National Institute for Health and Care Excellence (NICE) develops guidance in collaboration with experts and based on latest evidence, setting out how high-quality social care should be provided. Despite the substantial investment in guidance development processes, very little is known about how guidance is used by people who make funding decisions or deliver adult social care, and whether and how it leads to improvements in quality of care, and at what cost.

Objective: To develop a practice-informed theoretical understanding about processes of implementing guidance and expected outcomes and impacts following an implementation science approach. This knowledge was sought to inform the planning of an evaluation study.

Methods: This article presents a Theory of Change model which was informed by the literature and co-developed with experts in the field during a 5-month scoping study from May to September 2021. We had online meetings with about 50 people knowledgeable about the implementation of guidance (either because they implemented or facilitated the implementation of it), held a workshop with them (which was attended by 25 people) and reviewed relevant documentation from the NICE website. Because we were interested in costs and value from an economic perspective, we asked questions focusing on activities, resources and cost consequences. We used an implementation science framework to structure what we read and heard.

Results: Where local systems implemented guidance (despite the many challenges), this involved resource-intensive (=costly) processes driven by individuals passionate about evidence-based practice, which were linked to and/or supported by NICE and other relevant bodies. Implementation activities ranged from reviewing and prioritising guidance, mobilising resources, to workforce development and adapting data recording or monitoring systems. Expected impacts included avoidance of legal proceedings, improving workforce retention, better partnerships with regulatory bodies and developing a more sustainable care system. Overall, the importance of allocating resources to fund quality improvement teams and initiatives was highlighted. For senior managers to commit resources, it required a good understanding of expected costs and impacts.

Conclusion: Through discussion we surfaced many of the challenges and drivers for adopting guidance in social care, many of which were expected to have direct impacts on costs and outcomes. This study identified the need for further research on appropriate outcomes and resource use, as well as capacities for research, and provided knowledge on how to conduct an evaluation.

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