• A E Powell, H T O Davies, J Bannister, and W A Macrae.
• Social Dimensions of Health Institute at the University of Dundee, UK. aep2@st-and.ac.uk
• J R Soc Med. 2009 Feb 1; 102 (2): 626862-8.

ObjectivesTo explore organizational difficulties faced when implementing national policy recommendations in local contexts.DesignQualitative case study involving semi-structured interviews with health professionals and managers working in and around acute pain services.SettingThree UK acute hospital organizations.Main Outcome MeasuresIdentification of the content, context and process factors impacting on the implementation of the national policy recommendations on acute pain services; insights into and deeper understanding of the generic obstacles to change facing service improvements.ResultsThe process of implementing policy recommendations and improving services in each of the three organizations was undermined by multiple factors relating to: doubts and disagreements about the nature of the change; challenging local organizational contexts; and the beliefs, attitudes and responses of health professionals and managers. The impact of these factors was compounded by the interaction between them.ConclusionsLocal implementation of national policies aimed at service improvement can be undermined by multiple interacting factors. Particularly important are the pre-existing local organizational contexts and histories, and the deeply-ingrained attitudes, beliefs and assumptions of diverse staff groups. Without close attention to all of these underlying issues and how they interact in individual organizations against the background of local and national contexts, more resources or further structural change are unlikely to deliver the intended improvements in patient care.

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