Much of the emphasis in knowledge mobilisation is on getting new things into practice. The term “implementation science” conveys this too: we want to implement stuff. But just as important can be getting things out of practice: de-implementation. The rationale is straightforward. A health service is much like a bicycle, and the case of Mrs Armitage makes clear the problem.
Mrs Armitage is a creation of English writer and illustrator Quentin Blake. She appears in three books: Mrs Armitage on Wheels, Mrs Armitage and the Big Wave, and Mrs Armitage, Queen of the Road. In both Wheels and Big Wave Mrs Armitage engages in similar behaviour. She takes something that works – in the first case a bicycle, in the second case a surfboard – and, perceiving various shortcomings, adds to it until disaster threatens. (I’ll come back to Queen of the Road, which is different.) On the bicycle Mrs Armitage is concerned that hedgehogs won’t hear her coming so she adds a selection of motorhorns; worried that she may need tools in case of breakdown so adds a toolbox; alarmed that her dog Breakspear is tiring so adds a seat for him; and so on: a snack box, a radio-cassette player, a mouth organ… etc.
So it is, all too often, with our health services. New technologies, new ways of working, new diagnostics come along and, if they seem to work and we can implement them, we add them to what we provide. But we often don’t or can’t remove or reduce the form of care or technology that the new one was intended to replace. In other situations, things are implemented on the basis of little or no evidence, never challenged, and persist indefinitely as established practice. Like Mrs Armitage’s bike, the health service gets bigger, more expensive, more unwieldy.
And what happened to Mrs Armitage’s bike? Overburdened and out of control, it crashes and she and Breakspear find themselves sitting amongst the wreckage.
To avoid the looming possibility of expensive and unwieldy health services that risk crashing whole economies we need, rather than constantly thinking about implementing and adding, to think also about how to disimplement and take things away. Implementation Science published a useful short article on this by Vinay Prasad and John Ioannidis in which the authors set out a conceptual framework for evidence-based de-implementation and followed by a note from the editors stating they welcomed further contributions on de-implementation. De-implementation is not just the opposite of implementation and is likely to require different approaches and thoughtful ways to identify practices and technologies that should be de-implemented, then work to find strategies and techniques to de-implement and sustain the necessary changes.
Perhaps Quentin Blake thought about this too. In Queen of the Road Mrs Armitage begins with an antiquated car from which bits gradually fall off – hubcaps, roof, doors, and so on, always received by Mrs Armitage with a statement such as “Hubcaps? Who needs them?” – until she’s finally left with a stripped-down and efficient-looking roadster and annointed, by her uncle and his friendly biker friends, as Queen of the Road.
Getting to a stripped-down and efficient health service is the ultimate aim of both implementation and de-implementation. We just have to make sure we don’t forget the second part.
Prasad V, Ioannidis JPA. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci. 2014; 9: 1. http://www.implementationscience.com/content/9/1/1
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