title: A managed clinical network for cardiac services: set-up, operation and impact on patient care.
abstract: OBJECTIVE
  To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care.
  
  
  METHODS
  This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use.
  
  
  RESULTS
  Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and 'bed down'. Its primary "modus operand" was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not statistically significant. There was no difference in resource use.
  
  
  CONCLUSIONS
  The Managed Clinical Network made a difference to ways of working, particularly in breaching traditional boundaries and involving the public, and made modest changes in patient care. However, it required a two-year "set-up" period. Managed clinical networks are complex initiatives with an increasing profile in health care policy. This study suggests that they require energetic leadership and improvements are likely to be slow and incremental.
authors.affiliation: Tayside Centre for General Practice, University of Dundee, Kirsty Semple Way, Dundee, DD2 4BF Scotland. k.hamilton@crichton.gla.ac.uk
authors.forename: Karen E
authors.initials: KE
authors.lastname: Stc Hamilton
authors.forename: Frank M
authors.initials: FM
authors.lastname: Sullivan
authors.forename: Peter T
authors.initials: PT
authors.lastname: Donnan
authors.forename: Rex
authors.initials: R
authors.lastname: Taylor
authors.forename: Divine
authors.initials: D
authors.lastname: Ikenwilo
authors.forename: Anthony
authors.initials: A
authors.lastname: Scott
authors.forename: Chris
authors.initials: C
authors.lastname: Baker
authors.forename: Sally
authors.initials: S
authors.lastname: Wyke