Commissioning. When push comes to shove.

A study of four HAs in three regions found that they had little influence on encouraging trusts to implement the recommendations of the Changing Childbirth report over the period 1993-98. Where changes had been introduced this was often through the influence of an opinion leader in the trust, such as directors of midwifery. The results suggest healthcare professionals providing services have substantial influence over the fate of strategic change initiatives.