Dear Sir

We thank Glenn for reading our paper and it does seem as though he thought about every word – which is good. Words are important. Implementation science is still a new field within health care and active discussion of its terminology, methodology and culture is to be especially welcomed. We identified four points in Glenn's letter and we would like to make the following comments:

  1. Glenn seems to think we were attacking the aged when we wrote of inertia. As well as being multiprofessional, our team is multigenerational. Although some of us are a little slowed by shot knees, we would probably all agree that our preparedness to engage with and act upon new guidance is not a function of the number of candles on our cake, even though they might seem a little harder to extinguish with each passing year. So no, we do not believe greater age equates with an increased lag time to implementation. What we meant by inertia were those things that get in the way of local adoption of best practice; lack of time, lack of system support, lack of ambition. But yes, there is a negative connotation to inertia; delay in the availability of safe effective care.
  2. Artificial neural network science lies outwith our experience and expertise but it does sound interesting. Different scientific disciplines do well to share concepts. Implementation science took ideas from academics in industry.
  3. When reviewing evidence, it is important to be sure that what we view as reinforcing our beliefs is not simply confirmation bias. The Hannah example is interesting because the reaction of the academic community to those data seemed to work to remove the woman's choice for vaginal breech birth but we would question whether that was in the best interest of women? It could be that if service users had been involved in the interpretation of the results, that a wide range of opinions might have become evident. Academic judgments can also be at odds with clinicians in practice. After a debate at the RCOG in 2002, just one member of the audience of 200 clinicians put their hand up to support the conclusions of the Hannah breech trial. Perhaps, we need to consider more sophisticated means of synthesising evidence into guidance?
  4. Yes, we do see a difference between research evidence and best practice for the patient though we might phrase it slightly differently. Good research provides information that helps define interventions that can be offered to women, but we need to be cautious as to who makes that interpretation, ensuring that service users are involved. We also hold that whilst healthcare workers are bound by the spirit of co-created guidance, those seeking healthcare are not. When advising an individual woman, we need to use our expertise to take account of her individual circumstance, but we must also use our wisdom to allow her the freedom to line up her needs, wishes and beliefs alongside the guidance for herself. Put another way, national recommendations guide a doctor or midwife on how to advise a woman, but they do not tell the woman what to do. Put in a slightly heartless way – clinicians advise, patients decide. It might be that an individual woman does view a 1 in 300 risk to her singleton term breech baby as being high, but then again, she might not.