Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of different models of stroke care
Funded by the National Institute for Health Research Health Services and Delivery Research (HS&DR) Programme
September 2011 – March 2016
Co-investigators: Professor Ruth Boaden, Dr Rachael Hunter, Dr Christopher McKevitt, Professor Steve Morris, Mr Nanik Pursani, Dr Angus Ramsay, Professor Anthony Rudd, Sally Standley, Professor Pippa Tyrrell, Professor Charles Wolfe
Significant reorganisation of clinical care within the English NHS has been discussed in recent years, with the proposal to concentrate specialist services, such as major trauma, cardiac surgery, and specialist paediatrics, in fewer centres. Stroke services have led the way in making such changes.
The case for change in stroke services was strong: there was clear evidence of variations in the quality of care, with many patients not receiving evidence based care. Major system change for stroke was recommended by the Department of Health’s National Stroke Strategy. Recognising the need to improve stroke care at a system-wide level, London and Manchester led the way in the process, making radical changes to the way in which stroke services were organised.
The reconfigurations in Greater Manchester and London differed in terms of the models of care implemented, and the approaches taken in bringing about change.
In 2012, Greater Manchester began preparations for further reconfiguration of their services. In addition, NHS organisations in the Midlands and the East of England began planning to reconfigure their stroke services. In November 2012, the NIHR Health Services and Delivery Research (NIHR HS&DR) programme awarded additional funds to extend the project so that these new reconfigurations might also be evaluated.
In this study, we examine what works well and what is less successful in delivering these changes. In addition, we investigate whether these changes have delivered real improvements in quality of care and outcomes.
Our research questions are:
1) What are the key processes of and factors influencing the development and implementation of the two stroke service reconfigurations?
2) To what extent have system changes delivered process and outcome improvements?
3) Have changes delivered improvements that stakeholders (e.g. commissioners, staff, patients and the public, and reconfiguration leads) think are worthwhile?
4) Have changes delivered value for money?
5) How is service reconfiguration influenced by the wider context of major structural change in the NHS?
This study brings together quantitative data on ‘what works and at what cost?’ with qualitative data on ‘understanding implementation and sustainability’. Routinely collected data on processes of care and their outcomes (e.g. morbidity, mortality, and cost) will be analysed to assess services’ performance before and after reconfiguration. Drawing on innovations theory and the concept of the ‘social matrix’, stakeholder interviews (with people who planned and implemented the reconfigurations, stroke service providers, commissioners, and stroke patients and carers) and project documentation will be analysed to establish drivers for change, how the reconfigurations were governed, designed, and implemented, and how they are perceived to have influenced service quality.
It is certain that health services will continue to be reconfigured. Other parts of the English NHS are now also seeking to reconfigure their services, and the lessons drawn from this evaluation should help ensure such efforts are carried out in an effective and evidence based way. These lessons should also be applicable to other services that are likely to change in the near future, such as major trauma, vascular and cardiac surgery and paediatrics.
This project is commissioned by the NIHR Health Services and Delivery Research (NIHR HS&DR) programme under the management of the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC), based at the University of Southampton.