title: Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of two models of stroke care.
abstract: BACKGROUND
  Significant changes in provision of clinical care within the English National Health Service (NHS) have been discussed in recent years, with proposals to concentrate specialist services in fewer centres. Stroke is a major public health issue, accounting for over 10% of deaths in England and Wales, and much disability among survivors. Variations have been highlighted in stroke care, with many patients not receiving evidence-based care. To address these concerns, stroke services in London and Greater Manchester were reorganised, although different models were implemented. This study will analyse processes involved in making significant changes to stroke care services over a short time period, and the factors influencing these processes. We will examine whether the changes have delivered improvements in quality of care and patient outcomes; and, in light of this, whether the significant extra financial investment represented good value for money.
  
  
  METHODS
  This study brings together quantitative data on 'what works and at what cost?' with qualitative data on 'understanding implementation and sustainability' to understand major system change in two large conurbations in England. Data on processes of care and their outcomes (e.g. morbidity, mortality, and cost) will be analysed to evidence services' performance before and after reconfiguration. The evaluation draws on theories related to the dissemination and sustainability of innovations and the 'social matrix' underlying processes of innovation. We will conduct a series of case studies based on stakeholder interviews and documentary analysis. These will identify drivers for change, how the reconfigurations were governed, developed, and implemented, and how they influenced service quality.
  
  
  CONCLUSIONS
  The research faces challenges due to: the different timings of the reconfigurations; the retrospective nature of the evaluation; and the current organisational turbulence in the English NHS. However, these issues reflect the realities of major systems change and its evaluation. The methods applied in the study have been selected to account for and learn from these complexities, and will provide useful lessons for future reconfigurations, both in stroke care and other specialties.
authors.affiliation: Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom. n.fulop@ucl.ac.uk
authors.forename: Naomi
authors.initials: N
authors.lastname: Fulop
authors.forename: Ruth
authors.initials: R
authors.lastname: Boaden
authors.forename: Rachael
authors.initials: R
authors.lastname: Hunter
authors.forename: Christopher
authors.initials: C
authors.lastname: McKevitt
authors.forename: Steve
authors.initials: S
authors.lastname: Morris
authors.forename: Nanik
authors.initials: N
authors.lastname: Pursani
authors.forename: Angus Ig
authors.initials: AI
authors.lastname: Ramsay
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Rudd
authors.forename: Pippa J
authors.initials: PJ
authors.lastname: Tyrrell
authors.forename: Charles
authors.initials: C
authors.lastname: DA Wolfe
mesh_terms: D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics / Q000592:standards*; D004059:Diffusion of Innovation; D004739:England; D005069:Evaluation Studies as Topic; D006302:Health Services Research; D006801:Humans; D009936:Organizational Innovation; D010043:Outcome and Process Assessment, Health Care; D011787:Quality of Health Care; D020521:Stroke / Q000191:economics / Q000628:therapy*