title: Lessons for major system change: centralization of stroke services in two metropolitan areas of England.
abstract: Our aim was to identify the factors influencing the selection of a model of acute stroke service centralization to create fewer high-volume specialist units in two metropolitan areas of England (London and Greater Manchester). It considers the reasons why services were more fully centralized in London than in Greater Manchester.
  
  
  
  In both areas, we analysed 316 documents and conducted 45 interviews with people leading transformation, service user organizations, providers and commissioners. Inductive and deductive analyses were used to compare the processes underpinning change in each area, with reference to propositions for achieving major system change taken from a realist review of the existing literature (the Best framework), which we critique and develop further.
  
  
  
  In London, system leadership was used to overcome resistance to centralization and align stakeholders to implement a centralized service model. In Greater Manchester, programme leaders relied on achieving change by consensus and, lacking decision-making authority over providers, accommodated rather than challenged resistance by implementing a less radical transformation of services.
  
  
  
  A combination of system (top-down) and distributed (bottom-up) leadership is important in enabling change. System leadership provides the political authority required to coordinate stakeholders and to capitalize on clinical leadership by aligning it with transformation goals. Policy makers should examine how the structures of system authority, with performance management and financial levers, can be employed to coordinate transformation by aligning the disparate interests of providers and commissioners.
authors.affiliation: Senior Research Associate, Department of Applied Health Research, University College London, London, UK Senior Research Associate, National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care North Thames, London, UK simon.j.turner@ucl.ac.uk.
authors.forename: Simon
authors.initials: S
authors.lastname: Turner
authors.affiliation: Senior Research Associate, Department of Applied Health Research, University College London, London, UK.
authors.forename: Angus
authors.initials: A
authors.lastname: Ramsay
authors.affiliation: Research Associate, Alliance Manchester Business School, University of Manchester, Manchester, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Perry
authors.affiliation: Professor of Service Operations Management, Alliance Manchester Business School, University of Manchester, Manchester, UK.
authors.forename: Ruth
authors.initials: R
authors.lastname: Boaden
authors.affiliation: Professor of Social Sciences & Health, Department of Primary Care and Public Health Sciences, King's College London and National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: McKevitt
authors.affiliation: Professor of Health Economics, Department of Applied Health Research, University College London, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Patient Representative, King's College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, UK.
authors.forename: Nanik
authors.initials: N
authors.lastname: Pursani
authors.affiliation: Professor of Stroke Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK and National Clinical Director of Stroke, NHS England, and London Stroke Clinical Director, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: Rudd
authors.affiliation: Professor of Stroke Medicine, Stroke & Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK.
authors.forename: Pippa
authors.initials: P
authors.lastname: Tyrrell
authors.affiliation: Professor of Public Health Medicine, Department of Primary Care and Public Health Sciences, King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London, and National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care South London, London, UK.
authors.forename: Charles
authors.initials: C
authors.lastname: Wolfe
authors.affiliation: Professor of Health Care Organisation and Management, Department of Applied Health Research, University College London, London, UK.
authors.forename: Naomi
authors.initials: N
authors.lastname: Fulop
mesh_terms: D003695:Delivery of Health Care; D004739:England; D006801:Humans; D007857:Leadership; D013222:State Medicine; D020521:Stroke / Q000628:therapy*
keywords: centralization; major system change; service transformation; stroke care
references.citation: BMC Health Serv Res. 2014 Dec 19;14:643
references.pmid: 25523241
references.citation: Health Serv Res. 2007 Aug;42(4):1758-72
references.pmid: 17286625
references.citation: Milbank Q. 2012 Sep;90(3):421-56
references.pmid: 22985277
references.citation: Stroke. 2015 Aug;46(8):2244-51
references.pmid: 26130092
references.citation: BMJ. 2014 Aug 05;349:g4757
references.pmid: 25098169
references.citation: Qual Health Res. 2014 Jan;24(1):46-54
references.pmid: 24277776
references.citation: Milbank Q. 2009 Jun;87(2):391-416
references.pmid: 19523123
references.citation: BMJ. 2012 Feb 16;344:e953
references.pmid: 22344306
references.citation: J Health Soc Behav. 2010;51 Suppl:S94-106
references.pmid: 20943586
references.citation: BMJ. 2008 Feb 9;336(7639):313-7
references.pmid: 18230646
references.citation: Health Policy. 2015 Aug;119(8):1005-10
references.pmid: 26094752
references.citation: Implement Sci. 2013 Jan 05;8:5
references.pmid: 23289439