Title: Innovations in major system reconfiguration in England: a study of the effectiveness acceptability and processes of implementation of different models of stroke care
Funder: Department of Health (England)

Abstract: THEORETICAL FRAMEWORK. We propose to study the reconfigurations in two ways. First taking a more traditional health technology assessment approach to address what works and at what cost?. However this approach pays little attention to structural pressures e.g. professional pressures or processes whereby organisations innovate as a result of economic or regulatory reasons (1). It also assumes innovation is progressive and poor adopters are conservative whereas resistance may be a rational response (2). Therefore drawing on innovations theory we will study the reconfigurations in terms of Websters (2) notion of a social matrix i.e. not as a technical rational set of issues but in terms of requiring co-creation by a range of stakeholders that is only as strong as the network of relations that hold it together. Further a major review of the evidence on diffusion of innovations identifies the characteristics of innovations that are more likely to be sustainable (3); we will assess the extent to which the approaches taken by the reconfigurations reflect these characteristics particularly in the light of unprecedented changes to the English NHS. Studying the implementation of different models of system innovation in two contexts (London and Manchester) will allow us to understand the relationship to organisational context. Given the changing nature of the healthcare landscape we are proposing a formative evaluation providing lessons to the two cases involved over the course of the study. SAMPLING. Reflects the areas in which services were reconfigured i.e. Manchester and London and because the scale of the work is unprecedented in these contexts. Participants will be drawn from staff in related organisations (incl. service providers both active and decommissioned and commissioners) and relevant communities (incl. patients and local networks). DATA COLLECTION & ANALYSIS. DOCUMENTS (Q1).We will analyse all available documentary evidence to build an understanding of the development and implementation using a framework drawn from the evidence base on effective organisational change (4) incl issues such as preconditions planning implementation to reveal the approaches taken to the reconfigurations and identify events that may have influenced progress of the work. PERFORMANCE DATA (Qs 2 3 4 5). We will analyse all available data from Ambulance services primary and secondary care and Office of National Statistics. A dataset including measures of structure process and outcome covering the whole of the in-patient pathway and some aspects of care after discharge will be used including the SINAP prospective audit of acute care and items identified in the NICE Quality Standards. Data will be analysed for changes in performance from base line over the study period comparing between the Centres and hospitals within each centre examining trends in e.g. access to services multidisciplinary input early supported discharge and follow up. Analyses will adjust for age sex severity of stroke and subtype of stroke to identify the factors in Manchester and London that predict good outcome (survival independence). We will analyse frequency of hospital complaints and performance on local patient surveys to understand patient experiences pre during and post reconfigurations. ECONOMIC COMPONENT (Qs 4 5). A health economic risk model will be developed based on patient level data from the South London Stroke Register (SLSR) to estimate patient outcomes; estimate patient level resource and cost use associated with different treatments in the London and Manchester reconfigurations which will be calculated using data on the long term care pathways; model different reconfiguration options outcomes and costs using the developed risk model and the estimated costs. Data collected will include resource use and unit cost data; time to admission; time spent in hospital; destinations on discharge and long-term care; and mortality. To establish the cost-effectiveness of the reconfigured services we will produce a decision analytic model. Outcomes will be a combination of death and activities of daily living score based on the Barthel Index (5). Incremental cost-effectiveness ratios (ICERs) will be calculated as cost per QALY to assess the cost-effectiveness of the different strategies. INTERVIEWS/ GROUP DISCUSSIONS (Qs 1 2 3).We will conduct interviews and focus groups at two points in time: at baseline (months 10-15); followed up 15 months later (months 26-31). We will conduct 1:1 semi structured interviews with a range of stakeholders including reconfiguration leads commissioners and service providers (20 per site per phase); and conduct group discussions with patients and carers (2 per site per phase). Interview schedules will be developed over the initial phase of the project and will be informed in part by evidence provided by the documentary analysis to explore perceptions of the processes of planning and implementing the reconfigurations and perceived impact on services staff service users and carers; and contextual factors that influenced progress of the work. Data will be digitally recorded and transcribed. Ongoing iterative and thematic analysis of all data will be undertaken concurrently according to well established procedures of constant comparative analysis (6). Initial analysis and category building for will be conducted by the researcher and will include category mapping and constant comparison. Validity will be assessed in relation to Patton’s four criteria of validity in qualitative research: verification rival explanations negative cases and triangulation (7).1.Lemieux-Charles L Barnsley J. An innovation diffusion perspective on knowledge and evidence in health care. In: Lemieux-Charles L Champagne F editors. Using Knowledge and Evidence in Health Care: Multidisciplinary Perspectives. Toronto ON: University of Toronto Press; 2005. 2.Webster A. Health Technology and Society: A Sociological Critique. Basingstoke: Palgrave Macmillan; 2007.3.Greenhalgh T Robert G Bate P Kyriakidou O Macfarlane F Peacock R. How to spread good ideas: a systematic review of the literature on diffusion dissemination and sustainability of innovations in health service delivery and organisation. London: National Co-ordinating Centre for NHS Service Delivery and Organisation 2004 Contract No.: 12th May 2009.4.Worrall A Ramsay A Gordon K Maltby S Beecham J King S et al. Evaluation of the Mental Health Improvement Partnerships programme. London: National Co-ordinating Centre for NHS Service Delivery and Organisation 2008.5.Mahoney F Barthel D. Functional evaluation: the Barthel index. Maryland state medical journal. 1965;14:61.6.Mays N Pope C. Qualitative research: rigour and qualitative research. BMJ. 1995;311(6997):109.7.Patton M. Qualitative evaluation and research methods. Thousand Oaks CA: Sage; 2002.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: STROKE