Open Access Open Badges Study protocol

Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of two models of stroke care

Naomi Fulop1*, Ruth Boaden2, Rachael Hunter3, Christopher McKevitt4, Steve Morris1, Nanik Pursani5, Angus IG Ramsay1, Anthony G Rudd6, Pippa J Tyrrell7 and Charles DA Wolfe4

Author Affiliations

1 Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom

2 Manchester Business School, University of Manchester, Booth Street West, Manchester, M15 6PB, United Kingdom

3 Research Department of Primary Care & Population Health, University College London, Royal Free Campus, London, NW3 2PF, United Kingdom

4 Division of Health & Social Care Research, School of Medicine, King's College London, Capital House 7th Floor, 42 Weston Street, London, SE1 3QD, United Kingdom

5 King’s College London Stroke Research Patients and Family Group, Division of Health & Social Care Research, School of Medicine, King's College London, Capital House 7th Floor, 42 Weston Street, London, SE1 3QD, United Kingdom

6 Guy’s and St Thomas’ NHS Foundation Trust, St Thomas' Hospital, London, SE1 7EH, United Kingdom

7 The University of Manchester Stroke & Vascular Centre, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Eccles Old Road, Stott Lane, Salford, M6 8HD, United Kingdom

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Implementation Science 2013, 8:5  doi:10.1186/1748-5908-8-5

Published: 5 January 2013



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.


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.


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.

Stroke; Improvement science; Service reorganisation; Organisational change; Outcomes; Leadership; Implementation; Health services research; Cost effectiveness