A mixed-methods evaluation of transformational change in NHS North East

Background: The North East Transformation System (NETS) was conceived as an experiment in adopting large-scale transformational change across a NHS region in England. Although the NHS in the North East performs well, the health of the population ranks among the poorest in the country. The NETS was viewed as a means of addressing this conundrum. It comprised three components: Vision, Compact and Method. Objectives: The evaluation study comprised six elements: a literature review; an evaluation of the evolution and impact of the NETS; an identification of the factors facilitating, and/or acting as barriers to, successful change; an assessment of the role of the NETS project team; establishing how far the changes introduced through the NETS became embedded and sustained; and an evaluation of the impact of the NETS on end users. Design: The research comprised a longitudinal mixed-methods study conducted over 3.5 years. Research methods included 68 semistructured interviews, observation, two focus groups, documentary analysis and interrupted time series (ITS) analysis. The ITS component comprised analysis of five rapid process improvement workshops in two of the sites. Setting: The research setting was the NHS North East region until its abolition in April 2013 following the UK government’s NHS changes. Fourteen sites were selected for the study, comprising primary care trusts as commissioners, and provider trusts including mental health, community, acute care and ambulance services. Participants: The study respondents were members of staff in the 14 sites drawn from different levels of their organisations. Interventions: The NETS comprised a complex set of interventions aimed at improving the efficiency and effectiveness of care pathways for staff and patients. Main outcome measures: The ‘receptive contexts for change’ framework was used to evaluate the transformational change process and its outcomes. Data sources: Qualitative parts of the study drew on semistructured interviews, focus groups, observation and documents. Quantitative parts of the study used routinely collected NHS data. Results: Transformational change in a complex system takes time and demands consistency, constancy of purpose and organisational stability. The NETS was seriously disrupted by the NHS changes announced in July 2010. Progress was sustained at four of the study sites, but slowed or ceased at the other sites. Leadership style was found to be critical to the success of transformational change. Conclusions: The NETS was a bold and ambitious initiative which succeeded in bringing about real and lasting change in some parts of the North East. However, it was unable to fully realise its vision and purpose partly because of the widespread reorganisation of the NHS by the new coalition government. Future work: There is a need to develop new methods to understand how change occurs, or fails, in complex settings like the NHS. There is a need for more in-depth studies in those sites that were able to implement and sustain change. This would inform future policy and practice. The results of the quantitative analyses were less conclusive than those obtained by qualitative methods. Further development of mixed-methods approaches would provide additional support for evidence-based decision-making. Funding: The National Institute for Health Research Health Services and Delivery Research programme