How Do You Modernize a Health Service? A Realist Evaluation of Whole‐Scale Transformation in London

Abstract

Context: Large-scale, whole-systems interventions in health care require imaginative approaches to evaluation that go beyond assessing progress against predefined goals and milestones. This project evaluated a major change effort in inner London, funded by a charitable donation of approximately $21 million, which spanned four large health care organizations, covered three services (stroke, kidney, and sexual health), and sought to "modernize" these services with a view to making health care more efficient, effective, and patient centered.Methods: This organizational case study draws on the principles of realist evaluation, a largely qualitative approach that is centrally concerned with testing and refining program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. This approach used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the case and follow its fortunes over the three-year study period. The methods included ethnographic observation, semistructured interviews, and scrutiny of documents and other contemporaneous materials. As well as providing ongoing formative feedback to the change teams in specific areas of activity, we undertook a more abstract, interpretive analysis, which explored the contextmechanism-outcome relationship using the 392 T. Greenhalgh et al. Findings:In this example of large-scale service transformation, numerous projects and subprojects emerged, fed into one another, and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernization effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose widely differing approaches and met with differing success. The realist analysis of the fortunes of different subprojects identified aspects of context and mechanism that accounted for observed outcomes (both intended and unintended). Conclusions:This study was one of the first applications of realist evaluation to a large-scale change effort in health care. Even when an ambitious change program shifts from its original goals and meets unforeseen challenges (indeed, precisely because the program morphs and adapts over time), realist evaluation can draw useful lessons about how particular preconditions make particular outcomes more likely, even though it cannot produce predictive guidance or a simple recipe for success. Noting recent calls by others for the greater use of realist evaluation in health care, this article considers some of the challenges and limitations of this method in the light of this experience and suggests that its use will require some fundamental changes in the worldview of some health services researchers.

Collective action for knowledge mobilisation: a realist evaluation of the Collaborations for Leadership in Applied Health Research and Care

“…Over time, through engagement and reflection on events, meaning and understandings about CLAHRCs were constructed. In contrast to previous conceptualisations, this sense making did not necessarily result in a consensus about a shared identity or cohesiveness 114,115 CLAHRCs were not born within a vacuum, and our findings indicate that CLAHRC-like entities need time to learn and develop, 51 particularly in the absence of history 50,116 or any pre-formative work. 16,54,73 Their ongoing formation and development, rather than reflecting the stages and phases that others have proposed (e.g.…”

Tackling disinvestment in health care services

“…An important source of support identified in the research could be clinical champions, however, as has been noted by commentators such as Haas et al (2012), they will not be effective in supporting disinvestment if wider structural incentives are not in place. In addition to information and stakeholder support the other key requirement of successful service redesign is project management (Greenhalgh et al, 2009), which may itself be in short supply in a context of fiscal retrenchment. However, whilst financial pressures can inhibit programmes of change, they can also help to bolster the claims of those arguing for more radical approaches to tackling scarcity (Hewison 2010).…”

“…This requires information, analysis and local intelligence and in order to be successful requires the backing (or at least acquiescence) of stakeholders (Ham 2003;Greenhalgh et al 2009;Watt et al 2012) . An important source of support identified in the research could be clinical champions, however, as has been noted by commentators such as Haas et al (2012), they will not be effective in supporting disinvestment if wider structural incentives are not in place.…”

Empowering change: Realist evaluation of a Scottish Government programme to support normal birth

“…Realist evaluation has been used in a wide range of healthcare evaluations including individual healthcare interventions aimed at patient/practitioner behaviours (Rycroft-Malone et al, 2010, Fairhurst et al 2005, Tolson et al, 2007, local-level changes to healthcare delivery (Wand et al, 2011, Marchal et al, 2010, Byng et al, 2005 and large scale programmes of health service change (Greenhalgh et al, 2009, Evans & Killoran, 2000, Kennedy et al, 2005. This approach to evaluation has resulted in deeper insights into why a programme/intervention did or did not work and what contextual factors were associated with outcomes.…”