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Theme 1: Health service redesign: from structure to function

Health Service Redesign worked closely with three NHS Trust partners in the West Midlands: University Hospitals Birmingham NHS Trusts, Walsall Healthcare NHS Trust and Sandwell and West Birmingham Hospitals NHS Trust.

Each of the partners had undergone – or planned to undergo - major transformations, including the development of new hospital facilities. In addition their services were being redesigned to make them more responsive, accessible and sustainable for the benefit of patients.

Changes to services offered an opportunity to carry out long-term studies into the physical, cultural or financial pressures which drive change, and the redesign of the services themselves. There were also opportunities for cross-site comparisons.

Our approach

Theme 1’s research assessed what factors drive change within different levels of each organisation.
Initially we carried out a baseline study in association with the three local NHS Trusts. Following this, four clinical conditions were selected for further study: heart failure, STEMI (ST elevated myocardial infarction), acute cholecystectomy (gall bladder removal) and end of life care.

The way in which these services were managed, across the Trusts, was monitored and presented as case studies of the pressures and changes that each service encountered. Issues included the hospital / community interface, the impact of changing demographics, and the effects of financial stringency on the delivery of services.

Research outputs included reports on progress against targets set by the organisations themselves; a summary of the emerging pressures and the manner in which NHS bodies deal with them; and conclusions about which models of change management are likely to be effective. Quantitative and qualitative markers were analysed to measure these outcomes.

Our projects

We carried out a baseline study in association with our three NHS Trust partners: University Hospitals Birmingham NHS Trust, Walsall Healthcare NHS Trust and Sandwell and West Birmingham Hospitals NHS Trust. Following this, four clinical conditions were selected for further study.

ST Elevated Myocardial Infarction (STEMI)
Myocardial infarction is the death of cardiac muscle cells caused by prolonged restricted blood supply. Today, the preferred method of treatment is primary angioplasty where a balloon catheter is inserted into the blocked artery to restore blood flow. A stent may be left to prevent re-occlusion.

Acute hospitals have different pathways to treat STEMI patients; this may include A&E, direct admission to cardiology departments or to specialist facilities. The aim of this project was to evaluate the changing pathways for STEMI patients across the three partner Trusts by comparing redesign and identifying the barriers or facilitators to redesign.

Heart failure (HF)
Heart failure (HF) is a complex clinical syndrome. Its diagnosis involves several physical symptoms along with tests to detect structural or functional abnormalities in the heart. Initial diagnosis - often in primary care - is complicated by the fact that many symptoms are not specific to HF. However, the presence of multiple clinical signs and symptoms can increase confidence in the diagnosis, but further investigation is usually required to identify underlying functional abnormalities and confirm the diagnosis of HF.

The study focused on evaluating HF by developing detailed descriptions of services across the Trusts to compare and inform redesign of pathways, identified barriers and facilitators to service redesign, and assessed the attitudes of staff and patients on all aspects of HF services.

Although models differed across the Trusts studied, nurses were seen as key in bridging the gap between primary and secondary care and it was recognised that the need for increased communication and information sharing was vital.

Acute cholecystectomy
Cholecystectomy is a surgical procedure to remove the gallbladder. Removal of the diseased organ can be carried out in an acute setting, whilst the gall bladder is inflamed, or electively once the inflammation has subsided.

All three of the Trusts aimed to increase acute procedures encouraged by positive clinical outcomes and incentivizing NHS tariffs. During the evaluation of services, and their planned redesign, it was seen that pathways can vary even within the Trusts themselves, where different specialties can take ‘ownership’ of the patient.

In addition to evaluation, regular formative findings were fed back to Trusts along with summary comparative analysis.

End of Life Care
Around half a million people die in England each year. Two thirds are over 75 and the majority follows a period of chronic illness such as heart disease, cancer or stroke. Some die as they would have wished, but many others do not.

The NHS End of Life Care Strategy was developed to improve the care pathway by identifying people approaching the end of life and starting discussions about their care preferences. The three NHS Trusts shared an aim to improve End of Life care services via redesign initiatives.

The research team interviewed consultants, nursing staff and managers to evaluate the Trusts’ end of life care service redesign initiatives, providing both formative findings to aid local development and summative data to inform comparative analysis. Although approaches vary between Trusts, common factors included the importance of sustained and continued education and training for staff.

Author(s) Title Journal

Publication date

Hewison A, Gale NK, Yeats R & Shapiro J An evaluation of staff engagement programmes in four NHS acute trusts Journal of Health Organisation and Management
Vol. 27 Iss: 1, pp.85 - 105
doi: 10.1108/14777261311311816
1 May 2013
Hewison A, Gale NK, Shapiro J Co-production in research: some reflections on the experience of engaging practitioners in health research Public Money & Management 2012; 32(4):297-302
14 May 2012
Bailey CJ, Murphy R, Porock D Dying cases in emergency places: caring for the dying in emergency departments Social Science & Medicine
2011; 73(9):1371-1377
doi: 10.1016/j.socscimed.2011.07.036
1 November 2011
Shapiro J, Jones CS

The future of public health in England

British Medical Journal
2011; 343:d4834
doi: 10.1136/bmj.d4834
28 July 2011
Shapiro J, Rashid S

Leadership in the NHS

British Medical Journal
2011; 342:d3375
doi: 10.1136/bmj.d3375
31 May 2011
Theme lead

Dr Alistair Hewison, Senior Lecturer, University of Birmingham

  • Sandwell and West Birmingham Hospitals NHS Trust
  • Walsall Healthcare NHS Trust
  • University Hospitals Birmingham NHS Foundation Trust