FinalReport

EvaluationoftheNeuroNetworkVanguard

AxelKaehne1,ChrisMidgley2,andJaneBradbury2

1Evidence-basedPracticeResearchCentre,2FacultyofHealthandSocialCare

EdgeHillUniversity,Ormskirk,UnitedKingdom

May2018

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AcknowledgementsThe authors are grateful for the support and assistance by all themembers of the programmeteam,inparticularStuartMoore,TheSeniorResponsibleOfficer,andJulieRiley,theProgrammeDirector.Wewould also like to thank everyonewho agreed to be interviewed by us. A specialthanksgoestotheVanguardEvaluationLead,AngelaHarrison,whohelpedusrecruitrespondentsforthestudy.

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ExecutiveSummaryTheWaltonCentrecommissionedanevaluationoftheimplementationandgovernanceprocessesoftheNeuroNetworkVanguardfromEdgeHillUniversityinJanuary2018.Theevaluationaddressedquestionsregardinghowtheprogrammewasimplemented,whatfacilitatedorhinderedtheimplementationoftheVanguard,whatwastheimpactoftheprogrammeonstaff,howdidthespecificcontextoftheWaltonCentreasatertiaryspecialistserviceproviderinfluencetheimplementationoftheprogramme,andwhatwerethelessonsforother,similarprogrammesinthefuture.Theevaluationusedamixedmethodapproach,conductingadocumentaryanalysisofprogrammedocumentsandaseriesofsemi-structuredinterviewswithkeystakeholders(n=15).Theevaluationfoundthatthegovernancearrangementsoftheprogrammewerewellthoughtthroughandprovidedasufficientlystable,yetflexibleframeworkfortheimplementationofaverydiverserangeofprojectsintheprogrammeacrosstwoworkstreams.Itwasnoted,however,thatpatientconsultationactivitiesmainlytookplaceduringtheprogrammeimplementationphaseratherthancommencedatdesignphase.Theevaluationalsofoundthattheprogrammeleadershipandstaffworkedinaverychallengingregionalproviderlandscapeandmanagedtoovercomesignificantstructuralbarrierstosuccessfulprogrammeimplementation.Thepreviouslackofengagementwithotherproviders,GPsandtheCCGsintheregionwasrepeatedlymentionedasanimportantfactorpotentiallyhinderingprogrammesuccess.TherewasunanimityamongstrespondentsthattheVanguardProgrammeestablishedgoodworkingrelationshipsandpartnershipswithsomeregionalservicesandenhanceditsreputationintheregionimmeasurably.TherewasalsoarecognitionamongstkeystakeholdersthatengagingGPsremainedaconsiderablechallengethroughouttheprogramme’slifetimeandthatthismayhavehadanimpactontheutilisationofsomeprojects.WhilsttheINNSservicewassingledoutforpraiseandthoughtthemostlikelyprojecttoimprovecarequalityforpatients,itwaswidelyacknowledgedthattheimpactofsomeotherprojectsonprimarycareoutcomesmayonlybefeltafterthecompletionoftheprogramme.RespondentsalsonotedthattheprogrammeattimesstruggledtobeperceivedwithintheTrustasanintegralpartoftheWaltonCentrecoreprovisioncontributingtothewiderstrategicvisionoftheCentre.Theevaluationidentifiedarangeoflessonsforprogrammedesigners,programmeimplementersaswellasforNHSEngland.WhilstthenatureoftheNeuroNetworkVanguardasaprogrammeledbyaspecialistprovidermaylimitthedirectreplicabilityoftheprogrammeinothercontexts,theevaluationoutlinedseveralgenerallessonsthatwouldbeapplicabletotransformationalchangeprogrammesinEngland.

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Contents

BACKGROUND 5

THEWALTONCENTRE 5ESTABLISHMENTOFTHEVANGUARDPROGRAMME 5THENEURONETWORKPROGRAMME 6

EVALUATION 7

AIMSANDOBJECTIVES 7

METHODS 7

ETHICALREVIEWANDGOVERNANCE 8

RESULTS 9

PARTICIPANTS 9GENERALCHALLENGESOFPROGRAMMEIMPLEMENTATION 9EXTERNALANDCONTINGENTFACTORS 9GOVERNANCEISSUES 10PARTNERSHIPSANDRELATIONSHIPSWITHOTHERPROVIDERS 11INFLUENCINGCLINICALPRACTICE 11ENABLERSANDBARRIERSTOSUCCESSFULPROGRAMMEIMPLEMENTATION 13ENABLINGFACTORS 13BARRIERS 13FIDELITYOFPROGRAMME 14PATIENTCONSULTATION 14IMPACT 15IMPACTONSTAFF 15IMPACTONPATIENTS 16IMPACTONHEALTHCARESYSTEMS 17IMPACTONCAREOUTCOMES 17SUSTAINABILITY 18PROGRAMMEEVALUATIONPROCESSES 18CONTEXTDEPENDABILITY 19LESSONS 20SHAREDLESSONPROCESSES 20LESSONSFORPROGRAMMEDESIGNERS 20LESSONSFORIMPLEMENTATION 21LESSONSFORNHSENGLAND 21

DISCUSSION 22

CONCLUSION 25

LIMITATIONSOFTHEEVALUATION 26

EVIDENCETABLE 28

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BackgroundIn 2015 The Department of Health invited proposals for transformational change programmesaround new models of care (https://www.england.nhs.uk/new-care-models/vanguards/about-vanguards/). The programme was commissioned by NHS England and carried significantinvestment.Theprogrammefundedavarietyofchangeprogrammesfromadiversityofproviderconsortia in England, amongst others, thirteen fromacute service providers.One of those, TheWalton Centre, following discussionswith partners, submitted an expression of interest in July2015andwasannounced inSeptember2015.Vanguardprogrammesitesare tasked toaddressthe triple aims of health care, as set out in the Five Year Forward1: to reduce unwarrantedvariations in health service delivery, improve quality of care and realise efficiencies byworkingtogetherwithlocalpartnerstocreateintegratedservicedeliveryforpatientpopulations.

TheWaltonCentreTheWaltonCentre isaspecialistserviceproviderofneuroscienceservices in theNorthWestofEngland. serving a population of about 3 million people. As a tertiary health care service itsservices are largely commissioned directly from NHS England through regional commissioningteams.TheWaltonCentreprovidesneurological,neurosurgical(inclspinal)painandrehabilitationservices.TheVanguardproposal setoutaplan toensure rapidaccess tohighqualityneurologyandspinalservicesbyestablishingnetworksofcarewithinMerseysideandCheshire.

EstablishmentoftheVanguardProgrammeEmbarkingonatransformationalchangeprogrammesuchastheVanguardwasambitiousfortheorganisationsinvolved.ItalsoreflectedtheWaltonCentreleadership’svisionofitsresponsibilityasasystemleaderintransformingcareforneurologyandspinalpatientsintheregion.Fundingwas confirmedbyNHS England inMay2016 for a two year programmeanticipated tocompleteitsworkbyMarch2018whenmostofitsservicesaresupposedtobecomebusinessasusual. The late commissioning of theNeuroNetwork as an Acute Care Collaboration Vanguardmeant that therewaseffectivelya timetable fordesign, implementationandcompletionof theprogrammewhichwasoneyearshorterthanothertypesofVanguardprogrammes(suchasMultiSpecialty Community Providers –MCPs). The funder required the programme leads to provideregularupdatesofprogress.ThereisalsoafinalevaluationreporttobesubmittedbyJune2018.The funder provided training and shared learning opportunities to the leadership of theVanguards.

1 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

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TheNeuroNetworkProgrammeThe Vanguard programme at the Walton Centre was conceived in Spring/early Summer 2015followingannouncementoftheNeuroNetworkVanguard,avaluepropositionsettingoutdetailedfunding applicationwas submitted toNHS England in February 2016. Following confirmationoffunding,theprogrammeleadsappointedrelevantstaffandestablishedtherequisitegovernancestructures for theprogramme.Theprogrammecontainedtwoworkstreams,one inneurologicalservices, one in spinal services. Eachworkstream contained a series of distinct yet interrelatedprojects.Theneurologyworkstreamwascomprisedof:

• aNurseAdviceLine(NAL),• aConsultantAdviceLine(CAL),• anIntegratedNeurologyNurseSpecialists(INNS)service,• FunctionalClinics,• atelemedicine/teleneurologyprojectand• aheadacheandseizurepathway.• Satellitereview

Thespinalworkstreamwasmadeupoftwodistinctprojects:

• thebackpainpathway,and• thespinalnetwork.

Theoriginalplansalsocontainedseparateeducationalproject.Asthiswasacrosscuttingthemeinalltheprojects,itwasdecidedtointegratethisintothetwoworkstreamsratherthanrunitasaseparate project. Details of the individual projects and the programme can be found athttps://www.england.nhs.uk/new-care-models/vanguards/care-models/acute-care-collaboration/neuro-network/.The Vanguard was led by the Walton Centre and operated through a partnership with otherorganisations. It was a collaborative programme with partners such as Clinical CommissioningGroups (CCGs),HospitalandCommunityTrusts,GPsandtheNHSEnglandNorthWestSpecialistCommissioning Team. The governance structure for the programme consisted of a programmeboard, a finance group (disbanded), an operational group, an evaluation group, and individualproject groups. Eachprojectwas ledbyaprojectmanager,witheachworkstreamheadedbyaworkstream manager. Partner organisations were invited on to the programme board andoperationalgroupwhichalsoincludedpatientrepresentatives.StrategicresponsibilitylaywiththeSeniorResponsibleOwnerattheWaltonCentre,andtheoperationalresponsibilitieswereinthehandsoftheProgrammeDirectorandProgrammeManager.Theprogrammemadenewappointments, used someof the funding for consultancy in specificareas and also seconded staff from existing services at the Walton Centre into the VanguardProgramme. The projects themselves were a mixture of newly commissioned services and thedevelopmentofexistingservices.Some,suchas thebackpainpathway,coincidedwithnationalprogrammes.Theultimateaimof theprogrammewas toachievean integratedservicedeliverysystemforneurologyandspinalpatientsutilisingatriedandtested‘hubandspoke’model.

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EvaluationTheNeuroNetworkVanguardwasmandatedbythefundertoconductanevaluationoftheimpactof the programme and decided to use amix of in house and externally contracted services todeliverthis.TheCollaborationforLeadershipinAppliedHealthResearchandCare(CLARHC)wastoactasacriticalfriendtotheevalutationdesignandtoprovideanalysisofkeydataaroundtheprimary outcomes, such as service utilisation rates and patient reported outcomemeasures. InDecember2017,theWaltonCentrecommissionedanadditionalpieceofevaluationfromEdgeHillUniversitytoprovideevidencearoundsomeofthesofterprogrammeoutcomes.Theremitofthisevaluation was to assess the way in which the programmewas implemented, to establish theviewsofkeystakeholdersintheprogrammeonprogrammefidelity,programmeeffectivenessandprogrammeoutcomes.Theevaluationwas thusbroadlydefinedasaprocessevaluationusingapredominantlyqualitativeapproach.

AimsandObjectivesThequestionstobeansweredbytheevaluationwere:

1. Howwasthenewserviceimplemented?2. Whatweretheenablersandbarrierstoasuccessfulimplementationofthenewservice?3. Whathasbeentheimpactofthenewserviceonprofessionals?4. Howdidthespecificcontextfortheseservicesinfluencetheimplementationofthenew

modelofcare?5. Whatarethelessonsofthisimplementationforothersimilarserviceimplementations?

MethodsThe evaluation used a mixed methods approach to answer the evaluation questions. Theevaluationteamconductedadocumentaryanalysisofkeyprogrammedocuments,selectedbytheNeuro Network evaluation manager to gain an overview of the programme, to produce aprogrammelogicandidentifythespecificprojectobjectivesandpredefinedindicatorsofsuccess.The evaluation team then interviewed 15 key programme stakeholders. The sample ofrespondentswas purposive and individualswere identified and approached by the programmeevaluation lead. All interviewees were then contacted by the evaluation team to schedule aninterviewatamutuallyconvenienttimeandday.The interviewswereconductedoverthephone(n=13)or facetoface(n=2)andall respondentswerebriefedaboutthepurposesoftheinterviewandtheevaluation,andaskedfortheirconsenttobeinterviewedandaudiorecorded.Theywerealsoinformedthattheycouldstoptheinterviewat any time or ask for it not to be recorded. The interviewswere guided by a semi-structuredinterviewingscheduleandlastedbetween30and45mins.Allinterviewswereaudiorecordedandrecordings were transcribed and anonymised at the point of transcription. Transcriptions werethenanalysedusingathematicapproach.TranscriptswerefedintoNVIVOandtwoindependentraterscodedalldatainafirstround.Codeswerethencategorised,doublecheckedandemergentthemeswereidentified.

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Through discussion between the two raters, emergent themes were consolidated and doublechecked where necessary by consulting raw data or established coding in a second round ofanalysis.A final listof themeswasagreedthroughdiscussion.Quoteswere thenretrieved fromthe data to evidence the themes. For the purposes of convenience and future reporting, theevaluation team produced a table detailing the themes with the relevant evidence/quotes.Themesare thereforenotdirectly validated in the textbelow through verbatimquotesbut arereferencedinthetablebydomainandcategory.Thisensuresthattheresultsectionbelowretainsabetter flowandallowstheevaluationteamtosupply theevidence inaconvenient format forfuturereference.

EthicalreviewandgovernanceTheevaluationprojectproposalwassubmittedtotheFacultyResearchEthicsCommitteeatEdgeHillUniversity,FacultyofHealthandSocialCare,anditwasdeemedtobeaserviceevaluationnotrequiringfullethicalreview.AlettertothiseffectwasobtainedfromtheFacultyResearchEthicsCommitteeChair.

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Results

ParticipantsFifteen key stakeholderswere identified for interviews throughdiscussionbetweenprogrammeleadsandmembersof theevaluation team.Allwereapproachedby theprogrammeevaluationleadat theWaltonCentreandallagreed tobe interviewed.One interviewwasconductedwiththreeothermembersofstaffpresentandwasthusconductedasagroupinterview.Respondentsin all other interviews were at strategic or management level and all had been involvedsubstantiallyintheimplementationoftheprogramme.Emergent themes are produced narratively and subsumed in the section below into 7 broadreportingcategories.Eachcategorycorrespondstoonesectionintheevidencetableappendedtothisreport.Eachcategorycontainsseveralsub-themeswhicharereportedseparatelyinthisresultsectionforconvenience.Thewiderreportingcategories(domains)are1. Generalchallengesofprogrammeimplementation2. Enablers/barrierstosuccessfulimplementation3. Fidelityofprogrammeimplementation4. Patientconsultation5. Impactofprogramme6. Contextdependability7. Lessonsidentified

GeneralChallengesofProgrammeImplementationThissectioncontainsevidencerelatingtoseveralsubthemes:

• externalandcontingentfactorsimpactingonprogrammeimplementation;• governanceissues;• partnershipsandrelationshipswithotherproviders,and• issuesaroundinfluencingclinicalpracticeandthecoherenceoftheprogramme.

Wewillreportoneachissueinturnbelow.

ExternalandcontingentfactorsEverytransformationalchangeprogrammeoperateswithinacontextwhichinfluencesitsshape,scope and chancesof success. For theNHS, the context is definedby thewider commissioningenvironment,theproviderlandscape,anddeliverypractices.Inaddition,therearefluctuationsinpatient demandand circumstances relating toworkforcedevelopment and staff capacitywhichinfluencetheimplementationofaprogramme.InthecaseoftheNeuroNetworkVanguard,our

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respondentshighlightedsimilarexternalandcontingent factorswhichwereusuallyperceivedtobeoutsideoftheprogramme’scontrol.TheprogrammeexperiencedsomesignificantstaffturnoverwhichwasseenastypicalfortheNHSandforaspecialistproviderwithahighlyskilledworkforce. Itwasthoughttohaveimpactedontheabilityoftheprogrammeleadstodeliversomeprojectseffectively insomeinstances. ItwasalsonotedthatsomestaffwereemployedbytheleadorganisationandsecondedtotheVanguardwhichenabledthemtolinktheVanguardandregularclinicaldivisions,yet,attimes,alsocreatedcompetingpriorities for some individuals.Given theenormous seasonalpressuresatacuteNHStrusts,itwasfeltthatitwasdifficulttoensurethatVanguardworkwasassignedsimilarprioritytostandard operations. Staff felt that, sometimes, Vanguard programme work took a back seat.Somerespondentsthusfeltthatsecondmentswereonlyusefultoalimiteddegree,whilstothersthoughtthatsecondmentsworkedusuallywellunderthecircumstances.The programme also encountered difficulties with external partners. Most prominently, theprogramme experienced some issues in implementing the spinal network. Discussions aboutanotherprovideralsoadoptingahubroleintheregionpotentiallyundercuttheprospectiveroleoftheWaltonCentretobethesoleregionalhubwithseveralspokesofservicedelivery.Equally,akey part of the spinal network changes hinged on decisions about the type of registry forprocedures.Sinceotherprovidersoptedforanotherregistrysoftware,acriticalcomponentofthespinalnetwork-theuseofcommonclinicaloutcomemeasuresandreporting-becamedifficulttoimplement.Since theWaltonCentrehadno influenceover thisdecisionbyotherorganisations,this was seen as a contingent factor in the programme delivery, outside of the control ofprogrammedesigners.

GovernanceissuesThis led to conversations about challenges associated with the governance of the programme.Whilst respondents thought that programmedesigners got the governance structures generallyright,thereweresomeissuesthatcouldhavebeenmitigatedagainstearlyonintheprogramme’slifetime.Itwascommentedthatoneoftheprojects(thebackpainpathway)failedtosetupanestablishedprojectgroupwhichmayhavehinderedtosomeextenttheeffectiveimplementation,communication and escalation of issues to the programme leads. Several respondents alsocommented on the suspension of the finance group. The inability to recruit to the planneddedicatedpositionof informationspecialistdevelopingandassessingrelevantevaluativemetricsandmapping data collection techniques across programme partners to the evaluation strategywasrepeatedlynoted.Itwasalsonotedthattheroleof theworkstreammanagerswasnotunderstoodor failedtobetaken up by the individuals occupying the positions. It was also felt that the workstreamsremained a collection of distinct projects rather than gelled into a coherent whole. This hadimplications for theway inwhich the programmeoperated as a unifiedwhole and how itwasperceived and communicated to other staff in theWalton Centre. Itwas also noted that somereporting practices diverged from the standard agreed governance structures which may havegiventheunhelpfulimpressiontosomestaffthatgovernancestructuresweretheretobeadaptedinlinewithpersonalpreferences.

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PartnershipsandrelationshipswithotherprovidersOneof themostdifficult issues forany transformational changeprogramme ishow tonavigatethe complex landscape of multiple service providers. The Neuro Network Vanguard requiredestablishingcloseworking relationshipswithseveralotherorganisations in the region toensureeffectiveimplementationoftheprojectsaswellasdeliveryofnewmodelsofcare.Successoftheprogrammewasthereforepartlydependentonthestabilityofworkforcesandcontinuityofstaffin partner organisations. In addition, theVanguard required engagementwith somedifficult toengagepartners,suchasGPpracticesandwithsomepartners,suchasCCGs,whichwerehithertooutside the purview of Walton Centre as a specialist service directly commissioned by NHSEngland.Respondentscommentedpositively that theVanguardsuccessfullymanaged to linkupwithCCGs in the regionand institutedcloseandrobustworking relationshipswithmostdistrictgeneralhospitals.However,someorganisationsorstaffweremoredifficulttoengage.Inparticular,theprogrammestruggledtofindawaytoapproachandcommunicateeffectivelywithGPs.ThishadconsiderableconsequencesfortheimplementationofseveralprojectsthatrequiredtheactivecollaborationofGPs,suchastheINNSandnurseadviceline.ItwasfeltthattheVanguardhadnot(yet)managedtofindawaytoeffectivelycommunicatewithGPpractices,exceptthoseGPswhowereattendingtheeducationaltrainingprogramme.Similarly, engaging emergency departments andMedical Assessment Units in hospitals proveddifficult. It appeareddifficult to identifywhoworked in those units,whobest to speakwith todisseminate knowledge of the programme and how best to raise awareness amongst staff inhospitals.ThedifficultiesofengagingGPs, and staff inAccidentandEmergencyDepartments inhospitals,echoestheexperiencesofotherNHSprogrammes.WithregardtoGPs,itmayhavebeenuseful,respondents thought, to have a more detailed conversation with patient representatives toidentifyalternativewaystocontactGPs.

InfluencingclinicalpracticeOne additional barrier to the successful implementationof theprogrammewas the capacity ofstafftoinfluencechangeofpracticeinotherorganisations.Theabilitytoalterprofessional,rule-guidedbehaviourinorganisationsotherthanyourown,isafunctionofyourprofessionalstatus,your organisation’s reputation and the partner organisation’s willingness to change. The latteragainisaresultofvariousfactors,suchastheneedforchangeandthelevelofawarenessofit.Acompounding factor is the need for evidence to support any recommendation to changebehaviourorpractice,inparticularwhereitconcernsclinicalpracticewhichisevidencebased.Theback pain pathway encountered specific challenges around convincing clinical staff at otherhospitals to implement relevant changes. Clinicians either argued that they already did worktowardstheguidelinesandpathway,ordisputedtheevidencetothecontrary.This highlights the challenges around implementing projects that require the collaboration ofother organisations. It also reveals the need for careful consideration of who is tasked tocommunicatetheneedforchangetootherorganisations’staffandhowthereputationoftheleadorganisationmay impacton thewillingnessofothers to change. Itwas feltby the interviewees

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that the backpain project got the level and seniority of these ambassadors for change right. Aconsultantwithsignificantexperiencewasappointedtoleadtheproject’sdisseminationtootherorganisations.ItwasnotedthattheseniorityofthismemberofstaffmayhavecompensatedforalackofhistoryofengagementbytheWaltonCentrewithsomeoftheacutetrustsintheregion.Respondentsalsoarticulatedsomeskepticismas to thegeneraldesignof theprogramme.Theyfelt that theprogrammewasoften seenandalso feltmore like a collectionof distinct projectsrather than an organicwhole. Thismay have been amplified by the failure of thework streammanagerstoplayamoredynamic,programmeshapingroleasmentionedabove.However,therewere also some comments about whether the aims and objectives of the two work streamsactuallywerereconciledinameaningfulway.Thishadimplications,respondentsthought,fortheoverallaspirationoftheprogramme,todevelopandtestanewmodelofcare.Therewassomeuncertaintyastowhethertheprogrammecouldforgeonesinglemodelofcareoutof twoverydisparateworkstreamswithdifferentworkpractices.Whilst theprogrammedesignersmadenoclaim for the programme to operate as a single model of care, staff often perceived theprogrammeasawholeintermsofonesingularmodel.Whilst it was not felt that this impacted negatively on the way in which the projects weredeliveredanditwaspositivelymentionedthattheprogrammeleadsprovidedsufficientflexibilityfor the adaptation of projects to local circumstances, it did have repercussions for the way inwhich the programme was perceived by staff inside and outside the Vanguard. It appeareddifficultforsomekeystakeholderstoconveytheimpressionthattheVanguardwasaprogramme,logicallyunifiedaroundaconsistentnovelmodelof care. Itwas thought that thedifferences inpatientneedsandservicedeliveryofthetworelevantpatientpopulations(neurologyandspinalpatients)necessitatedthemorevariedandflexibleapproachinprogrammeimplementationthatwasactuallyutilised.These comments revealed a tension at the heart of the programme between its conceptualaspirationtoarticulateanddevelopanewmodelofcareandaprogrammeofchangeimprovingpatient care through flexible implementation processes. Respondents thought that theprogrammeleadershiptooktherightapproachbyimplementingtheprojectsinaresponsivewayadapting to local circumstancesandworkingconstructivelywith local intelligence.Thishowevermeant that some staff felt that a unified vision of a single model of care remained possiblyinsufficiently articulated or communicated. Since it was not the intention of the programmedesigners to forgeasinglemodelofcare, thisperceptionhighlightssome lackofunderstandingamongstsomestaff.

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EnablersandBarrierstoSuccessfulProgrammeImplementationThis section details respondents’ perceptions about the enabling and hindering factors forsuccessful programme implementation. In contrast to the general challenges of programmeimplementation, enablers and barriers are structural in nature yet within the control of theprogrammeteam.

EnablingfactorsInterviewees were clear that a determining factor facilitating the implementation of theprogrammehadbeenstrongpositiveleadershipbytheprogrammeSeniorResponsibleOfficer,theprogramme director and the programmemanager. It was commented explicitly that they hadprovidedaclearvisionoftheprogramme,coupledwithaflexibleandadaptableapproachwhichallowed project managers to work in a dynamic environment and feel confident to escalateproblematic issues. Respondents also noted that the programme leaders had put in place aprogramme structure that generally worked, and provided sufficient conflict resolutionmechanismswithintheprogramme.Theprogrammeleadershipwaspraisedfortheirstrongvisionandambitionaswell as their practical focusonproblem solvinganduseof a collaborative andcollegialapproach.

BarriersThere was agreement amongst most respondents that the lead organisation provided anaccommodating yet at times challenging environment for the programme. Intervieweesarticulatedsomeconcernthat theprogramme’svisionwasperhaps insufficientlycommunicatedto other staff outside the Vanguard programme, that the programme itself may have beeninsufficientlyembeddedintheclinicaldivisionsoftheWaltonCentreorthatitproveddifficulttoinsulate the programme against the seasonal pressures during theWinter months. In essencetherewasafeelingthattheVanguardprogrammeremainedperipheraltothecorebusinessoftheWaltonCentreandthat,attimes,competingprioritiesmadethemselvesfelttothedetrimentoftheprogrammedelivery.Althoughitwaspositivelynotedthattheprogrammedirectorhadmadesignificantefforts todisseminateknowledgeabout theprogrammetoallclinicaldivisionswithintheWaltonCentreitwasthoughtthattheawarenessoftheprogrammeamongststaffremainedlowandcross-Centresupportforitcontinuedtobefragile.ItwasmentionedthatotherWaltonCentrestaffmayhaveperceivedtheprogrammeasmarginalto the core business of the organisation and its long term aims and objectives were eitherinsufficientlycommunicatedorpoorlylinkedintotheWaltonCentrecorebusinessstrategy.Itwasalsonotedthatthishadimplicationsforembeddingprogrammeprojectsintothecorepracticesofthe lead organisation, transforming the programme components into business as usual. A keybarrierwas to identify the right support fordatacollectionanddataanalysis,ensuring financialandservicesustainabilityaftertheprogrammecametoanend.

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FidelityofProgrammeTheevaluationteamconductedadocumentaryanalysisofprogrammedocumentsatthestartoftheevaluation.Itproducedaseriesoflogicsfortheindividualprojectcomponentsaswellasfortheprogrammeasawhole.Theteamthencomparedtheprogrammelogicswithcommentsfrominterviewrespondentstoascertainthefidelityofprogrammeimplementation.The overall finding was that the programme had been implemented in line with the originalproposal and the value proposition with only minor changes. It also became clear that theprogrammeleadershipcontinuedtopursuemostprojectsasplannedandoptedforaflexibleandadaptable approach which allowed staff to be responsive to local circumstances rather thandiscontinuing projects where conditions became challenging. This speaks for the tenacity andambitionoftheprogrammeleadershipaswellastheexceptionalabilityoflocalstafftoadapttocircumstances.Itwascommented,however,thatthisalsomeantthatsomeprojectsmayhaveconsumedenergyandeffortsof staffeven though theyhadultimately shown littleprogressorchanceof success.Lowuptakeof telemedicineanddifficultieswith theconsultantadvice linewere singledout forsomecriticism.Itwasacknowledgedhoweverthattheseprojectsstilldeliveredproofofconceptwhichmaybeimportantforfutureprogrammedevelopment.In summarymost respondents felt that theprogramme leadershiphad struck the rightbalancebetween a flexible implementation model accommodating challenges through reasonablealterationstotheoriginalblueprint,andinsistenceonfidelitywiththebroaderprogrammesetup.

PatientConsultationPatient engagement activities may range from patient consultations to full co-production ofservices.Thereisaconsensusamongstprogrammemanagersanddesignersthatcomprehensiveco-productionofservicesremainsanaspirationratherthanareality.Whilsttherearesomegoodexamples of co-produced services, co-production in those instances rarely extends all the wayfromthedesignstagetoservice implementation,servicedelivery,serviceauditandreview.Oneimportantbarriertothesuccessfulutilisationofpatientinvolvementinservicedesignis,accordingtotheliterature,thatorganisationsneedtoknowwhichquestionstoask.Itthenremainsdifficulttotranslatetheanswerspatientsgive intoorganisationalprioritiesandmappatientexperiencesontoservicedeliverystructures.Respondentsinourinterviewswereclearthattheprogrammestaffundertookenormouseffortsto involvepatients andpatient representatives in ameaningfulwayduring the implementationperiod. They were also adamant that patient views had some influence on the way in whichservices and projects had been implemented. There was however also a strong consensusamongst respondents that the programme had been designed without effective patientinvolvement due to the extremely short time lead period between invitation to bid and thesubmission of a proposal to NHS England. It was felt that the nature of patient involvementthroughout patient consultation exercises of the Vanguard was approximating the model ofconsultationratherthangenuineco-production.However,itwasmentionedthattheprogrammehad accumulated a considerable amount of expertise and knowledge during the patient

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consultations,whichallowedstafftoasktherightquestionsinfutureandmayleadtogenuineco-productionofservicesinsomeareas.An additional challenge to genuine co-production was also mentioned by respondents. Theprogrammewasperceivedas thoroughlymedically focused,which resistedeasy translation intopatientconcernsandperspectives.Oneaspectofthiswasaroundterminologyandlanguageandhow programme designers and managers could ensure that members of the public couldunderstandandmeaningfullycontributetodebatesaroundservicestructuresandtheirdelivery.Respondents also acknowledged that the two workstreams were targeted at different patientpopulations, each having different patient concerns. There was also a recognition that spinalpatientswere a less homogenous group in termsof patient needs,with less developedpatientsupportgroups.Thisposedaproblemtoprogrammeandprojectmanagerswhenitcametodrawon existing support networks for patient consultation exercises or patient involvement inprogrammedesign.It was widely accepted amongst respondents however that the programme had formulated aprogramme vision and value propositionwith a notion of patient needs at the centre and hadgenerallyrunexcellentpatientengagementactivities.

ImpactTheinterviewsgatheredaconsiderableamountofevidencerelatingtotheviewsandperceptionsof respondents on the impact of the programme. There were six sub themes that emergedthroughanalysisof transcribed interviewswhere impacthasbeenperceivedassignificant.Theywere impact on staff, impact on patients, effects of the programme on health care systems,consequences of programme activities on care outcomes as perceived by our respondents,remarksaboutthesustainabilityofservicesandprojects,andcommentsonhowtheprogrammewasevaluated.Wewillreporteachsubthemeinturnbelowwithrelevantevidencereferencedintheevidencetableattached.

ImpactonStaffThere were two broad subject matters that respondents explored as to the impact of theprogrammeonstaff.Firstly,theynotedthedifficultyoftheprogrammetochangeclinicalpracticeeffectivelyandthechallengeofinfluencingstafftotakeaccountoftheprogramme’sobjectivesinstandardpractice.Thisrelatedtostaffwithinaswellasoutsidetheleadorganisationandrevealedsome important insights into how to effectively disseminate knowledge and awareness aboutnovelpracticesorwaysofworking.Italsohighlightedtheneedforevidencebasedargumentsvis-à-vis other clinical staff and the depth and quality of evidence required to influence decisionmakers in other organisations. It also, secondly, concerned the way in which the programme‘landed’within the lead organisation, how it accommodated or disrupted existing relationshipsandhowitattemptedtotransformcurrentworkpractice.Thefirstaspectofimpactonstaffthuswas pertinent to issues of leverage and capacity to transform, whereas the second aspectdisclosedthelinkbetweentheprogrammeambitionforchangeanditspositionwithintheWaltonCentre.

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For the first domain, respondents noted that the Walton Centre worked under difficultcircumstancesgivenitsspecialistpositionwithintheproviderlandscapeandthusatthebeginninglacked the relationships with other health care organisations, especially the CCGs, or wereperceived as competitors by other hospital trusts. Interviewees agreed that the Vanguardachieved an enormous amount of progress in creating from scratch very effective partnershipswithotherorganisations,andthenewlycreatedlinkswiththeCCGsweresingledoutforspecialpraise.Respondentsalsonotedthatsomeoftherelationshipswerenecessarilyfragilebeingforgedwithindividualsandcolleaguesinotherorganisationsandgiventhelackofhistoryofengagementwiththem.This also, so some respondents thought,mayhave limited theabilityof theVanguard toleverageotherhealthcareproviders tochangereferralpracticesor tocreate trulycollaborativerelationships.ItwascommentedthatrobustrelationshipsbetweenpartnerswereusuallyrequiredtotransformVanguardactivitiesintobusinessasusualandtofurtherembedandadvanceprojectsintheregionalhealthcareprovision.Whererelationshipsweremorefragileortenuous,thiswasseenasinsufficientlystrongtointroducelastingchangetothebenefitofpatients.The secondaspect concerned theabilityofVanguard staff to formulatea coherentprogrammevision,tocommunicatethistostaffattheleadorganisationandtoarticulateaconsistentmessageof change to other Walton Centre staff. The interviews revealed a unanimous view that theVanguardleadershipundertookenormouseffortstodisseminatetheVanguardprogrammevisiontostaffattheWaltonCentrebutmayhavestruggledtogaintheirunderstandingofhowserviceinnovationpilotedthroughtheprojectsshouldandwouldbecomepartofregularservicedelivery.Itwasmentioned that thismay have been because theWalton Centre had little experience intransformational change programmes, and thus lacked the expertise on how to implementchange, embed it in the leadorganisation andmarshal effective and strong support for it fromTruststaffoutsidethosedirectlyinvolved.Thislinkedstronglywithcommentsbyoneindividualastoapossiblybeneficialdifferentgovernancearrangementwheretheleadsoftheclinicaldivisionscouldhavebeeninvitedtotheprogrammeboardtoensuretheirawarenessandongoingsupportfortheprogramme.

ImpactonPatientsThe interviews generated a lot of data on the views of respondents with regard to theprogramme’s impact on patients and their care. There was a strong consensus amongstinterviewees thatone specific project, the IntegratedNeurologyNurse Specialists (INNS), hadasignificanteffectonpatientcare.RespondentsalsothoughtthatINNSweretheprojectmostlikelyto show significant financial gain, considerable improvements to patient care and possibly therealisation of efficiencies over time. It was also felt that hard evidence of positive patientoutcomeswaseasiertoproduceforthe INNSservicethanforotherprogrammeprojects.ThereweresomecommentsthattheNurseAdviceLine(NAL)mayalsobeyieldingsomeevidenceofapositiveimpactonpatientcareovertime.Most respondents felt that it would be difficult to demonstrate similar gains in efficiencies orpatientcarequalityimprovementsforotherprojectsintheVanguard.Thereasonsweremanifoldbut ranged from ‘too short a timeline’ to capture effects on service delivery outcomes toinsufficientutilisationofsomeprojectservicestocalculateimpact.Therewasalsoaviewamongstsomerespondentsthatitwasdifficulttoassesstheoverallimpactofadiverseprogrammesuchas

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theNeuroNetworkVanguardandthatadditionalworkhadtobedonetoevidencethepossibleeffectoftheprogrammetomakethesystemasawholemoreresponsivetopatientdemandsandpatientneeds.Therewassomeskepticismthatthewayinwhichtheevaluationwascurrentlysetupwouldbeadequatetomeasuretheoverallsystemimpactoftheprogramme.

ImpactonHealthCareSystemsIntervieweeswereresoluteintheiropinionthattheVanguardprogrammehadapositiveeffectonthe reputation of the lead organisation in the region. They argued that it had increased thevisibilityandsubstantially improvedtherelationshipsoftheWaltonCentrevis-à-visotherhealthcareorganisationsinthearea.Theprogramme’simpacthoweverpositivelyextendedbeyondtheimmediatevisibilityoftheleadorganisation and, when prompted, respondents articulated a more ambivalent view on theCentre’sabilitytoinfluencethesystem’schallenges.ItwasfeltbysomerespondentsthatthepotentialoftheVanguardtoimpacthealthcaredeliverypatternswas a functionmainly of the perceptions of strategic and operational staff in partnerorganisations as to how collaboration would benefit them and their organisation. It was alsomentioned that the Vanguard’s capacity to influence others may be a reflection of otherorganisations’ viewsas towhether theprogrammewouldmitigate theirmostpressingdemandproblems.Where it did, partner organisationswerewilling to cooperate,where itwas thoughtperipheraltotheirservicepressures,theVanguardstruggledtoelicitsupportandcollaboration.Withinthisinterpretativeframeworkofpotentialgainsandbenefits,itwasalsocommentedthatthe individual projects landed differently in different partner organisations, evoking differentresponses.Whereprojectswereperceivedasbringingaboutpositive improvementsdue to lowbaselinesinpatientcareorservicedelivery,partnerorganisationswerewillingtoengage.Wherepartnerorganisationswereconvincedthatprojectswouldbringlittleimprovementinpatientcaremainly due to high care quality anyway, partner organisations were more reluctant to getinvolved.There was also a clearly articulated view amongst respondents that many regional providerslackedanunderstandingof thepurpose andpotential impactof theVanguardeven some timeintotheprogramme’slifetime.Itwasfeltthattheprogrammestaffmaynothavedemonstratedclearlythepotentialtoimprovepatientcareandhowthiswouldmattertootherproviders.

ImpactonCareOutcomesRespondents were keen to discuss the potential for measuring patient outcomes of theprogrammeandhowitcouldbefacilitated.Therewasastrongconsensusamongstthemajorityofintervieweesthat itmaybedifficult todemonstratethefinancial impactoftheprogrammeasawhole. In their opinion thiswas due to a range of factors, some extraneous and others in thecontroloftheprogramme.Withregardtothelatteraspect,respondentsthoughtthattherewasalack of knowledge regarding data sharing and data harmonisation across providers amongstprogramme staff. Data sharing practices were thought to be insufficiently robust to ensureeffective monitoring of relevant patient data. In particular, a lack of deeper understanding by

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programmestaffof routinedata capturepracticesamongstotherproviders,how theydivergedandhowthiswouldimpactonmeasuringprogresswasrepeatedlymentioned.Withregardtothechallengesinternaltotheprogramme,itwasarguedthatmetricsdevelopment,andmappingthemagainstprogrammeobjectivestookplacequitelateintheprogrammeandstaffstruggledtoreconcilethisprocesswithroutinedatacollectionpatternsinpartnerorganisations.Several respondents mentioned that success in recruiting an information specialist may havealleviatedthisdifficulty.

SustainabilityEnsuringthesustainabilitywasseenascriticaltoprotectingtheimpactoftheprogrammeinthelongterm.Respondentsthoughtitwasdifficulttoseeallindividualprojectsbecomingbusinessasusual,eventhoughtheystronglysupportedsuchamove.Respondentswerealsoskepticalastothesustainabilityoftheprogrammeasawhole,andwhethertheissueoffinancialsustainabilityoftheprogrammewassufficientlyaddressedandprogressedwithcommissioners.Some thought this reflected the actual nature of the programme, seeing it as a collection ofdiscrete projectswithin two separateworkstreams. In their opinion, it was therefore right andpropertoanticipatethatprojectswereassessedonacasebycasebasis.Thereweresomevoiceswho supported the view that sustainability should have been an assumption for all projects.However, most respondents endorsed a more pragmatic perspective which left room forexaminingthevalueofprojectsonanindividualbasisandjudgingtheirabilitytobecomebusinessasusualonebyone.Somerespondentsalsonotedthattherewasafundamentaltensionbetweenthemainlocationoftheprogramme’sinvestment(attheWaltonCentre)andmostofthegainsbeingrealisedfurtherdownstreamwithinother services.Thiswasdeemedtohavesome impactondiscussionsaboutsustainability of programme components and should have been factored into the valuepropositionandprogrammefinancialplans.Ingeneral,therewasagreementthatwhilstmeetingswereheldwithdivisionaldirectors,itappearsthatfirmplansregardingtransformingprojectsintobusinessasusualwereformulatedquitelateintheprogramme’slifetime.

ProgrammeevaluationprocessesRespondentshighlightedonemoreaspectof theway inwhichtheprogrammesetup influencedthe programme’s outcomes. They pointed to the key role of evaluation in assessing theprogramme’scapacitytointroducelastingchange.Respondentsstressedthatthedevelopmentofmetrics, the identificationof suitable indicatorsand requisitemeasures toassessprogresswerecritical toprogrammeevaluation.Therewassomeconcernthatmetricsdevelopmenthappenedquitelateintheprogrammeandwasnotadequatelyresourcedatallstages.Somehintedatalackofunderstandingofthecomplexityoftheissueandashortageofexpertiseinthisareaavailabletotheprogrammeleadership.Priortestingofmetrics,soitwasthought,mayhavemitigatedsomeofthe potential risks to successful programme evaluation if it had taken place early enough. Inaddition, the inability to recruit a data analyst and the subsequent delay data analysis until

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supportfromtheCommissioningSupportUnit(CSU)materialised,hadalongtermimpactonthewayinwhichtheprogrammecouldbeevaluated.Thecaseof spinal injectionsmayserveasausefulexampleof thecomplexityofdatagatheringand evaluation.One respondents argued that, though therewas confidence that the back painpathway had changed clinical practice of some clinicians in the region, it would be difficult todisentangletheeffectofthebackpainpathwayinthedatafromtheeffectoftheintroductionofrelevantNICEguidelines.Thecollectionofprimaryoutcomedatamaybeinsufficientlysensitivetoattributeimprovementsinclinicalpracticetooneortheothercauses.Therewasalsoaviewthatmostmetricswereclinicallydefinedwhichreflectedthemedicalthrustof theprogrammeandaclear focusonpatientcareoutcomes.Whilst thiswasnot thecase forprojectleveloutcomeswhichincludedasignificantnumberofpatientleveloutcomes,therewasaperception, probably gained through a view of the NHS England Dashboard, that medicaloutcomes dominated. Some staff felt, that this may have diminished the potential to identifyimpacts of the programme on wider health systems which, again, demonstrated adisproportionateemphasison individualprojects rather than theprogrammeasacoherentandunifiedtransformationalchangeprogramme.

ContextdependabilityTheevaluationwastaskedtoidentifyfactorsthatindicatedthecontextdependabilityofthewayinwhichtheprogrammewas implemented inorder toassess its replicability forothersitesandsimilarfutureprogrammes.OnerespondentexpressedconfidencethattherewasstronginterestamongotherspecialistprovidersinEnglandinwhattheNeuroNetworkVanguarddid,howitdiditandhowitcouldbepotentiallytransposedtoothersimilarcontexts,suchastertiaryproviderledchangeprogrammes.TherewashoweveralsoastrongfeelingamongstrespondentsthattheNeuroNetworkVanguardwasunusualinitspositionasachangeprogrammeinitiatedbyaspecialistproviderandtherewasthereforelittlepotentialofreplicabilityforothers.WhatwasmorepromisingwereexperiencesofVanguard programme staff regarding how they dealt with generic challenges of changeprogrammes.Themain issues in this respect related todifficulties inengagingGPsandhospitalstaff, as well as the relationship between Walton Centre and other providers in the region.DrawingoutthelessonsfromtheVanguardontheseissueswasseenasacriticalcomponentforpossiblesharedlearning.

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LessonsThe evaluation proposal contained a task to distil the lessons learned from the programmethrough interviewswith key stakeholders. The interviews revealed four domainswhichwereofcentral importance in theopinionof respondents.The firstdomain related to theway inwhichsharedlearningwasoperationalisedandembeddedintheprogrammeitself.Second,thereweresomelessonsforprogrammedesigners.Third,therewerelessonsforthosetaskedtoimplementprogrammes like the Neuro Network Vanguard. And last, there were some lessons for NHSEnglandwhichmayhavesomeapplicationtootherVanguardsites.

SharedlessonprocessesMaximisinglearningacrossprogrammestaffisakeyfactorforrapiddisseminationofprogrammeknowledge, sharingofexpertiseandexperiencesandpromotinga senseofparticipation in,andownership of, the programme. Respondents thought that the programme at timesunderestimated thepotentialeffects robust shared learningprocesses couldhaveon increasingmutual understanding between by and large discrete projects. It was noted that therewas noformalprocessinplacetoenhancesharedlearningacrossprogrammecomponentsanditwasfeltthatprojectsthuslabouredattimesinisolationfromeachother.Severalrespondentsfeltthatthisrepresentedamissedopportunitytomaximisecross-fertilisationofknowledge,eventhoughtherewerefortnightlyteammeetingsatwhichcrossprojectissuesandlessonslearnedwerediscussed.It appears that themainmechanism to share learningwas informal, rather than built into theprogramme’s DNA. Thismay have contributed to a failure to create a sense of reciprocity andbelonging to a unified integrated programme. The impression of silo working was mentionedrepeatedly,despitethecollegiatesetupandgovernancestructureoftheprogramme.

LessonsforProgrammeDesignersThere was a series of lessons that respondents pointed out for future programme designers,inevitablywiththebenefitofhindsightaffordedtothem.Thefirstaspectwasthattheprogrammearticulated but struggled to continuously and consistently convey a vision of purpose for theprogrammeasawholeratherthanitsparts.Itwasacknowledgedthattheprogrammeleadershiphadidentifiedausefulformulafortheprogrammevisionbystatingtocreateaservicethatkeptpatientshealthyoutsidehospitalandinthecommunity.However,intheviewoftheinterviewees,itwasnotclearhowthisformulawasoperationalisedinvariouscomponentsasanorganicwhole.Somerespondentsalsothoughtthedifficultyofgraspingtheprogrammeasaunifiedwholewasreplicated by other organisations looking in and exacerbated problems in eliciting positivecollaborative responses from partner organisations. As mentioned it was not an objective ofprogrammedesigners to imposeasinglemodelofcareontothetwoworkstreams,butratheraperceptionbysomestaff.Thisissueappearedforsomerespondentstobelinkedtotheroleofworkstreammanagers,theirability tocreate integratedandsensibly fusedworkstreamsandtostrategicallyconnectthetwoworkstreams together. It was thought that work streammanagers had been unable to do thiswhich again, influenced theway inwhich the two programmeworkstreamswere perceived bystaffaslargelyseparateentities,whichtheyweresupposedtobe.Thistiedinwithissuesaround

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aneffectivecommunicationplanandstrategytocreateinternalcohesionaswellasconveyingtheprogrammepowerfullytootherstaffattheWaltonCentre.Whether this programme had a coherent rationale that bound the individual projects andworkstreams together was echoed in some comments wondering if programme designers hadsufficientintelligenceandrelevantdataduringprojectdesignandselection.Itwasfeltthattheremayhavebeensomeopportunismwhendecisionsweremadeaboutwhichprojectstoincludeintheprogramme.Thislinkedinwithconcernsamongstsomerespondentsthatthespeedwithwhichmoneyshadtobe spent, asdirectedbyNHSEngland, impactedon the feasibilityofprojects, theway inwhichtheywereimplementedandtheirpotentialtosucceed.Inparticular,thetelemedicineprojectwassingled out for some critical remarks where a broader based assessment could have led todifferent selectionof sites in somecircumstances. Sinceutilisationof the service remained low,thesediscussionsmayhavemadeadifferencetotheimpactoftheproject.

LessonsforimplementationRespondents generally acknowledged the enormous challenges for all programme staff and inparticular for the leadership increatingaviableprogrammeplanand implementing itwithinanextremelytighttimetable.Theyrecognisedtheextraordinaryeffortsoftheprogrammeleadershipandstafftoembedtheprogrammeinrobustandlastingpartnershipsintheregion.Therewasalsohoweverasensethatprogrammevision,consensusaroundthisvisionandenduringrelationshipswithotherprovidersrequiredalongtermeffort,continuinginvestmentinresourcesandcapacityand that neither of these were available to the programme. There were some ideas thatrespondentsvoicedwhichmayhaveimprovedprogrammeworkingpractices,suchasco-locatingprogramme staff with operational teams, but there was a general acceptance amongstintervieweesthatlongtermgoalsrequiredlongtermperspectivesandthattheturnaroundtimefortheprogrammewassimplytooshortforthis.

LessonsforNHSEnglandRespondents were adamant that NHS England could have assistedmore in several respects tomitigatesomeofthechallengesandriskstotheprogramme.TherewasasensethatNHSEnglanddid not provide sufficient training and information around some of the transfer to business asusualandhowtocreatesustainability.TherewasalsoafeelingthatNHSEnglandneverarticulatedacoherentrationaleforthepurposeoftheVanguardProgrammeasawholebeyondthenotionofnewmodelsofcare.ItwasfeltthattherewasalackofinformationabouthowtheprogrammesfitintothewidertransformationagendaandwhattheycouldcontributetothechangesoutlinedintheFiveYearForwardReviewandhow.Therewerealsosomecriticalcommentsaboutthefundingsystem,whichcreatedsomepressurestoimplementprojectsquickly,duetothefactthatmoneyshadtobespentjustafterprogrammefundingapproval.

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DiscussionThediscussionsectionbelowwill focusonaselectnumberof issuescuttingacrosssomeof thethemes and issues identified above. Since the themes are individually evidenced in the Resultssection,thediscussionwillnotcontainreferencestotheevidencetable.An important element of any change programme in health care services is governance. Therespondents were generally complimentary about the arranged governance structures and theevaluation found that, by and large, governancewas implemented as planned. Itwas howevernotedthatoneprojectdeviatedfromthegovernancearrangementsbynothavinganestablishedprojectteamwithrequisiteteammeetings.Theevidencefromtheevaluationinterviewdatawasnotsufficientlysaturatedtodrawanyfirmconclusionsaboutthereasonsforthis,but itseemedthattheremaybesomeadditionaluseful lessonsforfutureprogrammeplanners.Particularly, itmaybeof interest to seewhether theway inwhich theprojectwas runandexternal partnerswereidentifiedandapproached,maybeassociatedwiththeleadprofessional/consultanttaskedwith the implementation of the project. There may be lessons about professional status,credibility andexpertise thathavenotbeenuncovered yetbut influencedprojectmanagementandprojectdelivery.There were also some comments about the divided nature of the programme with twoworkstreamsrunning largelysidebyside.Thisclearlyhadsomespillovereffect into theway inwhich the programme was perceived, how it was communicated and how Vanguard staffconstructedtheirnotionofprogrammeownership. Itappearsthatmostgovernanceactivityandmotivationalprocessesbystaffcentredonindividualprojects.Theprojectsappeartohavebeentheengineroomsoftheprogrammeandthesources forprogrammelegitimacy.Thisprefiguredthespace forprogrammeactivitiesaroundthecommunicationstrategyvis-à-vis staffwithin theWaltonCentreaswellstaff inpartnerorganisations. Itmayalsohavepreconditionedthewayinwhichtheprogramme’stransferfromVanguardtobusinessasusualislikelytooccur,withacasebycaseassessmentofsustainabilityofprojects.The fact that individual projects have been the focal point for programme development andprogramme implementation, at the possible expense of overall programme logics, may haveinfluenced theway inwhich staffallegiances to theprogrammewereconstructedand justified.Thismay have impacted on theway in which Vanguard staff communicated and disseminatedknowledge about the programme within the Walton Centre. However, there was insufficientevidencetovalidatethisissuefurther.Akeyfactorofsuccessforanyprogrammeworkingwithpartnerorganisationsisthescope,depthandqualityofthepartnershipsentered.Giventheheterogeneityoftheprogrammewithvariousprojects collaborating with different external partners, it was difficult to distil generalisablemessages that have applicability across all programme components. However, it appears thatprojectmanagement ran up against some issues thatmay have salience for wider programmemanagement.First,itwasnotedthatseveralprojectsstruggledtoengageeffectivelysometypesofpartnersinthe region, in particular GPs. It also transpired that some providers were ultimately not in aposition to follow up on project opportunities that the programme offered or felt unable toproceed for contingent reasons. It may have been useful to assess rigorously the viability of

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potentialpartnerstodeliverpriortoenteringpartnerships.Thisincludedariskassessmentofthepossibilityofstaffchangesinthoseorganisationsandthedependabilityofpartnershipsonspecificstaff.Datasharingisacriticalpartofthepartnershipagreementsanditmayhavebeenbeneficialtopilotdatasharingprocessesaspartofassessingpotentialriskstodelivery.Ultimately,itmaybeuseful to formulate alternative plans, or an exit strategy for individual projects, if certainrequirementswerenotmet.DiscontinuingaprojectwouldhaveofcourseimplicationsforfundingandwouldhavetobejustifiedtoNHSEngland.Itmayhoweverpermitstafftofocusattentionandresourcesonprojectsthatarelikelytosucceedandhavepotentially ahigh impact.Muchdependswith regard toexit strategieson theoverallobjectiveoftheprogramme.IfthepurposeoftheVanguardwastodemonstrateproofofconcept,closingaprojectmaybeunwarranted.However,ifprojectsuccessisbenchmarkedbyevidencingthe effect of a project on patient outcomes, project discontinuation may be a useful way torelocatetightresources.Changingwork practices is a core delivery element of any transformational changeprogrammesuchastheVanguard.Rigorouslyassessingthecapacityandwillingnessofthe leadaswellasofpartnerorganisationstochangeshouldhelpmakingan informedjudgementabouttheabilitytodeliver.This includes examining the potential of the lead organisation to effectively influence externalpartners in making the relevant changes and how to support them in this. It includesconsiderationsabout leverage,capacitytochangeandcapacityto influence.Thisextendsallthewaydownthelistofdeliveryissues,rangingfromorganisationalrelationshipstotheminutiaeofdatasharingandroutinedatacollectionpractices.Therewasafeelingamongstrespondentsthatthe programme operated on the basis of some general assumptions about the ability of theprogrammetoinfluenceotherorganisationsthroughthesheerforceofgoodwill,orbyvirtueoftheprogramme’sgood intentionsandpotentialbenefits topatients. Itmayhavebeenuseful toexplore in more detail weak systemic links in partnerships and possible stumbling blocks forproject delivery. This would entail detailed discussions with operational and strategic staff inpartnerorganisationsaswellaswithintheWaltonCentre.Whilstdifficult,thesediscussionsmayhave resulted in a more realistic assessment about project delivery and, ultimately, to a re-assessmentofsomeprojects’viability.Theinterviewsgeneratedaconsiderableamountofevidenceastothenatureoftheprogramme,therelationshipbetweenthetwoworkstreamsandwhetherornotitwasaprogrammeofchangeor a pilot programme testing the feasibility of different care delivery modes. This linked withsignificantskepticismastowhethertheprogrammewasaunifiedwholeandhowtocommunicateit to awider audience atWalton Centre. It appears thatmost Vanguard projectmanagers haddecidedtopromoteandjustifytheprogrammeonthegroundsofthebenefitsandadvantagesoftheirownspecificprojectwhilstmaintainingthatitfitsintoawiderwhole,improvingpatientcare.Therewere however few activities that actively tried to bind the various projects and the twoworkstreams together above and beyond a belief that governance arrangements, such as theprogramme board, would provide coherence to disparate programme components and ensureeffectivereporting.Thismayhaveledprogrammeleadstounderestimatethepotencyofsharedlearningforstaffacrossprojects.SharinglessonsandexchangeofopinionsacrossVanguardstaffmayhavebeenparticularlyusefulwherespecificprojectsfacedsimilarchallengessuchaspatientinvolvement,engagingpartnersincommunityprovisionormayhavesupportedthedevelopmentofacommonsenseofownershipacrossprogrammestaff.

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Theprogrammewasanticipatedtodeliverchangestoservicedeliverythroughthedevelopmentand testing of a model of care, defined as a satellite or hub and spoke model of acute andcommunityserviceprovision.Respondentsclearlyarticulatedsomedoubtsastotheprogramme’sability to produce robust evidence of patient care improvement within the extremely tighttimetable. This skeptical view is supported by international evidencewhich speaks of a five toeightyearcycleforefficienciestoberealisedinsimilarcontexts.Theissueabouttheprogramme’sabilitytodemonstrateefficienciesorimpactonpatientcarehasimplicationsforthedefinitionoftheprogramme,itspurposeanditsperceptionbystaffandhowtheprogrammeiscommunicatedtoothers.Italsoshapesexpectationsofsuccessorfailure.Demonstratingeffectivenessofprojectsalsorelates to theabilityof theprogrammeto instituterobust data collection procedures, data sharing agreementswith partners and identify suitableindicators reflecting primary and secondary outcome measures. There was a feeling amongstrespondentsthatitwouldhavehelpedifadditionalresourceswouldhavebeenmadeavailabletoensure appropriate metrics were developed and tested prior to programme or projectcommencement. The identification and testing of metrics were perceived by respondents as acriticalfactorfordemonstratingprogrammesuccesstofunders.

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ConclusionTheevaluationcollectedaconsiderableamountofdataonhowkeystakeholdersperceived theprogrammeanditsimplementation.Therewasgenerallyanagreementthattheprogrammehadbeen implemented well and that the programme SRO, programme director and programmemanagerhadprovidedexcellentleadershipthroughouttheprogramme’slifetime.Therewasalsoabroadconsensusamongst interviewees that theprogramme’sgovernancearrangementswerebyandlargeappropriateandworkedwell.Overall,respondentsthoughtthattheprogrammeprovidedaresponsiveandsufficientlyflexibleframeworkforarangeofdiverseprojectswhichallowedprogrammestafftoimplementindividualprogrammecomponentsaccommodatinglocalcircumstancesandcontingentconditions.TherewasalsostrongagreementamongstrespondentsthattheINNSprojectwasthemostlikelyprogramme component to generate robust evidence of positive impact on patient care andpossiblyrealiseefficiencies.Forotherprojects,whilsttherewasconfidencethattheprogrammedemonstratedthefeasibilityofmostprojects,therewasaviewthattheprogrammedurationwastooshorttoallowpotentialimpacttomaterialiseortoberigorouslyevidenced.Respondents however were unanimous in thinking that the programme had enhanced thereputationandstandingoftheleadorganisation,theWaltonCentre,andimprovedimmeasurablyitsrelationshipswithotherprovidersintheregion.The programme also encountered some significant challenges which were clearly identified byinterviewrespondents.Engagementwithsomepartnersandpartnerorganisationsproveddifficultat times and may have impacted on the delivery of some projects, leading to a realisticreassessment of the programme’s aspirations. General practitioners and some hospitaldepartments (in other providers) proved problematic to involve, which echoes similar pastexperiencesoforganisationalchangeprogrammesintheliterature.There was also a sense amongst respondents that the programme itself found it difficult toarticulateacoherentvisionofaunifiedprogrammeandtocommunicatethiseffectivelytostaffinsidetheleadorganisationaswellastoexternalpartners.Thisreflectedalackofsharedlearningopportunities across programme components as well as the general view for interviewedmembersofstaffthatthe individualprojectsweretheengineroomsoftheprogrammeandtheoriginalsourcesforprogrammelegitimacyandfocusofstaffmotivationandallegiance.Thismayhaveinfluencedthewayinwhichsustainabilityprocesseswereconceivedbyprojectstaffaswellastheprogrammeleadership,furtherfracturingprogrammeplanstoestablishedbusinessasusualpracticesonacasebycasebasisforindividualprojects.Whilstthisrepresentsthemostsensibleway forward under the circumstances, it may reflect modified expectations about thesustainabilityoftheprogrammeasawhole.

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LimitationsoftheevaluationDuetoitsshortdeliverytimelinetheevaluationusedonlyprojectdocumentsandinterviewswithkey stakeholders to generate evidence to answer the evaluation questions. There are severallimitationsthatresultfromthis.Firstly,therecruitmentprocessrestrictedtheevaluationteamtothosekeystakeholderswhichwereactivelyinvolvedandpositivelyengagedwiththeprogramme.Thismayhaveledtoundueemphasisintheopinionsofthosewhowerecloselyinvolvedwiththeprogramme,andproducedanunduerelianceontheirviewsattheexpenseofotherstaffwhohadlessintensiveinvolvementandwhomayhaveprovidedadifferentperspective.Thetighttimetablefordeliveryalsomeantthattheevaluationteamwasnotabletoapplyamorestructuredframeworkwhenanalysingthedata.Inparticular,theuseofRE-AIMoraprogrammematrixapproachmayhavebeenusefultodistilmoregeneralisablelessonsforfutureprogrammeleaders.Lastly,theevaluationwasnotabletobuildupapictureofbeforeandafteroftheimplementationprocess through conducting interviews at the start of the implementation process to chart thedevelopment and change in stakeholder views over time. Programme implementations aredynamic processes which snapshot evaluations struggle to capture adequately. We tried tomitigate this risk by conducting an initial documentary analysis which provided us with someinformationanddataontheoriginalplansandaspirationsoftheprogramme.

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EvidenceTableSection Domain Theme Evidence/Quotes

Imple-mentation

Generaldifficulties

StaffturnoverCompetingprioritiesSharedworkforce(secondments)

‘Therewereacoupleofprojectsthatlaggedbehindalittlebitintermsoftheirimplementationbutthatwaspredominantlystaffingissuesandagain,whenyou’redeliveringaservicethat’squiteaspecialistserviceandyou’vegotstaffsicknessetc.,partofthatisobviouslyoutsideoftheproject’scontrol’‘IttookusawhiletogettoknowwhotogettointheCCGs,becausetheyhavegotverystrangejobroles,titles.Andyouareneverquitesureandtheydon’treallystayaroundtoolong,soyouthinkyouhavemadeacontactandthenyouhavetodoitagain.’‘Idothinktherewasleadership,butIthinktherewastoomanycompetingpriorities.’‘Yourheadspaceneedstobeverydifferent[fortheVanguard]andsometimesyouwerepulledbetweenthetwoandthatcauseddifficulties’‘It’sbeendifficulttofindabalanceintermsofthechallengesinbalancingyourdayjobwithbeingpartofvanguard,thatproveddifficultattimes.’

Spinalnetworkchallenges

‘theyhaddecidedthattherewouldbetwoHubsinCheshireandMerseyside,whichwouldbetheWaltonCentreandthe[hospital],whichmeantthatengagementwiththe[hospital]waskindofnullandvoidbecausetheyconsideredthemselvestheirownHub’‘AtfirstweweregoingtouseSpineTango,butagain,becauseoftheGettingitRightFirstTimeproject,theywentwiththeBritishSpineRegistry,becausethatiswhatGIRFTwerepromoting’

Governanceissues ‘Ithinkbecausethebackpainpathwaydidn'thavearecognisedprojectgroup,madethemobilisationquitedifficultandfairlylooseinitsgovernance’‘Ithinktherewasarecognitionastheprojectwentonthatpotentiallysomeoftheoutcomesandsomeofthedeliverablesarenowstartingtohappenquitelateonintheprojectandmaybesomeofthatplanningphaseandsomeoftheearlywork,wereallyneededtounderstandsomeoftheintelligenceandsomeofthefinanceandsomeofthebackgroundinformationinalittlebitmoredetail’Thereweretwoworkstreammanagers,theprogrammemanagerandhersupport,there

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weretwoofthose,therewasonebefore[name3].Ithinktherewereanumberofprojectmanagerswithintheteam,whichmeantthatIdidn’tknowwhowasworkingonwhat.‘[It’s]againdowntopersonalities,youhadsomeoftheProjectManagers:ohIdon’tlikethatworkstreammanager,socanIreportdirectlytotheDirectorandthatwasagreed.’‘Ithinktheprogramme/projectcouldhavebeenbetterembeddedintotheDivisions.’‘Ithavebeenmorebeneficialtohavejustonepersonoutofthedivisionsupportingthevanguardlinktotheotherpotentially’‘Whenyoubringinserviceimprovementteams,thattheysitseparatetothedepartment,peoplethingsarebeingdonetothem.Idon’tthinkthatpeoplefeltlikethisherebutjustgenerally,ifyouwanttodochange,doitfromthepeople,doitwiththepeopleintheteam,goabitnativeifyouwill.’

Partnershipsandrelationshipswithotherproviders

‘GPsweremuchhardertoengageonwiththis,much,muchharder,veryhardtogetappointments,veryhardtogettoseetherightpeople,othersmucheasier.AndwhenitwasaquestionofhowtogetitouttotheGPs,Iwasstruckbyhowtheredidn’tseemtobeanyclearwayofdoingthat.’‘IthinkGP’srequirementto,kindof,learningandteachingopportunitieshavedeclinedsignificantly,soIreckonthatengagementandgettingthatopportunitytospeaktothemdirectlytopromotetheConsultantAdviceLinehasbeenextremelydifficult.’‘[Patients]couldusefullyhavethatinformationabouttheconsultantadvicelinetopasstotheGPwhentheyweremeetingwiththeirGP,andsay,wellifyouarenotsurewhattodoringthisnumber.’‘TherewasalotofworkincontactingtheclinicalleadsforA&EandwhatwecallMAU,MedicalAdmissionUnits,ineachhospital.Notalwayseasytofindoutwhothesepeopleare,thencontactthemandthensaycanIcomealongandtalktoyouaboutthis.’‘IthinktheinfluenceonClinicalCommissioningGroupshasbeenfantastic’

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Influencingmedicalpractice ‘Alotofthesedepartments,indeedallofthem,believedtheywerealreadydoingthis;butitwasabsolutelyclearfromtheauditsthattheyweren’t.Sowewereactuallyabletoshowthemthefiguresfromtheirowndepartmentandsayactuallyyouarenotdoingthis,becauseofthepeoplecomingtoyourhospitalwithaseizure,only30%ofthemareappearinginneurologyclinicssubsequently.Tosomeextent,therewasadisconnectbetweenwhattheybelievedtheyweredoingandwhatwasactuallyhappening.’‘Sowetalkedabouttheprogrammes[toothers],butitwasverymuchabout,ohthatdoesn’treallyinvolveus,sothereforewearenotreallyinterested.

Coherenceofprogrammecomponents

‘Ithinkfrommyperspective,boththeneurologyelementandthespinalwhereobviously2verydistinctiveprojects’‘There’sbeenarecognitionthatthere’snota,kindof,onesizefitsallintermsofwhatamodelofcareforaparticularsystemmayactuallylooklike.’‘Ididn’tfeelitwasgelledverywellbetweenthetwoworkstreams.Theywereworkingquiteinasilo,whichIfoundquitedifficult.’‘IthinktheNurseAdviceLineandtheINNSprojecthaveworkedquitecloselytogether,justbecausereallywehavetheNurseAdviceLine,sothey'vehadtolink,really.’

Enablers Strongprogrammeobjective ‘Therewasalotofcommunicationthathappenedinternally,…theteamworkedreallyhardtogetouttopeople.’‘Externally,thesupport,theengagement,thesuccessoftheprogrammeislookeduponvery,verypositively.’

Barriers WaltonCentre–leadorganisationCompetingprioritieswithinWC

‘Theonlything,…,callingitthevanguardproject,createsalittleseparationfromitbeingtheneurologyservice.’ButIfeltthatweweren’tlookeduponasapriority[withinWaltonCentre].‘You’vegottoengagewiththosesub-specialities,whetheritbethenursesortheconsultants,you’vegottogetthatelementrightandIdon’tnecessarilythinkthatwedidatthebeginning.’

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SeasonalprioritiesWC(winterpressures)

‘So,forexample,fromSeptembertoMarchyouarenotreallygoingtogetpeoplecomingandsittingroundforatwo/threehourmeetingbecauseobviouslytherearecompetingprioritiesforthemselves.’

Fidelity Telemedicineproject ‘Theconsultantbodywouldbeabletodothesevirtualconsultationswithintheexistingscopeiftheon-callworkpatternsandtheyreallycouldn’t.Todothesevirtualtele-medclinics…wouldneedtobethecreationofaseparateclinicjustforthat’‘[what]hasprovedmostchallenging,istheintroductionoftelemedicine,doingvirtualconsultationsforneurologyandthathasbeendifficultonanumberofgrounds,someofitcultural’

Patientconsultation

Patientconsultationexcellent

‘Itwasbeingbuiltaroundpatientexperience,becauseitwasabouttakingtheservicesoutclosertohome.’‘Wedidn’tdoany[patientconsultation]workbeforethepathwaysstartedlookingatpatientviewpointsofthispathway.…[we]didalotofworkingettingpatientfeedbackandpatientinvolvement[though].‘We'vegonetopatientgroupsandsortofliketohearthemtalkabouttheservice,andtheoverwhelmingpositivitythathadcomefromthepatientsisabsolutelyamazing.’‘Itdefinitelyaddressedsomeofthemorenegativepatientexperiencepeoplehave,particularlyaroundtravel,andstufflikethat,butitisthatfocusonthemedicalmodelreally,whereithasmissedit.‘Becauseofthetimeframeofhavingtobidforthefunding,becauseIthinkwehadawindowofopportunityofabouttwoweeks,wedidn’tactuallydoanyconsultationwiththepatientsatthattime[ofdesigningtheprogramme].’‘Fromaperspectiveofthepeoplewhousetheservices,[theVanguardis]verymedicallyfocused.’

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Impact Professionals/staff Changecapacityandagency ‘Ididthinkunderestimatechangewithindividualsandthatcomparatoryworktogetpeopleonboard,getsomechampions,gettingpeopletoseethevalueofwhat’sinitforthem,thatcouldhavemadethingseasier’‘Youknow,soIthink…everybody’slookingtoimproveandmoveforwardsandworkinamoreeffectiveway,…andit’showthoseindividualsreacttothatchangeandwhatthatchangeis,andhowiteffectsthempersonallyintermsoftheirpractice.’‘ThethingthatstruckmeaboutitthatIlearnedfromtheexperience,washowharditistomakeverysimplechangesthatareselfevidentlynecessary.Imeanthesewereverysimplethings…These…wereveryeasy,simplechangesthatnobodycouldarguewithclinically,andyetitwasterriblyhard.’‘[Staff]don’treallystayaroundtoolong,soyouthinkyouhavemadeacontactandthenyouhavetodoitagain.’

Patients INNSserviceexampleofimprovingcarequality

‘Nowthatwe’vegot[theINNS]outthere,wecanseethebenefits.’Forthepatientsbeingtreatedclosertohomeandwidenourgeographicalareasothatwecandothishasbeenapositivethingandhasbeenreallygood.’

System ReputationalgainforWaltonCentrePartnershipsdeveloped

‘Ithashelpedboostitspositionintheregionaswell,asakeypartner.’‘WewereabitofanunknownentitytoourCCGcolleaguesandtosomeextenttoouracuteproviders.Soweneededtodevelopthoserelationshipsandgetthemtoknowus.’‘Ithinkithadsomepositiveeffectsuponthatsystem.AndIwouldsaythebiggestonefrommyperspectiveistheimpactontheClinicalCommissioningGroups,notallofthemengagedbutallofthemrecognisedthatyouknowitisanimportantareatowork.’

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ServiceOutcomes DifficultytogaugeprogrammeimpactDifferentialimpactonpartnersDifficultytomeasureoutcomes

‘We’venotaffectedanyofthedemandassumptionsforanyofthevanguardsbecauseatthispointintimewedon’tknow,someofthemwehaveandsomeofthemwedon’t.[…we]willpickupsomeoftheimpactbutmaybenotthefull12montheffect.’‘DifferentCCGshavedifferentpriorities,soIthinkthere'savarietyofengagements,andsomeCCGshavegainedmorethanothers,anditdependedon,asIsay,theirinternalpriorities,theirknowledgeandunderstandingofwhattheprogrammewasabout,theirbaselineposition,soiftheyhadalottogainandtheycouldseethesolutionwascomingfromthevanguard,clearlytheyweremoreengagedthanothers.’‘IthinkwearestillchewingoverthefiguresonthemetricsandIthinkitremainstobeseen whetherwearegoingtoshiftpracticeonthis,ornot.I’mslightlyworriedthatwemightnot,butIjustdon’tthinkweknowtheoutcomeyet.’‘I’vealwaysstruggledtofullyunderstandwhatthefinancialimpactofallofthisworkhasbeen.’‘TherewassupposedtobeanInformationManagerwithinarole.Theycouldn’trecruitforthatanditdidmeanthatalotofthatwasdelayed.’

Sustainability Assessedprojectbyproject

‘We’verealisedsomeofthosebenefitsquitelateonintheprojectandIthinkinhindsightsomeofthatprobablycouldhavebeendeliveredinalittlebitmoretimelyway.’‘Ifeelthatbyallowingchoiceaboutwhetheryouadapt[aproject]ornotcreatesinconsistenciesintheoverallendresult.Forthepatients,forme,itcreatesaninequitableserviceandIthinkoneofthekeydriverswasinsuringthatpatientshadanequalchanceofthesameexcellentstandards.…Iwouldn’tadvocatethepickandmixoption,Idon’tthinkthatthatwouldbeoptimal.’

Evaluation Experienceandexpertise

‘The[evaluationis]onlyactuallyproducingtheinformationthroughcontractanalystsnow,whichhashadabigimpactonwhattheyhavebeenabletoevaluateandidentifytofindthoseproblems.’So,again,therearelessonslearntaboutwhatskillbaseyouwantthere[whenevaluatingaprogramme].…AndIthinkthatisaboutbeingveryclearinthefutureaboutwhatyouwant.

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Attributabilityofeffects

But…whenwestartedthisprogrammeitwassomethingwehadneverdonebefore.‘LikeIsaidaboutspinalsurgerystoppingandnewNICEspinalguidelinescameoutwhichthenstoppedinjectionsinsecondarycare.SothatyoucannotattributethechangejusttotheVanguardandthatwouldbedifficult.YougotaninstructionfromNICEsayingdonotdospinalinjectionsinsecondarycaresoeveryonewasbannedfromdoingthem.Now,youcouldsaythatisaresultoftheVanguard,ifyoulookattheinjectiondrop,itcouldbenothingtodowithit,itcouldjustbeimplementationofNICEguidelines’

Contextdependability

ReplicabilityandSpecificity

Interestbyotherproviders,butWCisunique

‘IthinkthechallengeistheWC[hospital]hasquiteauniqueset-upthere,oneofEngland’sonlyneurosciencecentresanditdoesn’thavetocompetewithotherserviceprioritieswithinthathospital,itdoesn’thaveanA&E,itdoesn’thaveproblemsin.WhenothercolleaguesarelookingattheWC[hospital]tryingtothinkabouthowthatcouldbereplicatedwithintheirstructures,itdoesn’talwayslenditselftosomethingthatcanwork’

Lessons Sharedlearning Nosharedlearningacrossprojects–nostructureputinplace

‘Ididthinkthatmaybeifwehadhadcloserrelationshipsbetweentheprojectthemselvesandtheworkstreams,wecouldhavelearntfromoneanother,and,youknowsomebodymighthavehadacontact,orawayofgoingaboutthings.So,withintheneurologybasedworkstreams,somebodytheremighthavehadacontactintheRoyal,ormighthavehadanapproachthatworkedpreviously.Butbecauseweallworkedinsilosthatdidn’tseemtohappen.’‘Isuppose,astheprogramme'sgoneon,therehasn'tbeenacentralrepositoryoralibraryor,yeah,anythinglikethatthatwouldfacilitatethatlearning.’

Lessonsforprogrammedesigners

Programmevision–programmediversity

‘Soitlookedlike[thetwoworkstreams]wouldworkextremelywell,andIthinkifitwasgivenmoretimeitwouldhaveembeddedwell,butstraightawayjoiningtheteam,itwasobvioustherewasgoingtobeproblemswithinthatstructure.’‘Ithinkwherewehaven’tworkedquitesowell,islinkingininternallyandwhatworkingoutwould itwouldmeanimpactwisefortheinternaldivisions.’‘Itwaspushedthroughalittlebitquicklybecauseofthefactthatwasmoneythathadtobeutilised.’

Lessonsforimplementation

WorkingrelationshipsInternalcommunication–depth

‘Youknowabi-weeklycatchupdoesn’tnecessarilypromotestrongworkingrelationships,theyhavetobebuiltupovertime.AndonewayofdoingitIthinkwouldhavebeentohavehadusallsatinaroomtogether,working’

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andscope ‘Ithinkwecouldhavedoneabetterinternalcommunicationplan.Andperhapsre-enforcedourmessagesmoreassertively.’

LessonsforNHSEngland

Expertise,trainingandsharedlearningopportunities

‘[NHSEngland]lackedtheknowledgebaseortheabilitytobeabletosupportusaroundsustainabilityorreplicability.Itwasoneofthekeycomponentsoftheprogramme,buttheyactuallydidn’tknowhowtodoit.’‘Itwaspushedthroughalittlebitquicklybecauseofthefactthatwasmoneythathadtobeutilised.’