Six examples of large-scale transformation and what we can learn from them

Our new report, written jointly with The King’s Fund, calls for a dedicated Transformation Fund to oversee and be accountable for essential changes to NHS services. Making change possible: a Transformation Fund for the NHS draws on the experience of funding other transformations in the health sector and beyond.

The report includes six detailed case studies of UK and international examples of transformation, which provide invaluable learning about the process of transformation and where improvements can be made. The case studies and learning points are summarised below.

Six examples of large-scale transformation funds

*Costs in brackets show 2015/16 prices

1. Deinstitutionalisation in UK mental health services: Since the mid-1980s, mental health services have been radically transformed. A process of large-scale ‘deinstitutionalisation’ saw a shift in care and support for people with mental health problems from psychiatric institutions to community-based settings. In the UK, this resulted in the closure of all institutions, where approximately 100,000 people had lived. 
   Total cost: Not available / Cost per head per year: Not available
    
2. The National Service Framework for Mental Health in England: In the early 2000s, community mental health services in England underwent a national programme of development that was central to a 10-year plan to improve the outcomes and experiences of people with mental health problems. The programme resulted from public and media pressure to reform community care provision following a series of high-profile adverse events involving people with mental illness. 
   Total cost: £700m (978m) / Cost per head per year: Not available
    
3. Canada’s Primary Health Care Transition Fund: This CAD800m fund ran from 2000 to 2006, providing transitional costs to support the transformation of Canada’s primary health care system. Primary health care in Canada is publicly funded and mostly free at the point of use. Transformation in primary care was deemed a priority after public and political concerns over quality and access. 
   Total cost: £360m (503m) / Cost per head per year: £1.95 (2.73)
    
4. Denmark’s hospital transformation Quality Fund: In 2007 the Danish government introduced a national Quality Fund of DKK42.7bn (£5.9bn) to build new hospitals over a 10-year period. These would form the basis of a new infrastructure for health and care delivery. The Quality Fund operates as part of a wider set of reforms to health and local government structure implemented in 2007.
   Total cost: £5.3bn (5.9bn) / Cost per head per year: £96 (107)
    
5. The London Challenge: The London Challenge was established in 2003 to improve the quality of education and outcomes in secondary schools in London. It emerged in response to the limited progress being made in London towards meeting government commitments to education, despite a number of national initiatives and policies. Central government ran the Challenge from the Prime Minister’s Office and the Department for Education and Skills (DfES).
   Total cost: £80m (105m) / Cost per head per year: £22 (28)
    
6. Girls’ Education Challenge (GEC) Fund: This £354m fund was set up by the Department for International Development (DFID) in 2013 and runs for six years. It aims to help up to a million of the world’s poorest girls improve their lives through education.
   Total cost: £344m (354m) / Cost per head per year: £86 (88)

What do these case studies tell us about how to manage transformation

1. Ensure clear and coherent objectives for how funds are allocated: Be clear about the objective of transformation itself in addition to the objective of the funding.
    
2. Engage stakeholders in transformation: Engage with the public, patients, and staff, build a dialogue about the process of change, and actively address concerns as a means of facilitating transformation. 
    
3. Effective leadership is vital: Good local leadership is conducive to the bottom-up development of transformation plans and seeing them through to implementation, while strong national leadership is important to set and maintain direction.
    
4. Base plans on an established evidence base: Evidence should inform, where possible, decisions about what to implement as well as how to do it. A stepped approach to the requirement for evidence can be built into funding allocation. 
    
5. Balance implementation, innovation and risk: Innovation is essential to develop new solutions to existing problems and deliver cost efficiency, so there must be space for failure and risk taking. The GEC Fund provides a good example of this.
    
6. Set funding in line with the scale of transformation expected: In cases of major service transformation, it was common for costs to be underestimated. While mechanisms for releasing funding (including sale of estate, improvements in cost efficiency and reduced service use) were often core components of the original cost estimates, in practice, they largely failed to materialis.
    
7. Funding allocation must be sustainable and flexible: Funding should take into account longer term running costs of new provision (including double-running costs while establishing new services) and allow different streams of funding for different purposes. The ability to ring-fence transformation funding is also important.
    
8. Plan for the workforce implications of transformation itself: Projects must allow front-line staff to be released from their day-to-day roles in order to contribute to transformation, while also actively engaging with people to encourage their support for change.
    
9. Investment in learning and evaluation is essential: Several case studies failed to ensure appropriate evaluation and effectively disseminate learning, leaving new approaches open to criticism. The London Challenge and the GEC Fund demonstrate how learning and evaluation can be built into fund infrastructure. 
    
10.  Ensure accountability in management of transformation and funding allocation: A range of mechanisms have been used to improve accountability, including asking for matched funding, using milestones, basing accountability on peer-to-peer support and outcomes data, and setting up independent organisations to manage funding and the transformation process.
     
11.  Be realistic about timescales: It takes ‘longer than you think’ to achieve transformation. All four of our health care case studies exhibited delays beyond their original plans. 
     
12.  Choose wisely between national or local administration: Providing appropriate expertise and support will ensure that projects are capable of delivering and are sustainable. National guidance can support progress, especially where transformation impinges on areas under the remit of national bodies.
     
13. There are always unknown and unintended consequences of transformation: Strong evaluation helps, but extra resources are often needed to respond to emerging evidence. The value of establishing dedicated leadership and organisational support, such as was achieved as part of the NSF-MH and London Challenge, should not be underestimated.

Find out more

The case studies and learning points are described in further detail in chapter 3 of the report. Full length case studies are published in Appendix 1: Case studies of large-scale transformation. Download Making change possible: a Transformation Fund for the NHS.