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Additional file 1. Box 1. Patient and Public Perception Survey Responses

Context: The long-term sustainability of whole-system change programs is rarely studied, and when it is, it is inevitably undertaken in a shifting context, thereby raising epistemological and methodological questions. This article describes a transferable methodology that was developed to guide the evaluation of a three-year follow-up of a large health care change program in London, which took place during a period of economic turbulence and rapid policy change. Method: Using a mixed-method organizational case study design, we studied three services (stroke, kidney, and sexual health) across primary and secondary care. Each had received £5 million (US$7.8 million) in modernization funding in 2004. In 2010/2011, we gathered data on the services and compared them with data from 2004 to 2008. The new data set contained quantitative statistics (access, process, and outcome metrics), qualitative interviews with staff and patients, documents, and field notes. Our data analysis was informed by two complementary models of sustainability: intervention-focused (guided by the question, What, if anything, of the original program has been sustained?) and system-dynamic (guided by the question, How and why did change unfold as it did in this complex system?). Findings: Some but not all services introduced in the original transformation effort of 2004–2008 were still running; others had ceased or been altered substantially to accommodate contextual changes (e.g., in case mix, commissioning priorities, or national policies). Key cultural changes (e.g., quality improvement, patient centeredness) largely persisted, and innovative ideas and practices had spread elsewhere. To draw causal links between the original program and current activities and outcomes, it was necessary to weave a narrative thread with multiple intervening influences. In particular, against a background of continuous change in the local health system, the sustainability of the original vision and capacity for quality improvement was strongly influenced by (1) stakeholders’ conflicting and changing interpretations of the targeted health need; (2) changes in how the quality cycle was implemented and monitored; and (3) conflicts in stakeholders’ values and what each stood to gain or lose. Conclusions: The sustainability of whole-system change embodies a tension between the persistence of past practice and the adaptation to a changing context. Although the intervention-focused question, What has persisted from the original program? (addressed via a conventional logic model), may be appropriate, evaluators should qualify their findings by also considering the system-dynamic question, What has changed, and why? (addressed by producing a meaningful narrative).

Clinical leadership and engagement across organisational boundaries has been gaining significant attention over the last few years. Within the NHS, there has been an increased focus within policy directives and the literature on partnership working, collaborations, cross-organisational and cross-professional working. These innovative ways of working are seen as a means of improving the quality and co-ordination of patient care across the pathway, thus impacting on the patients‟ experience. Despite this focus, the evidence of what constitutes and therefore what can deliver effective inter-organisational clinical leadership and engagement within this context is sparse. This study identifies the characteristics and impact of effective clinical leadership, clinical engagement and team effectiveness when working across organisational boundaries. „Practical Recommendations‟ have been developed as a mechanism to disseminate the findings. This research is based in the real world, which is complex and messy. The study uses an interpretative stance and gains insights from a number of different perspectives. The methodological approach is action research with a single case study design. Both quantitative and qualitative data are used and these are collected through a team effectiveness tool, focus groups and semi-structured interviews.\ud The study demonstrates there are significant improvements in the delivery of healthcare and patient experience when clinicians work effectively across the whole patient pathway, spanning organisational boundaries. The study findings are: the need for a focus or forum and for clinicians to have the time and space to initiate inter-organisational working; the power of the patient‟s voice, involvement and leadership in delivering impactful change; the need to understand organisational and personal barriers and risks to inter-organisational working; the\ud requirement to align incentives and accountability; the need for the NHS to value service improvement approaches as well as randomised controlled trials; the necessity for clinicians to have managerial and leadership skills to effectively run inter-organisational projects; and, the necessity for senior management and corporate engagement. These findings are supported by the existing literature, whilst also contributing to knowledge and understanding. The study aligns with the current direction of increased inter-organisational working within the NHS, and illustrates the benefits of working in this way. It demonstrates the fundamental role of clinicians (especially doctors) and patients when using this approach. The „Practical Recommendations‟ offer clinicians and managers an opportunity to consider the key elements that determine the success of improvement initiatives spanning a whole pathway or health system. Additionally, this study raises several new research questions and highlights some key recommendations such as: the need to agree the level at which NHS organisations can support inter-organisational working whilst remaining financially and competitively viable; the requirement urgently to review and revise training for doctors to ensure that in the future it equips them for effective participation in inter-organisational working; and the need to ensure the patient voice is focussed on enhancing quality of life through improvements in healthcare, rather than just simple redesign projects.