“Attending to History” in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration

Document Type : Original Article


1 Applied Research Collaboration Greater Manchester, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK

2 Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK

3 Alliance Manchester Business School, University of Manchester, Manchester, UK

4 Department of Applied Health Research, University College London (UCL), London, UK

5 UCL Research Department of Primary Care and Population Health, University College London (UCL), London, UK

6 Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK

7 Christie NHS Foundation Trust, Manchester, UK

8 Institute of Cancer Sciences, Manchester Academic Health Science Centre (MAHSC), Manchester, UK

9 Department of Targeted Intervention, University College London (UCL), London, UK


The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change (MSC) for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric (OG) cancer surgery services in a large urban area of England (Greater Manchester, GM), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts.

This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in GM. Forty-six interviews with relevant stakeholders were carried out, along with ~160 hours of observations at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of ‘simple rules’ for MSC.

Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge.

Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about MSC and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.



Commentaries Published on this Paper

  •  The Role of the Policy Process on Health Service Reconfigurations: Evidence, Path Dependency and Framing; Comment on “‘Attending to History’ in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration”

        Abstract | PDF


  • “Attending to Collaboration” in Major System Change in Healthcare in England: A Response; Comment on “‘Attending to History’ in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration”

        Abstract | PDF


  • Beyond Received Wisdom and Authorised Accounts: What Knowledge Is Needed to Avoid Repeating History?; Comment on “‘Attending to History’ in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration”

        Abstract | PDF


  • A Gateway Framework to Guide Major Health System Changes; Comment on “‘Attending to History’ in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration”

        Abstract | PDF



  • epublished Author Accepted Version: February 21, 2022
  • epublished Final Version: March 14, 2022
  1. Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Large-system transformation in health care: a realist review. Milbank Q. 2012;90(3):421-456. doi:1111/j.1468-0009.2012.00670.x
  2. Imison C, Sonola L, Honeyman M, Ross S. The Reconfiguration of Clinical Services: What is the Evidence? London: King's Fund; 2014.
  3. Fraser A, Stewart E, Jones L. Editorial: the importance of sociological approaches to the study of service change in health care. Sociol Health Illn. 2019;41(7):1215-1220. doi:1111/1467-9566.12942
  4. Suddaby R, Foster WM. History and organizational change. J Manage. 2017;43(1):19-38. doi:1177/0149206316675031
  5. Wilsford D. Path dependency, or why history makes it difficult but not impossible to reform health care systems in a big way. J Public Policy. 1994;14(3):251-283. doi:1017/s0143814x00007285
  6. Harrison MI, Kimani J. Building capacity for a transformation initiative: system redesign at Denver Health. Health Care Manage Rev. 2009;34(1):42-53. doi:1097/01.HMR.0000342979.91931.d9
  7. Best A, Saul J, Carroll S, et al. Knowledge and Action for System Transformation (KAST): A Systematic Realist Review and Evidence Synthesis of the Role of Government Policy in Coordinating Large System Transformation. Vancouver: Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute; 2010.
  8. Fulop NJ, Ramsay AI, Vindrola-Padros C, et al. Reorganising specialist cancer surgery for the twenty-first century: a mixed methods evaluation (RESPECT-21). Implement Sci. 2016;11(1):155. doi:1186/s13012-016-0520-5
  9. May CR, Johnson M, Finch T. Implementation, context and complexity. Implement Sci. 2016;11(1):141. doi:1186/s13012-016-0506-3
  10. Nasmith L, Ballem P, Baxter R, et al. Transforming Care for Canadians with Chronic Health Conditions: Put People First, Expect the Best, Manage for Results. Ottawa, ON: Canadian Academy of Health Sciences; 2010.
  11. Turner S, Ramsay A, Perry C, et al. Lessons for major system change: centralization of stroke services in two metropolitan areas of England. J Health Serv Res Policy. 2016;21(3):156-165. doi:1177/1355819615626189
  12. Vindrola-Padros C, Ramsay AI, Perry C, et al. Implementing major system change in specialist cancer surgery: the role of provider networks. J Health Serv Res Policy. 2021;26(1):4-11. doi:1177/1355819620926553
  13. Calman K, Hine D. A Policy Framework for Commissioning Cancer Services: A Report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. London: Department of Health; 1995.
  14. Department of Health. Improving Outcomes in Upper Gastro-Intestinal Cancers. London: Department of Health; 2001.
  15. Coupland VH, Lagergren J, Lüchtenborg M, et al. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004-2008. Gut. 2013;62(7):961-966. doi:1136/gutjnl-2012-303008
  16. Mason J. Overview of the Transformation Process for the Commissioning of Specialised OG and Urology Cancer in Greater Manchester. Manchester: Greater Manchester Combined Authority/NHS Greater Manchester; 2016. https://democracy.greatermanchester-ca.gov.uk/olddocuments/07_transformation_processes_for_the_commissioning_
    for_the_commissioning_of_specialised_cancer_services.pdf&MId=2107&D=20160713&A=1&R=0#search=%22Project%20Initiation%20 Document%20for%20Specialised%20Commissioning%20of%20 U r o l o g y % 2 0 O e s o p h a g o - G a s t r i c % 2 0 C a n c e r % 2 0 S u r g i c a l % 2 0 Services%22
  17. Britten N. Qualitative interviews in medical research. BMJ. 1995;311(6999):251-253. doi:1136/bmj.311.6999.251
  18. Gibbs G. Analyzing Qualitative Data. London: SAGE Publications; 2007.
  19. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758-1772. doi:1111/j.1475-6773.2006.00684.x
  20. Walshe K, Lorne C, Coleman A, McDonald R, Turner A. Devolving Health and Social Care: Learning from Greater Manchester. Manchester: The University of Manchester; 2018.
  21. Greater Manchester Combined Authority (GMCA). Taking Charge of Our Health and Social Care in Greater Manchester. Manchester: GMCA; 2015.
  22. Best A, Saul J. Complexity and Lessons Learned from the Health Sector for Country System Strengthening. Background Paper for the USAID Experience Summit on Strengthening Country Systems. United States Agency for International Development (USAID); 2012.
  23. Addicott R, Ferlie E. Understanding power relationships in health care networks. J Health Organ Manag. 2007;21(4-5):393-405. doi:1108/14777260710778925
  24. Fraser A, Baeza JI, Boaz A. 'Holding the line': a qualitative study of the role of evidence in early phase decision-making in the reconfiguration of stroke services in London. Health Res Policy Syst. 2017;15(1):45. doi:1186/s12961-017-0207-7
  25. Jones L, Exworthy M. Framing in policy processes: a case study from hospital planning in the National Health Service in England. Soc Sci Med. 2015;124:196-204. doi:1016/j.socscimed.2014.11.046
  26. Jones L, Fraser A, Stewart E. Exploring the neglected and hidden dimensions of large-scale healthcare change. Sociol Health Illn. 2019;41(7):1221-1235. doi:1111/1467-9566.12923
  27. Turner S, D´Lima D, Sheringham J, et al. Evidence use as sociomaterial practice? A qualitative study of decision-making on introducing service innovations in health care. Public Manag Rev. 2021:1-25. doi:1080/14719037.2021.1883098
  28. Lorne C, McDonald R, Walshe K, Coleman A. Regional assemblage and the spatial reorganisation of health and care: the case of devolution in Greater Manchester, England. Sociol Health Illn. 2019;41(7):1236-1250. doi:1111/1467-9566.12867
Volume 11, Issue 12
December 2022
Pages 2829-2841
  • Receive Date: 21 May 2021
  • Revise Date: 16 February 2022
  • Accept Date: 19 February 2022
  • First Publish Date: 21 February 2022