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”

Document Type : Commentary


1 University of New South Wales, Sydney, NSW, Australia

2 Western Sydney Local Health District, Sydney, NSW, Australia


Recent events – on both a global scale and within individual countries – including the lockdowns associated with COVID-19 pandemic, inflation concerns, and political tensions, have increased pressure to reconfigure social services for ongoing sustainability. Healthcare services across the world are undergoing major system change (MSC). Given the complexity and different contextual drivers across healthcare systems, there is a need to use a variety of perspectives to improve our understanding of the processes for MSC. To expand the knowledge base and develop strategies for MSC requires analysing change projects from different perspectives to distil the elements that drove the success. We offer the Gateway Framework as a collaborative transformational system tool to assess and reorganise operations, services, and systems of healthcare organisations. This framework and guiding questions, accounts for past events whilst being proactive, future orientated, and derived from externally defined and a standardised requirements to promote safe, high-quality care.


  1. Nimako K, Kruk ME. Seizing the moment to rethink health systems. Lancet Glob Health. 2021;9(12):e1758-e1762. doi:1016/s2214-109x(21)00356-9
  2. Schiavone F, Ferretti M. The FutureS of healthcare. Futures. 2021;134:102849. doi:1016/j.futures.2021.102849
  3. Kielmann K, Hutchinson E, MacGregor H. Health systems performance or performing health systems? Anthropological engagement with health systems research. Soc Sci Med. 2022;300:114838. doi:1016/j.socscimed.2022.114838
  4. Eljiz K, Greenfield D, Derrett A, Radmore S. Health system redesign: changing thoughts, values, and behaviours for the co-production of a safety culture. Int J Health Plann Manage. 2019;34(4):1477-1484. doi:1002/hpm.2798
  5. Perry C, Boaden RJ, Black GB, et al. "Attending to history" in major system change in healthcare in England: specialist cancer surgery service reconfiguration. Int J Health Policy Manag. 2022;11(12):2829-2841. doi:10.34172/ijhpm.2022.6389
  6. Waring J, Bishop S, Clarke J, et al. Healthcare leadership with political astuteness (HeLPA): a qualitative study of how service leaders understand and mediate the informal 'power and politics' of major health system change. BMC Health Serv Res. 2018;18(1):918. doi:1186/s12913-018-3728-z
  7. Greer SL, Stewart E, Ercia A, Donnelly P. Changing health care with, for, or against the public: an empirical investigation into the place of the public in health service reconfiguration. J Health Serv Res Policy. 2021;26(1):12-19. doi:1177/1355819620935148
  8. 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
  9. Harrison R, Fischer S, Walpola RL, et al. Where do models for change management, improvement and implementation meet? A systematic review of the applications of change management models in healthcare. J Healthc Leadersh. 2021;13:85-108. doi:2147/jhl.s289176
  10. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. Sydney: ACSQHC; 2017.
  11. Eljiz K, Greenfield D, Vrklevski L, Derrett A, Ryan D. Large scale healthcare facility redevelopment: a scoping review. Int J Health Plann Manage. 2022;37(2):691-714. doi:1002/hpm.3378
  12. Australian Commission on Safety and Quality in Health Care. Resources for the NSQHS Standards. 2022. https://www.safetyandquality.gov.au/standards/nsqhs-standards/resources-nsqhs-standards.
  • Receive Date: 13 September 2022
  • Revise Date: 28 February 2023
  • Accept Date: 28 February 2023
  • First Publish Date: 01 March 2023