A realist evaluation has found that informal trust-based networks provide the platform for successful implementation of large system transformation (LST) initiatives in the New Zealand health system. Research for the evaluation involved theory gleaning from a local LST initiative, a literature review, interviews, a workshop and an online survey. Findings showed that ten key elements need to be present in the health system to increase the chances of successful implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. Five contextual factors that influenced implementation of LST initiatives were also identified: (i) a history of working together; (ii) distributed leadership from funders; (iii) the maturity of Alliances; (iv) capacity and capability for improvement; and (v) a continuous improvement culture. Trust is built and nurtured over time through sharing of power by senior health leaders, creating a positive history of working together and increasing the maturity of Alliances.
