Executive summary

What this report is about and why it matters

How to spread new ideas and effective practices from one organisation to another to improve care and reduce unwarranted variations in performance is one of the central challenges facing the NHS.

For decades, centuries even, people have debated the problem of the slow spread of innovations in health care. A classic example is the incorporation of citrus fruit into sailors’ diets to prevent scurvy – demonstrated by James Lancaster in 1601 and again by James Lind in 1747, but not adopted by the British navy until 1795. And since Everett Rogers published his classic work The Diffusion of Innovations in 1962, much debate and scholarship on innovation has focused on the factors that affect whether people take up innovations or not and how quickly they do so.

This report focuses on a different problem, one that has received far less attention, but which we believe is equally pressing: that when an individual, team or organisation does take up a new innovation it may not work as well as it did first time round – something we see particularly with complex health care interventions that seek to make improvements in clinical processes or pathways. We therefore set out to investigate not the factors affecting the uptake of innovations in health care, but the factors affecting their successful uptake. We do this in several ways, reviewing the literature on this problem, drawing out lessons from Health Foundation projects and evaluations, and also interviewing key actors – innovators and adopters, who provide vital insights from the front line of health care, as well as expert stakeholders involved in supporting scaling and spread.

Indeed, this ‘replicability problem’ – the challenge of replicating the impact of a new intervention as well as its external form – is arguably the more urgent question for the public sector, and for the NHS in particular, where all manner of mechanisms exist to encourage uptake, and indeed to mandate it in the last resort. But the last 70 years of NHS history have shown that mandating action does not automatically bring about the desired change in outcomes.

Achieving that is much harder. It requires teams on the ground to adapt and implement a new intervention in ways that will enable it to work in their own setting. Staff may need to develop new skills or learn to use new techniques. There may be a need for culture change, relationship building, new ways of working or undoing entrenched habits – none of which can be achieved purely through compulsion.

Framed in this way, it is clear that while the invention of new technologies, practices and models of care are exciting moments in health care, invention itself is only half the story. People sometimes fall into the trap of thinking that when an idea has been successfully demonstrated or piloted then the hard work is done. But exploiting the full potential of a new idea requires successful replication at scale – and this takes time, skill, resources and imagination.

So as policymakers and system leaders draw up the anticipated long-term plan for the NHS in England, it is important that debate is not restricted simply to identifying areas for improvement and potential solutions. The challenge is to get the solutions working well everywhere.

This report discusses some of the changes in thinking and approach needed to tackle this challenge, drawing on lessons from the Health Foundation’s programmes to support the spread of innovation and improvement in health care.

One part of the answer is changing the way we think about what is actually being spread. In the case of a discrete health care intervention, does our conceptualisation of the intervention encompass the full range of factors necessary for its success, such as underlying behaviours or cultural factors, the skills and capabilities required, the methodology for implementation, and so on? This applies not just to process innovations, quality improvement approaches or new service models, but also to interventions using new health technologies or medical devices – where there is often a tendency to focus on the technology itself, even though its effectiveness will depend on the skills, behaviours and organisational cultures of those using it.

Another part of the answer involves designing programmes that will better support the spread of new interventions. Do these programmes generate consensus on the new idea and buy-in from those adopting it? Do they provide for sufficient support during implementation to enable the idea to be successfully reproduced? Factors such as these could have major implications for the success of programmes to scale up new ideas or reduce variation in the NHS.

We hope the analysis and insights in the report will be relevant both for innovators and adopters, and also for those designing and leading spread programmes. The latter includes those overseeing local programmes, whether they are run by commissioners, academic health science networks (AHSNs), regional and national improvement bodies or professional networks. It also includes policymakers and system leaders overseeing national change programmes, such as Getting It Right First Time or RightCare, and national bodies whose remit includes spreading innovation and improvement, such as the National Institute for Health and Care Excellence, royal colleges and professional bodies.

The central argument of the report

Our central argument is that successfully spreading complex health care interventions will require packaging them up in more sophisticated ways and designing programmes to spread them in more sophisticated ways.

The point of departure for the report’s analysis is to note that the success of a complex intervention is likely to depend heavily on its context: the underlying systems, culture and circumstances of the environment in which it is implemented. This means that adopting a complex intervention and making it work in a new setting is not a straightforward matter; in fact, as many of the Health Foundation’s grant holders tell us, it can be extremely hard work. Successful implementation may require adaptation of the intervention or a long journey to build new relationships, shift the prevailing team culture or develop new skills.

Recognising the influence of context highlights the important role adopters play in translating interventions to new settings. This poses a challenge for traditional approaches to spreading innovation, which tend to assume that once an innovator has developed an idea and successfully piloted it, it can then be ‘diffused’ and taken up by others in a straightforward way. By contrast, we argue that reproducing a complex intervention at scale is a much more distributed effort, often involving a good deal of creativity and reinvention from those taking it up, with the intervention itself sometimes undergoing substantial revision and refinement in the process.

We argue that designing spread programmes that can meet the challenges of adoption will therefore place a greater focus on adopters, to some extent reversing the conventional focus on the innovator. This requires ‘codifying’ interventions in ways that support adopters to adapt them appropriately. It requires designing programmes in ways that build adopters’ commitment to implementing the intervention. It requires mechanisms such as peer networks to capture and share the learning that adopters generate as they tackle implementation challenges. Above all, a greater focus on adopters requires building their capability and readiness for implementation and providing them with the resources, time and space needed to do the hard work of translating the original idea to their own setting.

Chapter summary

Chapter 1 gives a brief overview of the ‘replicability problem’.

Key points:

  • When initially successful interventions are spread to new settings, they may fail to achieve the same impact, or indeed any impact at all.
  • One explanation for this may be that interventions are not being conceptualised and described in ways that enable them to be successfully reproduced in new contexts, and programmes to spread interventions are not being organised in ways that adequately support adopters to reproduce them.
  • These challenges become especially acute with complex health care interventions, such as innovations and improvements in clinical processes and pathways.

Chapter 2 looks at why the complexity of many health care interventions poses challenges for spreading them.

Key points:

  • Complex interventions tend to have certain properties that make codifying and replicating them difficult: they are social, context-sensitive and dynamic in nature.
  • Various approaches and schools of thought exist for analysing complexity, such as realist evaluation or complex adaptive systems theory, but they all represent routes for capturing and responding to these properties of complex interventions.
  • Insufficient appreciation of complexity can lead to mistakes and misconceptions in attempts to codify and spread interventions. These can include failing to consider the social as well as technical components of the intervention, failing to distinguish between the instrumental and expressive effects of intervention components, or failing to recognise capability-building as an integral part of the intervention.

Chapter 3 considers some approaches to codifying complex health care interventions in ways that can support effective replication.

Key points:

  • Some approaches to codification aim for ‘tight’ descriptions of the intervention through comprehensive and detailed accounts, for example, specifying the methods for implementation or the social mechanisms and behaviours required for success. Other approaches aim for ‘loose’ descriptions, focusing less on the details of each intervention component and more on the ability of adopters to formulate their own versions of these components in their own setting, for example, by setting out the underlying principles and goals, the intervention’s theory of change, or the skills and capabilities required. Furthermore, tightening and loosening approaches can sometimes be blended.
  • Whichever approach is taken will have implications for the concept of fidelity to the intervention, as well as for the broader approach to spreading the intervention.
  • Innovators and programme leaders should be aware of different possible approaches to conceptualising and describing interventions; they should be seen as a standard part of the innovator’s toolkit.

Chapter 4 looks at the initial spread process and at how early adopters generate new learning about an intervention as they implement it in new contexts.

Key points:

  • As innovators cannot necessarily ‘see’ their own context, introducing a new intervention into a diverse range of sites can generate fresh insights into what is (and isn’t) significant for making it work. This allows the innovator to revise the description of the intervention accordingly, and in some cases to refine the intervention itself.
  • There may be value in recognising this testing and revision phase as a formal part of the innovation cycle in health care, distinct from attempts to spread interventions at later stages of maturity.
  • This has implications for the design of the initial spread process, in terms of setting expectations, selecting initial adopter sites to ensure diversity, fostering good relationships between the innovator and the initial adopters, and ensuring that mechanisms are in place to capture and share new learning.

Chapter 5 looks at some consequences for the design of large-scale spread programmes.

Key points:

  • Spread programmes need to be designed in ways that build and maintain adopters’ commitment to implementation, including seeking consensus on both the problem and the proposed solution.
  • These phenomena have important psychological, behavioural and social dimensions that should be considered when designing spread programmes. Important areas where behavioural insights can inform the design of programmes include peer leadership, peer communities and adopter ownership.
  • Successful spread also relies on adopters’ ability to implement the intervention and on them having sufficient opportunity to do so. This implies that spread programmes need to build adopter readiness and capability (for example, through providing training or enabling relationship building), include appropriate support for implementation (for example, funding to cover the upfront costs of adoption, or assistance with analytics and evaluation), and be based on realistic timescales.

The conclusion draws out the implications for policymakers and those overseeing spread programmes.

Key points:

  • Adopters make a crucial contribution to the successful spread of new ideas, both through the hard work involved in adoption and their role in generating new learning about an intervention as it spreads.
  • This perspective challenges conventional notions of the division of labour between innovator and adopter. It also challenges the ‘knowledge pipeline’ model of innovation, which sees new knowledge as generated purely by the innovator and which casts adopters as passive recipients of this knowledge during the diffusion process.
  • There needs to be greater emphasis on the role and status of adopters within spread programmes, both in terms of how interventions are codified and how programmes are designed. Beyond specific spread programmes, policymakers can ensure health care providers are better equipped for adoption more generally by supporting them to build their improvement capability.
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