NHS practitioners and managers are striving to provide high quality services. Thousands of improvement projects are run every year, but not all succeed. This scan examines research into what gets in the way of improvement in the NHS – because if we have a clear idea of what the barriers are, we are in a better position to consider solutions.

Purpose

The Health Foundation is interested in drawing together experience and evidence about the barriers and facilitators to improvement in the NHS so that future projects and policy making can reflect the best available knowledge. This evidence scan draws together published research about barriers to change to support this.

The key question that the scan seeks to address is:

• What are the main barriers to implementing improvement projects in the NHS?

The focus is on barriers because this is a gap in knowledge. More work has focused on facilitators.

Barriers are defined as things that get in the way, slowing progress or stopping improvement programmes from succeeding. Examples may include lack of staffing, difficulties sharing information between IT systems and so on. It cannot be assumed that the opposite of a barrier will always be a facilitator.

For the purposes of the scan, improvement projects are defined as interventions that seek to improve NHS service delivery, organisation or ways of working. This is broader than interventions termed ‘quality improvement’ and incorporates wider change initiatives. However, it does not include service reconfiguration or structural or system-level interventions without a key focus on improving delivery or outcomes for service users.

Approach

The scan focused on readily available research published about the UK NHS. It was completed in November 2014.

To be eligible for inclusion in the scan, material had to:

• include empirical data
• be readily accessible in print or online
• be about improvement in the NHS
• include information about barriers to improvement
• be published in the English language.

To identify relevant research, two reviewers independently searched 12 bibliographic databases for studies of any design. The databases comprised: Pubmed/Medline; Embase; Cinahl; PsychLit; the Cochrane Library and Controlled Trials Register; National Library for Health; Social Services Abstracts; TRIP; ASSIA; Health Business Elite; Google Scholar; and the Health Management Information Consortium. All databases were searched from their inception to the end of October 2014.

Combinations of search terms such as the following were used: NHS; improvement; change; innovation; adoption; barrier; constraint; challenge, feasibility, sustainability, embed; variability; implementation; diffusion; evaluation; health care; UK.

Abstract and title searches identified more than 4,000 articles about improvement in the NHS, though many were descriptive and did not contain empirical data. These articles were scanned and the full text of promising material was read. Only studies that explicitly included empirical material about barriers were eligible, so this excluded a number of broad studies about NHS projects.

In total, 73 empirical articles met the inclusion criteria.

In addition, more than 100 studies from other parts of the world were used to provide contextual information. Although the scan focused on the NHS, we wanted to understand whether barriers in the NHS were unique in any way so made comparisons with reviews and studies undertaken in other countries.

Findings were extracted from all publications using a template and themes were grouped according to the type of barriers identified.

The scan reports some brief examples of NHS improvement projects, but the focus is on drawing out trends and learning points, rather than the findings of individual studies.

All of the evidence was sourced and compiled systematically, but the scan is not a systematic review and does not seek to summarise every study about barriers to improvement in the NHS.

Studies included

Of the 73 studies, 53% focused on the hospital context, 16% focused on primary care and 30% looked at combined primary and secondary services or allied professions such as dentistry (see table 1).

Almost a third of the studies spanned multiple regions in England or were national (32%). The midlands and northern regions were slightly better represented than southern England. Studies were also available from Scotland, but there was little material from Wales or Northern Ireland.

Seven out of 10 studies had been published since 2010 (69%), perhaps suggesting more of a focus on identifying barriers in recent years.

Half of the studies were small cross-sectional designs (49%), meaning that they may not provide the most robust evidence (see table 2).

Table 1: Country and context of studies included in the scan

	Primary care	Secondary care	Other eg combined, pharmacy, dental	Total number
Scotland	6	1	3	10
Northern Ireland				0
North England	3	7	5	15
Midlands		11	4	15
South England	2	7		9
England national /multiple regions	1	13	9	23
Wales			1	1
Total number	12	39	22	73

Table 2: Research design and ear of publication of studies included in the scan

	Up to 1999	2000-2009	2010 onwards	Total number
Review		1	4	5
Randomised trial			2	2
Follow-up over time			10	10
Large cross-sectional study		6	14	20
Small corss-sectional study	4	11	21	36
Total number	4	18	51	73

A great deal of research has explored barriers to innovation and improvement. This section summarises key messages from international research and Health Foundation programmes to provide a basis for comparing what is happening in the NHS.

Learning from international research

International research suggests that barriers to healthcare improvement relate to:

• the initiative itself and how it is implemented
• characteristics of the individuals involved
• organisational factors
• features of the wider environment.,,

Table 3 summarises the main potential barriers under each of these headings.

Barriers relating to the improvement project itself include being difficult to use, not being compatible with existing services or systems, not having a strong evidence base and not being perceived to be better than alternatives. There are also practical implementation barriers, including not allocating enough time or financial resource and not having appropriate IT systems.

Barriers related to the characteristics of health professionals and managers include people’s attitudes, perceptions, patterns of behaviours, skills and confidence.

Barriers related to organisations or teams include having a hierarchical structure, poor organisational culture, lack of teamwork or collaboration and insufficient infrastructure.

The wider environment may also raise challenges, including the regulatory context, national targets and feedback from patient groups.

Table 3: Potential barriers to improvement sourced from the international literature

Factor	Potential barriers
Characteristics of the initiative itself4–15	Not easy to use No clear information or guidelines about use Not consistent with existing procedures Not able to be tested on a small scale before rolling out Results not immediately visible to professionals or other stakeholders	Not thought to be relevant or add value May carry risk to patients or organisations Not been used much in the past/not well tested Lack of evidence base
Practical issues relating to implementing improvement16–21	Lack of financial resources Lack of other resources such as equipment or IT interfaces Lack of incentives Lack of administrative support Lack of time available	Lack of staff available to coordinate implementation Lack of involvement of professionals and patients in development Lack of opinion leaders or champions who influence others
Characteristics of the individuals involved22–54	Lack of leadership buy-in/engagement Lack of support from colleagues and managers Lack of role modelling by colleagues Perceived increase in workload Perception that project is not advantageous Lack of skills and knowledge among professionals	Lack of confidence among professionals to make change Lack of autonomy of professionals to make decisions/changes Lack of perceived ownership of improvements/top-down implementation Health professionals’ assumptions about acceptability to patients Perceived ethical issues
Organisational factors55–68	Lack of formal reinforcement or championing by management Top-down decision-making process/hierarchical structure Organisational size and type Staff turnover Lack of teamwork or silo working	Poor relationships with other departments or organisations Lack of collaboration Lack of improvement culture Culture of blame Number of potential professionals/users to be reached
Contextual/ environment factors69–78	Project does not fit into existing rules, regulations or legislation Priorities of commissioning organisations Behaviour of other organisations eg using different approaches Patients not willing to take part	Patients doubt whether professionals have skills or capacity Financial burden of the change on patients, organisations or systems Counter-incentives such as financial targets for other things

Learning from Health Foundation projects

The Health Foundation funds a wide variety of improvement programmes in the NHS. In 2012 the Health Foundation commissioned a team to draw together lessons from 14 evaluations of Health Foundation-funded initiatives. The researchers concluded that there are 10 key challenges to improvement in the NHS. These challenges can be divided according to whether they occur during the design, delivery or dissemination stages (see box 1).

There are some similarities and differences between these evaluation findings and the international literature. The Health Foundation work focused less on organisational, team and individual capabilities and more on dissemination and sustainability issues than published international research.

The report emphasises that insufficient planning can get in the way of improvement in the NHS and it encourages teams to spend time reflecting, developing monitoring tools and networking before starting an improvement programme. Similar to the international literature, it is acknowledged that not having an evidence base for change or buy-in can act as barriers.

‘The report concludes that structured improvement is complex and takes time and, unless the conditions for success are in place, is unlikely to fully achieve set objectives. This reinforces the importance of the role that organisation and system leaders play in supporting successful improvement efforts.’

Many case studies, evaluations or small research projects have described barriers to improvement in the NHS. While the barriers from these studies may not be generalizable, they provide useful themes. This section explores the most frequently identified barriers to improvement in the NHS.

Overview

Our scan of empirical studies outlining barriers to improvement in the NHS found that challenges could be classified in terms of whether they related to:

• the intervention itself
• individuals associated with implementation
• organisational or team-related factors
• system-wide barriers.

This section briefly describes some of the barriers identified in each of the four broad areas.

These four factors are similar to the international literature (as described overleaf). However, research about the NHS tends not to focus so much on barriers associated with the interventions themselves.

Initiative-related barriers

Issues related to the specific characteristics of improvement initiatives in the NHS included the following.

Usability

• Perceptions that tools or changes were not easy to use or implement.
• Complexities of care pathways or the number of stakeholders involved.,
• Number of improvements or changes implemented simultaneously.

Fit

• Perceptions that improvements did not sit well with existing processes or organisational realities.
• Lack of evidence base.

Below are some examples from individual studies.

Individual-related barriers

The key barriers related to individuals identified in studies in the NHS included the following:

Attitudes

• Resistance from clinicians and managers.,,,,,
• Lack of trust in the process, stakeholder organisations or data.,
• Perceived conflicts between the views of patients and professionals.,
• Assumptions about what patients want.

Skills and training

• Lack of confidence among professionals about their abilities.,
• Lack of skills in improvement approaches.,
• Lack of skills in project management.
• Lack of skills in change management.
• Lack of analysis skills.,
• Lack of pre-registration training and continuing professional development about improvement.,,
• Differences in individual learning styles.

Time/prioritisation

• Lack of time available to think about improvement.,
• Lack of time available to implement improvement.
• Competing priorities.

Professional roles

• Strong disciplinary demarcation of roles.,
• Culture of specific professions.
• Lack of authority or autonomy to undertake improvement.
• Failure to assume responsibility.

Resources

• Reimbursement and contractual issues, particularly for GPs and dentists.

Staff resistance to, or lack of acceptance of, change was repeatedly highlighted. Factors identified as affecting staff acceptance involved the perceived negative impact of service change, staff–patient interaction, credibility and autonomy and technical or design issues.

Below are some examples from individual studies.

Organisational barriers

The key barriers related to organisational or team factors identified in studies in the NHS included the following:

Culture

• Lack of culture of improvement.,
• Perceived culture of blame.
• Lack of priority placed on improvement.
• Risk averse culture and prioritisation of defensive practices.
• Rituals that undermine improvement.,

Leadership

• Lack of strong leadership and clear shared vision for improvement, including at board level.,,,,
• Hierarchical leadership structure rather than transformational or engaging leadership.
• Undue focus on either clinical or managerial leadership.
• Not ensuring leadership and autonomy for improvement at multiple organisational levels.
• Lack of accountability for improvement.

Focus

• Resistance to things imposed externally rather than perceived organisational needs.,,,
• Limited focus on person-centred services.
• Attempting to localise everything rather than drawing on regional or national expertise.

Resources

• Lack of organisational management time or capability.
• Staff shortages and use of agency staff.
• Lack of dedicated funding.
• Systems not set up to support integration of improvement into existing processes.,

Information

• Lack of information sharing within organisations and teams.
• Insufficient use of the data available.,,
• Insufficient information and analysis systems.,
• Lack of, or inflexible, feedback structures in place.

Timing

• Wanting to see ‘quick wins’ rather than allowing improvement time to embed.,
• Not allowing dedicated staff time for training or implementation of improvement.,,

Engagement

• Insufficient engagement of professionals and patients.

System-wide barriers

System-wide or contextual barriers have been a particular area of study for UK research. The key system-related barriers to improvement identified in studies in the NHS included:

Consistency

• Lack of stability in the system, meaning time is spent on reorganisation and reconfiguration rather than targeted improvement.
• Conflicting priorities, perverse incentives and guidelines from regulatory authorities.,
• Differences in the priorities of policy makers versus professionals and patients.

Drivers

• Perceived lack of strong policy context or guidelines for improvement.,,
• Political rhetoric.
• Perceived ‘interference’ from regulatory or policy bodies.
• Lack of incentives or funding for improvement.,
• Lack of champions or early adopters.

Structures

• Fragmentation and silos across services and sectors.,,
• Lack of structures for disseminating learning quickly and routinely.,

Relationships and roles

• Lack of relationships between organisations or with policy makers and commissioners.,,
• Strong professional pressure groups.

Below are some examples from individual studies.

This section summarises the main learning points and compares findings from research about the NHS to other countries.

Key barriers

Many policymakers and NHS managers and practitioners are passionate about improving health services – and a wide variety of initiatives have been tested. There are some examples of tangible change in the way that care is delivered and the outcomes for service users and staff. However, there may be just as many examples of improvement initiatives that fail to get off the ground. Once initiatives are established, their effectiveness may be inconsistent. Improvement is essential for the NHS – but it is not easy.

The published research suggests that the key barriers hindering improvement initiatives from developing, flourishing and embedding in the NHS include, in order of frequency researched:

1. organisational issues such as culture, leadership, teamwork, collaboration and IT infrastructure
2. system-wide issues such as perverse incentives, lack of coherent policy and infrastructure and lack of systems to support information sharing
3. individual-level barriers such as resistance among professionals and lack of time and capacity
4. initiative-related barriers, such as the design and usability of specific improvements.

Research about barriers to improvement in the NHS has particularly emphasised the importance of system-wide issues.

‘Individual activities, roles and specific service configurations seemed far less significant than the overall culture, stability and long-term commitment to a service in a given area. Time is required for new service configurations to stabilise so that staff are able to overcome barriers and develop the necessary facilitators for quality care provision.’

However, just because more research has focused on this does not mean that it is the most important barrier. This scan has provided lists of various types of barriers, but there is little empirical evidence to say whether one barrier is more prevalent or important than another. It is also true that the prevalence and priority of barriers is likely to depend on the context and the type of improvement occurring. Thus it is potentially unhelpful to try to distinguish the ‘most important’ barriers as these will differ according to context.

It is also important to note that although this scan has divided barriers into those focused on the initiative, individual barriers, organisational issues and system-wide factors, barriers may not fit easily into just one of these categories. There is much overlap and the barriers may interlink and feed off one another. Furthermore, barriers may occur at all four of the different levels simultaneously.

As well as thinking about barriers in terms of their substantive content, barriers can also be categorised according to where they occur along the improvement journey. In other words, barriers are evident at the design, delivery and dissemination stages.

The most commonly researched barriers are spread across varying stages of the improvement process (see table 4).

This scan adds value because this categorisation of barriers, according to both content and implementation stage is new.

Table 4: Spread of barriers to improvement at various stages of implementation

Potential barriers	Before implementation – design	During implementation – delivery	After implementation –dissemination
Initiative and implementation-related issues
Evidence base	X		X
Usability of equipment/tools		X
Fit with existing practices		X
Individual-related issues
Attitudes/resistance	X	X
Lack of knowledge and skills		X
Culture/role demarcation in disciplines		X
Organisational-related issues
Organisational stability	X	X
Culture	X	X
Leadership	X	X
Management skills	X	X	X
Use of information and data to support change	X	X	X
Time allocation	X	X	X
Financial resources	X	X	X
System-wide issues
Policy/NHS culture/regulation	X	X	X
Stability of NHS system/ reconfiguration	X	X
Partnership working		X	X
Incentives	X	X
Funding streams	X	X
Note: Crosses indicate where barriers have been found to exist most prominently.

Is the NHS different?

The list of key barriers in the NHS largely conforms to what has been found in the international literature and in evaluations of Health Foundation-funded NHS initiatives. However, there are differences in emphasis.

When considering important facilitators to improvement, there is often a focus on training in specific improvement approaches and in change management, but this emerged less frequently in NHS literature about barriers. Individual-related factors focused more on potential resistance to change, lack of time and lack of capacity generally, rather than highlighting a need for specific training.

In the published international literature, the role of patient voices and advocacy groups has been explored as both a facilitator and barrier to change. In NHS research, there is little mention of the potential for patient knowledge or attitudes to act as a barrier to improvement. It is uncertain whether this is because this is not an issue in the NHS or because it has been overlooked by research.

The barriers identified in the NHS relate less to individual attributes or characteristics of the changes themselves, and more to organisational and system-wide issues. These are areas where policy intervention can have a major impact.

It is important to note that just because barriers are not well covered in the empirical literature does not mean that they do not exist in practice. The published empirical evidence is unlikely to capture all the subtleties and details about barriers to improvement, but it does highlight that organisational, team and environmental barriers are a core issue in the NHS. International literature is beginning to focus on these issues too, but perhaps to a lesser extent.

When looking at the differences and similarities between NHS research and international findings, it is important to consider whether aspects of the NHS are unique. Some argue that improvement may occur more slowly in the NHS compared to other health systems or sectors.,, There are a number of potential reasons. The top three issues outlined in the empirical research, were:

1. NHS structure and culture,
2. expertise and experience
3. gaps between evidence and practice.

We briefly outline these issues, drawing together findings from the discussion sections of all 73 empirical studies included in the scan. To avoid repetition, all 73 citations are not provided again.

1. NHS structure and culture

Empirical research notes that the NHS is a large and complex system, with components that change frequently due to ongoing reforms. The lack of stability may lead to fragmentation, duplication and frustration and this may act as a barrier to improvement., So too may the hierarchical structure and the constantly changing landscape of organisations and stakeholders with whom to interact.,,

The issue of stability is important because organisations and teams may not have a strong sense of themselves as improvement agents and may be loath to begin large-scale improvement that spans different financial years. Organisational restructuring means that effort is expended setting up systems and structures, leaving less time to focus on improvement in service delivery.

With widely varying priorities, improvement may not be valued within the NHS as a core task of organisations and individuals. Research suggests that there is little socialisation or sense of urgency to improve., Commissioners and provider organisations may not have a shared vision of improvement and there may be few incentives for improvement built into the system on a local, regional or national basis. Furthermore, collaboration with social care and the third sector may be limited.

The NHS also contains many specialised and powerful professional groups who may not wish to change or who support particular ways of working. This can act as a barrier to improvement because it can be difficult to integrate new ideas with existing practices.

The focus also tends to remain on individual ‘projects’ rather than embedding a culture of improvement or wider-level systems thinking, focused around the needs of patients and pathways.

Regulation and performance management may mean that professionals are averse to taking risks or trying something new. Furthermore, regulatory and inspection priorities may not be aligned with improvement. There may be a focus on poor performing organisations and regulatory bodies may not provide tools and incentives that encourage professionals to take part in improvement.

2. Limited expertise and experience

Research suggests that generating ideas for improvement, putting them into practice and sustaining and sharing them, may require skills that are not traditionally within the scope of NHS health professionals and managers.

A lack of experience and expertise in improvement methods and in dissemination approaches may be a major barrier in the NHS which is perhaps less evident in the international evidence. This is not to say that the NHS has less skilled or experienced personnel overall, but perhaps in the past, less emphasis has been placed on upskilling and supporting staff to engage in improvement.

There may also be unrealistic expectations about how quickly improvements can be achieved, or a lack of staff time devoted to improvement programmes. While some professionals and managers may have time allocated to improvement work, this is not consistent across the sector. For instance, doctors may be more likely to be able to negotiate time to undertake improvement than health care assistants. Even the notion of ‘undertaking improvement’ points to a specific mindset, whereby improvement is seen as a distinct entity or a project, rather than an entire culture or way of doing things.

3. Evidence versus practice gap

Although there are pockets of good practice, research suggests that the NHS can be slow to adopt evidence for improvement. This may be more pronounced than in other industries or in some other health systems due to fragmented commissioning and procurement practices in the NHS; a lack of frequent and productive interactions between industry and the public sector; and sub-optimal use of the many repositories of evidence-based reviews and guidance.,, Use of evidence to guide decisions may be increasing, but the pace of change may be slower than in the private sector, where there is a need to innovate to survive.

Information is essential to improvement but information technology and data collection may not be well developed in the NHS. There are difficulties sharing information across services and sectors due to technological issues and because of legal and ethical issues. Analytical capability has not historically been a strength of the NHS.,

The way information is communicated to individual professionals and teams may also act as a barrier, with people not knowing the gap between their practice and good practice, or what to do about it. This gap in accessible information is one where policy makers and supporting organisations could make a substantial contribution.

This scan has identified what is getting in the way of improvement in the NHS according to published research. Table 5 summarises the key findings. While some research suggests that reported barriers to improvement may be used as an ‘excuse’ or a way of avoiding change, other research suggests that there are very real organisational and structural issues that hinder progress.,,

The scan has not sought to identify solutions, but it is clear that tackling these sorts of barriers may require a complex set of educational and regulatory interventions and may take some time to achieve. No matter how dedicated, informed and experienced an NHS manager, professional or team is, some of these barriers cannot be tackled alone. There is much that individual professionals and teams can do to keep making NHS services even better, but policy makers also have a key role to play in facilitating those improvement efforts and addressing some of the hurdles that teams face.

Table 5: Key barriers to improvement in the NHS

Focus areas	Potential barriers
Initiative barriers
Usability	Initiatives are difficult to use or do not fit well within existing structures or processes
Resources	Insufficient resources allocated to develop and sustain improvement Basic equipment may not be available or may take a long time to source
Evidence base	Lack of agreed evidence about how to improve Lack of access to evidence base leading to not selecting the ‘right’ things Not examining learning from other sectors Lack of resource put into evaluating and sharing lessons learned
Individual barriers
Staff attitudes	Resistance to change Lack of agreement that change is needed and the best way to improve Different views between disciplines about the best way forward Hierarchies in views about who should be involved in improvement
Staff skills and knowledge	Insufficient improvement planning, implementation and dissemination skills Insufficient data analysis skills Insufficient skills in improvement methodologies
Organisational barriers
Organisational culture	Culture of blame rather than improvement Lack of focus on improvement Focus on ‘quick wins’ rather than sustained change
Leadership	Lack of transformational and supportive visible leadership Lack of investment in leadership development Lack of leadership buy-in Lack of leadership ability to interpret and act on data Lack of connection between boards, managers and frontline staff Unrealistic expectations
Management skills	Lack of project management skills Lack of clear communication and governance processes
Use of data	Difficult to track data over time IT systems incompatible between organisations and sectors May be difficult and time-consuming to access data quickly and regularly
Time allocation	Insufficient time allocated to think about ways to improve Insufficient capacity allocated to implementing improvement Duration of time allowed for projects is too short to show impacts
System-wide barriers
NHS culture	Perspective that real improvement is not a priority Potentially risk-averse culture rather than willingness to change radically Improvement not seen as ‘everybody’s business’ Focus on targets rather than improvement
Stability	Changing policy priorities and competing drivers Lack of stability of organisations in the sector and across sectors Lack of stability of key roles (leaders and frontline staff) No stable group leading and coordinating improvement efforts
Partnership working	Silo working, protectiveness and tribalism Not involving all key partners, including patients and carers and social care
Incentives and funding	Lack of incentives to improve Inverse/perverse incentives (eg Quality and Outcomes Framework targets, waiting targets) Financial crisis meaning less resource is available to experiment

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