HSJ Awards winners reveal their secrets of service change

The NHS has a poor reputation for adopting and disseminating novel ways to deliver care. Yet, as the HSJ Awards demonstrate each year, many in the NHS do know some of the secrets − they manage to introduce and sustain a variety of healthcare service innovations.

Researchers from Brunel University in London sought out this group of award-winning innovators to distil some of the principles of their success. We interviewed NHS employees who won HSJ Awards from 2007 to 2009 for successfully implementing service innovations across 15 primary and secondary NHS organisations.

They spoke about what facilitated or obstructed them in establishing and spreading their innovations. This data was then processed, employing established techniques of qualitative analysis.

‘Quantitative data enabled innovators to verify the effectiveness of the new service, and was powerful for persuading stakeholders’

From our lengthy discussions with 18 healthcare professionals, a key factor was enumerating hard data showing the innovation’s value. That meant a lot more than just quantitative data proving the innovation worked and saved money. Evidence that the innovation was widely accepted and considered useful by others also weighed heavily in determining success.

Furthermore, good partnerships between organisations and within units, and strong leadership plus a genuine openness to change in NHS organisations, were rated as vital by these successful pioneers. We hope our findings will be a useful tool to those pursuing the quality, innovation, productivity and prevention agenda and its focus on sustainable innovation.

A decisive parameter was the availability of evidence. “Our outcomes are important to us because they give us a language by which we can articulate the success of the change,” explained one innovator. 

Quantitative data in particular enabled innovators to verify the effectiveness or efficiency of the new service, and was a powerful tool for persuading key stakeholders. The availability of evidence was critical many times in the innovation journey. It was not only significant for the diffusion of the new service to other departments or organisations − “hard” data also facilitated the initiation of the new practices from the outset.

Desirable innovation

The interviewees repeatedly came back to this foundation for change. However, they also highlighted additional types of evidence that mattered. For example, they drew attention to the uptake of innovations by their intended users − evidence of acceptance − and indicators illustrating the necessity or the scope for change − evidence of relevance.

“There are 101 primary care organisations across the UK and Ireland now offering one or more of our programmes, under that kind of scheme,” was a selling point from one typical innovator.

It is not enough to have evidence that an innovation works and leads to cost reductions. An innovation must also be desirable to its users and timely to their needs. This rich and wide-ranging notion of “value” reflects the fact that most innovations involve multiple stakeholders with diverse needs, so success requires widespread acceptance.

‘The openness and readiness of an organisation to accept change and to assume risks was critical’

The second ingredient for innovation success was the development and maintenance of trustful working partnerships. NHS innovators regarded the connection with other organisations as essential. Indeed, past failures to consolidate and disseminate service development were often attributed to the absence of such partnership, even when sufficient financial support was in place.

One innovator, typical of others, noted: “Then, as we were looking around, we realised we hadn’t really got any formal links with other services… and actually, whilst we’d got a good level of resource going into the [previous innovation], we weren’t getting the impact that we wanted. So that’s where it started from.” 

Partnerships provided innovators with material support and helped them to publicise their service to the wider community, raising public awareness. In some instances, the resulting partnerships, along with the trust and commitment that were developed between organisations, were considered part of the essence of the innovation itself. Moreover, inter-organisational links could smooth out anticipated future resistance, especially when the change was radical. 

Advocates within and outside the organisations were also judged a substantial resource for innovation success. Support, mostly in the form of financial resources, from top and senior managers was key. One innovator commented: “We’re fortunate, we’re led from the top, our chief executive and our chairman are very passionate, as are our trust board, about sustainability.”

Take a risk

However, lower-level employees also acted as crucial champions, helping with the uptake and rolling out of the service. Their opposition could have damaged progress because of their informal influence on colleagues. One person noted how the uptake of the service by the nursing staff helped it spread to other departments.

“We just started off with very small pilots in non-acute areas, and developed a process which was so much better for the nursing staff,” they said. “They were so delighted to have it that they would work with us and become advocates for us when we went to new clinical areas.”

Additionally, champions outside the NHS, such as the users or members of the community, were seen as influential in the sustainability and diffusion of innovations.       

The circumstances within − and between − healthcare organisations were recognised as important influences on success in adopting innovation. Specifically, the openness and readiness of an organisation to accept change and to assume risks was critical. Having the right staff to execute change, as well as an organisation’s capacity to promote the innovation to the external world, through awards and publications, were also vital factors.

“There was an environment of being prepared to take a risk, with the right kind of conditions to support that,” said one innovator.

Working differently

‘Despite all the challenges, NHS employees do attempt to work differently to better serve the public’

Finally, the broader economic, political and ideological environment also played a role (positive or negative) in success. For instance, a difficult fiscal climate got in the way of service innovation that required considerable financial investment. The failure of regulatory bodies to get behind innovative activities was also considered to be a barrier to service innovation at the periphery of healthcare provision.

An employee, who was trying to organise the hospital food supply on the basis of sustainability, said: “The problem is there is actually no national body responsible for food. If you ring the Department of Health and say: ‘Who’s responsible for food in the NHS?’ You’ll get a complete blank.”     

So what does all this tell us about the prospects for successful innovation in the NHS? First, most encouragingly is despite all the challenges, NHS employees do attempt to work differently to better serve the public. In the course of their entrepreneurial efforts, they can see clearly the factors that make change happen. These may be obvious, but they are often difficult to achieve within the NHS.

Gathering evidence that demonstrates the value of innovation from different angles is vital, as is building trustworthy inter-organisational partnerships, gaining support and commitment from other people, and working within a favourable inner and outer context.

Establishing mechanisms that would routinely enable staff to achieve these factors would maximise the benefits of the continuing efforts of so many imaginative and committed practitioners. 

Julie Barnett is professor in health research, Konstantina Vasileiou is a doctoral student, and Terry Young is professor of healthcare systems at Brunel University