Thinking big: lessons for the NHS on large scale change

With the announcement of a new funding package and a new 10 year plan, the pressure will be on the NHS to deliver measurable improvements on a large scale. The time is ripe for the NHS to pay attention to the mechanics of spreading and scaling innovation, drawing on a range of evidence and experience, including from other countries and sectors, to create a lasting movement for change.

The need to plunge ahead

William Gibson once observed that “The future is already here, it’s just not evenly distributed”. In these wise words, a science fiction writer captured one of the biggest challenges facing health systems everywhere.

Effective practice is one of the most difficult aspects of any innovation programme

Most changes that are needed to improve the health system are already happening for someone, somewhere. Significant transformation will occur through the spread of what already exists, rather than the invention of something new.

Broadly introducing, effective practice is one of the most difficult aspects of any innovation programme. There is often insufficient attention to how spread will be supported, and the NHS has a particularly poor track record in this regard.

There is an ambition for sustainability and transformation partnerships and integrated care systems to be the vehicles for spreading innovation from vanguard sites, and this is likely to form part of the new 10 year plan. But to avoid repeating past mistakes, the NHS needs a clear strategy and infrastructure to support this.

In April, The King’s Fund and the South West Academic Health Science Network invited Joe McCannon to visit England and work with us on the question of what it would take to unleash improvement on a much bigger scale. He has led and supported large scale health care improvement initiatives in the US and other countries and co-founded the Billions Institute, which supports large social movements in areas as diverse as climate change, homelessness and human trafficking.

What lessons can the NHS take from this work? We’ve picked five:

Relying on passive diffusion is not enough

There is a prevailing view in health and other sectors too, that all it takes to spread a proven idea is to tell people about it, publishing in a journal or presenting at a conference. While these vehicles raise awareness, they are rarely sufficient to bring about change on their own. Leaders also need to think about how to cultivate genuine commitment to the innovation, from among the many new practices providers could adopt, and how to support them in local implementation.

Unleash the frontline

The central enterprise for any serious large scale change effort is to unleash the passion and creativity of local managers and clinicians; without this, efforts will proceed slowly and unevenly. Successful leaders of change regularly engage with the frontline to reach agreement on concrete, time bound and apportioned aims for improvement; to understand local impediments to progress that they can remove by providing resources, training and other support; and to celebrate and disseminate breakthrough ideas.

This approach was taken in the vanguards programme, where local leaders, clinicians and staff led the design and implementation of new care models with some central resources and supporting infrastructure. The challenge now is to do this on a much larger scale.

Don’t stifle progress by instilling fear

The most damaging impediment to spread of effective practice is often management itself to the degree that it creates fear or confusion. Inspection oriented evaluation systems, rigid contracting structures and unrealistic timeframes for improvement can all undercut progress.

There is a note of caution here for national leaders driving the current NHS reform agenda. Integrated care systems and partnerships are complex changes requiring behavioural shifts for many organisations and individuals.

International experience of developing integrated systems such as the Canterbury health system in New Zealand, demonstrate the time it takes for changes of this nature to deliver results. Interim progress measures can help to provide political air cover while changes are developed and embedded.

Peer to peer connections are more effective than central broadcasts

Instead of just pushing out information, spread should be supported by connecting people to their peers as efficiently as possible so that they are able to share “tacit” knowledge, the practical details of implementation. There are many ways to facilitate this exchange, including peer to peer visits, ”extension agents”, learning networks, collaboratives and communities of practice. No single method is superior, and it is often appropriate to use more than one.

Find and celebrate adaptation

In most cases, achieving spread is not simply a case of dragging and dropping a model. It usually requires a complex process of adaptation to take something developed in one context and make it work in another.

Often, this process can yield significant improvement, and leaders of large scale change should regularly scan national data to find and investigate exceptional local performance. Successful large scale improvement initiatives like the 100,000 Homes Campaign – a US initiative that housed over 100,000 homeless people, actively encourage every community to make the best interventions work in their setting.

Empowering every local setting to trial new adaptations at a high tempo accelerates progress across the nation.

When the Five Year Forward View was published, Simon Stevens described the NHS as a social movement. Its success and that of the 10 year plan may yet depend on whether the service is able to live up to this description in its approach to transforming services.