Could social franchising help to solve the problem of scale up within the NHS?

The International Centre for Social Franchising (ICSF) was born out of frustration that successful solutions often fail to scale, so social organisations waste scarce resources by needlessly reinventing the wheel. ICSF seeks to identify, ‘scale’ (replicate) and share ideas that work. Over the past five years that’s taken a lot of different forms, using innovative replication models to scale the use of buses that allow homeless people to shower and keep clean in San Francisco, with Lava Mae, to working with NSPCC’s Baby Steps team, increasing support to new parents to care for and reduce the stress associated with the arrival of their new baby.

New solutions for the NHS?

The NHS is under constant pressure to find solutions that have the potential to improve health care outcomes or deliver cost savings at scale. This has become even more apparent to me over the past few months as I’ve explored scaling up in the UK health care sector more closely. ICSF has been travelling across the country to meet with project teams that have been supported by the Health Foundation.  

We’ve seen inspirational clinicians and managers who go above and beyond every day, to invest in improvement and innovation solutions to boost health care outcomes. The landscape of possible solutions is diverse, ranging from delivering multi-disciplinary support to advanced symptom Parkinson’s patients, to preventing prescribing errors in GP practices. But too often these solutions exist as isolated pockets of excellence and are infrequently implemented at wider scale locally or nationally.

As we explored the specific challenges of replication within the UK health care sector we found that a popular way to ‘scale up’ an approach or intervention to improve patient care is through sharing best practice. ICSF calls this activity ‘dissemination’. It can work excellently for particular solutions or contexts, for example clinical networks - where clinicians share best practice and ideas for making small scale changes to practice. But for other approaches and interventions, particularly those that are more complex, dissemination alone can be insufficient.

To begin to understand why dissemination only works for some solutions or contexts, we listened and we learned through available literature and interviews with people working in the health care sector. We heard time and again about the challenges associated with dissemination – that more support was needed to create behaviour change, or that there was a lack of clarity about the approach or intervention being scaled up.

We believe more structured ways of replication such as social franchising or licensing have particular potential to help scale solutions across the NHS. Social franchising is based upon the commercial franchising model where companies, such as the Body Shop, use franchises to expand. Our chief executive Dan Berelowitz spent time with The Body Shop, McDonald’s and some great social enterprises, understanding what makes replication and franchising work.   In this model a proven business model is ‘boxed’ up and passed on to others to replicate with appropriate support. Social franchising follows the same principle, allowing an organisation to package what works and provide support to others to adopt it, with a focus on replicating impact. This retains the essence and fidelity of the core elements of the approach, while remaining flexible and open to adaptation to the local context.

It is this model that we recommended to NSPCC for scaling their Baby Steps programme, with the charity transitioning from being the direct provider of the service, to acting as a franchisor overseeing implementation by local mainstream organisations such as Children’s Centres and also by midwifery teams. We believe this model enables NSPCC to ensure fidelity to the evidence-based model, whilst enabling local ownership.

Case study: Can this model be translated to a primary care setting? 

One of the project teams we met with to explore these replication models was the team responsible for IRIS (Identification & Referral to Improve Safety), a general practice-based domestic violence training, support and referral programme for primary care staff. Since beginning the research trial in 2007 to becoming a commissionable model in 2010, IRIS has been commissioned across the UK, leading to increased identification and referrals for victims of domestic violence. Having successfully scaled to date by responding to requests for their service, the IRIS project team is now at a point in their scale journey where the team wants to be more proactive in its replication approach.

We worked with the IRIS team to discuss what they felt was working well with their current network and any areas for improvement. Together we considered the type of relationship the central IRIS team need with those delivering IRIS locally, so they are able to be effective and achieve the desired level of impact. This included exploring what they considered to be the core requirements for delivering the IRIS programme at local sites and how they can best quality assure and support local teams.

The team is now working to convert their current replication system to a social franchise, developing the details of their required relationship with teams delivering the IRIS programme and the legal agreements which will form the basis of these relationships. Ultimately, the team hopes this more structured approach to replication will allow them to effectively support teams in new areas to adopt the IRIS model.   The IRIS social enterprise was incorporated in February 2017.

Next steps

As we met with project teams many echoed our excitement about these replication models, seeing them as an innovative approach to scale in the NHS.

We know there are a range of risks and challenges to making these models work in a system as complex as the NHS. Social franchising presents a new way of working which would require a significant culture shift, across practitioners, commissioners and other stakeholders.

However, at ICSF we believe that, sometimes, social franchising may just be the answer. The Health Foundation is starting to plan a new programme to further test social franchising. We look forward to meeting more teams across the country and to sharing learning over the coming months. 

Martha Paren is Director of Health at the International Centre for Social Franchising