Spreading improvement: nobody said it was easy

Spreading innovation and improvement has always been recognised as a challenge when it comes to health care.

Take handwashing. By the mid-19^th Century it had been convincingly demonstrated that handwashing by health care staff dramatically reduced patient infections. But it wasn’t until the 20^th Century that this principle was adopted into mainstream practice and even in the 21^st Century good practice is still far from universal, as NICE lamented in its 2014 Quality Standard on the matter.

Of course, not everything takes two centuries. But a study of more recent health care innovations from the 1960s to the 1990s nevertheless found it took an average of 17 years to implement them into standard care – hardly encouraging.

Stories like this should not breed defeatism, however. No-one said spreading innovation was supposed to be easy. But they do suggest something of the hard work and determination that is usually required for success.

For many years now the Health Foundation has worked with our grant holders to help them spread or scale up their ideas, so they can benefit the whole NHS. Our February newsletter showcases three of the 13 projects that have won grants in the latest round of our Spreading Improvement programme, which seeks to facilitate wider adoption of our grant-holders’ work.

The three projects all have ambitions of national spread, but working through different routes. Over the next three years, teams from South Manchester and South East Staffordshire will be working directly with sites across the UK to implement their new models of tracheostomy care and chronic obstructive pulmonary disease management, respectively. By contrast, the Devon Memory Service is looking to a partnership with Age UK as the mechanism for growing their new approach to supporting patients with Mild Cognitive Impairment, initially by training staff at local Age UK branches and then by developing a ‘train-the-trainer’ approach.

Looking back at the Health Foundation’s history of supporting spread further highlights the diversity of possible approaches.

For example, it was through funding a trial and then a commissioning guidance pack that we supported IRIS to spread, a training package to improve GP responses to domestic violence. By 2013, 13 Clinical Commissioning Groups (CCGs) were commissioning it, with training delivered to over 100 practices.

Another innovation we supported – featured in our recent Power of People films – was the ‘Flo’ text messaging app, which enables patients to receive reminders and health tips via their mobile phone, and this went down a social enterprise route to grow. Through Simple Telehealth, which licenses the package, it has now spread to more than 70 organisations, including CCGs in Birmingham, Coventry, Manchester and Newcastle. Later this year, the Health Foundation will be starting a new programme to create more opportunities for social franchising and licensing of the innovations and improvements we have supported.

And it isn’t just our own grant holders that we help to spread and scale their work.

We will shortly be announcing the successful applicants in the next round of our Scaling Up programme, open to all-comers who want to take successful health care interventions and deliver them at a larger scale. We are also a sponsor of the NHS Innovation Accelerator, a fellowship programme that supports proven innovations to be adopted faster throughout the NHS, delivered in collaboration with NHS England, UCL Partners and Academic Health Science Networks.

Elsewhere, we are supporting social investment approaches to spreading innovation through the Care and Wellbeing Fund, run by Social Finance, which aims to develop and scale community care services for people affected by cancer and other long-term conditions. In October, this Fund made its first investment – in Reconnections Limited, a ground-breaking programme for tackling loneliness and social isolation among older people in Worcestershire.

What our history of supporting spreading and scaling has taught us is just how complex it can be to take an idea from success in one place to success on a wider scale.

Perhaps the most fundamental lesson is the importance of context and method.

While drugs and medical devices tend to steal the limelight in textbook discussions of health care innovation, many of the projects that the Health Foundation has supported over the years are innovations or improvements in clinical processes. These processes are grounded in human behaviours and relationships, which makes spread complex. You can’t just ‘lift and shift’ an intervention from one setting to another, but need to work out what the specific ingredients of success were in each case – including, as highlighted in our article on lessons for promoting spread, how the intervention was implemented and why it worked.

This was a key conclusion of our Lining Up project, which studied the implementation of the ‘Matching Michigan’ programme, a National Patient Safety Agency initiative to reduce central venous catheter bloodstream infections (in an attempt to replicate the success of an earlier programme in Michigan). It found that even processes like infection measurement were social processes – dependent on staff attitudes and interactions – and so in reality practices varied widely between hospitals. Improvisation and adaptation mattered just as much as the activities specified in the project protocol.

The moral is that successful scaling and spreading is much more complicated than simply mandating action from the centre – which has historically been the National Health Service’s method of first resort. It is complex, takes time and above all requires taking other people along with you.

That’s why the teams the Health Foundation supports – people dedicated to working with others to spread improvements across the health service – play such an important role in advancing the quality of health care in the UK, and why we’re proud to support them.