Understanding the spread challenge

For several years now, the Health Foundation has supported teams to spread innovation and improvement through programmes like Closing the Gap and Scaling Up, with investment of over £26m in this area over the last decade. Along the way, we’ve seen that successfully replicating a new idea in a different setting can often prove a real challenge. In our recent research, we’ve had the chance to work with these grant holders and evaluators to learn directly from their experiences and draw insight from their work.

Why is spread such a challenge?

So many important policy agendas for the health service – such as improving quality, reducing variation and improving efficiency and productivity – are built upon the assumption that if something can work somewhere then it can work everywhere. 

But it’s not just that getting other organisations to take up new innovations and ways of working can be difficult. Even when they do, it can often be a challenge to get the innovations in question to work as well as they did first time round. Take surgical safety checklists, for example, which have had a significant impact in reducing mortality and surgical complications in some cases, and virtually no impact in others. The truth is that the very different contexts – different systems, cultures, and relationships – in which teams are working and their varying abilities to implement change often make it a real challenge to translate an innovation into a new setting, and to replicate the outcomes of a successful pilot.

Exploring what works

What’s the answer? Part of it is a more intelligent approach to thinking about the ‘what’ of an intervention – what it is that is actually being spread. Often, rather than focusing simply on the technical dimension of the intervention, successful spread also requires thinking about what needs to accompany it in terms of the skills, methods, culture and behaviours needed for successful implementation.

This can be seen in the Flow Coaching Academy. Several years ago, as part of the Health Foundation’s Flow Cost Quality programme, a team at Sheffield Hospitals NHS Foundation Trust developed an approach to improving flow along clinical pathways, which they are now seeking to spread through a coaching approach, delivered via an expanding network of academies across the country. Even though the Sheffield team’s original work resulted in a very successful and much imitated intervention, ‘Discharge to Assess’ (where patients are discharged from hospital once they no longer need hospital care and then have their needs assessed at home, rather than waiting longer in hospital), they are trying to achieve these benefits at a larger scale by spreading the capability and methodology, rather than the intervention itself. As Tom Downes, who set up the Flow Coaching Academy puts it, “It’s that ability to adapt to local context that made us want to develop the academies as a model for spreading this kind of improvement at scale in the first place, rather than just focusing on spreading specific interventions that we knew worked.”

Social franchising represents another possible approach for combining the specification of what matters most for an intervention to succeed, on the one hand, with the flexibility to adapt it to a new local context and the support that adopters need for successful implementation, on the other. 

In social franchising, an intervention is packaged up in a manual and accompanied by training and support; in return, the franchisee pays a fee to cover the costs and shares data with the franchisor (the franchising is ‘social’ because it is being done for a social purpose, where fees go into sustaining the roll-out of the model rather than profit-making). As such, social franchising has the potential to offer both greater levels of support to adopters than some approaches to spread, and also greater control to the innovator to ensure fidelity to the original model, while still allowing appropriate local adaptation. 

Crucially, social franchising can provide a route to financial stability, which, as Alex Bax and Medina Johnson explain in their joint blog this month, can often be a real challenge when trying to spread new ideas. The Health Foundation’s Exploring Social Franchising programme is currently looking at the feasibility of social franchising for replicating innovations in health and care at a larger scale.

Distilling the learning

The Health Foundation’s latest research on spread offers lessons for policymakers too. A clearer understanding of the hard work required to make interventions work in new contexts means that, as Professor Sir Mike Richards highlights in his interview, system leaders need to support adoption as well as innovation. This could include funding to cover the up-front costs of adoption, assistance with analytics and evaluation, and peer networks to share learning. Crucially, it should also include support for organisations to build their improvement capability so that they have the knowledge and skills they need to test and adapt new ideas, and to successfully implement change on the ground. 

That is why the Health Foundation is calling for the forthcoming NHS long-term plan to include a new fund to build the capacity, skills and knowledge of health care organisations to improve quality, and also to ensure that national programmes to spread innovation are better designed to support adoption. For it is ultimately only by ensuring that health care providers are receptive environments for new ideas and well-placed to take them up that we can maximise the chances of successful spread.

Tim Horton (@timjhorton) is Assistant Director (Insight & Analysis) in the Health Foundation’s Improvement team.