This is a talk that Helen Bevan gave at the NHS Transformathon with support from Zoe Lord, Jodi Brown and Hannah Wall at 4am on 28th January. The NHS Transformathon was a 24 hour virtual event to connect people from all over the world who are leading the way in transforming the health and care system. It took place on 27/28 January 2016. The entire event was a live broadcast on Google hangout. You can watch all of the sessions. Go to http://theedge.nhsiq.nhs.uk/transformathon/ and click on the title of the session you would like to view. The content is free and available to all. If you tweet about the content of the Transformathon, please use the hashtag #NHSTform

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Helen Bevan
@HelenBevan
Zoe Lord
@ZoeLord1

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Scale up and spread: definitions
“deliberate efforts to increase the impact of
innovations successfully tested in pilot or
experimental projects so as to benefit more people
and to foster policy and program development on a
lasting basis”
Norton and colleagues 2012
“Going to scale’ [means] at least 60% of the target
population that could potentially benefit from the
programme receives it”
Rabin and colleagues (2012)

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How do we measure success?
“Unless a program can be replicated and
sustained on a large scale, it will not be
transformational…..
We can no longer evaluate programs simply
based on how well they’ve performed in a
given locality. Instead, we need to factor in
their potential to achieve scale”
McKinsey on Society

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From 2001 to 2005, I was
responsible for the
Research into Practice
team within the NHS
Modernisation Agency
The team role was to
promote the spread and
sustainability of service
improvement and helped
to build a body of
knowledge
We found that the factors
of sustainability are also
the factors for effective
spread
Spread and sustainability

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We have more than 20 years experience of
spreading large scale change
“It has been positively
reviewed and reported in the nursing
& healthcare press and its implementation
is proven to produce significant savings in
productivity & efficiency”
White et al 2013
One of the most widely adopted and impactful
improvement programmes in the history of the NHS; “releasing
time to care”, typically 10-20% of the time of clinical professionals. The
changes were adopted by 78% of NHS hospital wards, 68% of mental health
wards, 54% of NHS operating theatres and 49% of community health
teams across England (SHA statistics) as well as 44 territories
across the globe
New Zealand: 19% of time“
released to care”
Oregon USA:
multi-factorial
improvements
Scotland:
“20% of time
released to care”
A significant,
positive impact on staff
engagement
Irish
research: the
effects were
sustained over
time
800,000
pledges;
engaged two
thirds of all NHS
organisations
Our most
successful ever
digital
campaign

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But the reality is often different

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Enthusiasts Visionaries Pragmatists Conservatives Laggards
Source: Geoffrey Moore, building on
the work of Everett Rodgers
Beware the chasm
The typical effect sizes of spread activities are perhaps 10-20% at
best (Grimshaw)

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Nine repeating patterns from pioneer/pilot type
programmes
#1
Promising pilot programmes are rarely
replicated successfully from pilot localities to
others; the wider and more complex the change,
(i.e., involving multiple organisations) the least
likely that spread will happen

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Kaiser Permanente spread model
Just do it
Innovate
Test and
replicate
CLEAR
COMPLEX
CHAOTIC
COMPLICATED
Source: Schall and Schilling

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Nine repeating patterns from pioneer/pilot type
programmes
#2
Most of the early effort and energy is needed to
make the pilot programme functional and issues
of spread & scale often end up being an
afterthought

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Nine repeating patterns from pioneer/pilot type
programmes
#3
We typically focus on extrinsic motivators to
change, rather than intrinsic & we don’t align the
motivators; as a result, change is often experienced
by people at the front line as “have to” (imposed)
rather than “want to” (embraced)

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Intrinsic motivation
People engage in the
activity for the pleasure
and satisfaction of doing it
Invokes many positive
behaviours
Extrinsic motivation
People engage in the
activity for the rewards or
avoiding punishment
Any external influence is
referred to as extrinsic
motivation
Images: pixgood.com

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The power of extrinsic drivers

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Three types of levers for large scale change
‘Prod mechanisms’
targets
performance
management
price & payment incentives
regulation
competition
‘Proactive support’
relies on building
‘intrinsic motivation’ in
staff to make
the right changes to
improve
‘People focused’
education and training
national contracts
professional
regulation
clinical
quality standards
Type one:
Type two: Type three:
Source: Health Foundation report Constructive
comfort: accelerating change in the NHS 2015

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Three types of levers for large scale change
‘Prod mechanisms’
targets
performance
management
price & payment incentives
regulation
competition
‘Proactive support’
relies on building
‘intrinsic motivation’ in
staff to make
the right changes to
improve
‘People focused’
education and training
national contracts
professional
regulation
clinical
quality standards
Type one:
Type two: Type three:
Source: Health Foundation report Constructive
comfort: accelerating change in the NHS 2015
Less than 10%
of the potential
for
improvement
at system level
can be
delivered
through type
one change

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Nine repeating patterns from pioneer/pilot type
programmes
#4
People outside of pilot locality don’t feel any
ownership of, or emotional connection with, the
pilot project. As a result, the change processes
can end up being “pushed” onto other localities
rather than “pulled” by them

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“In a world of mounting performance pressure,
[organisations and change processes] need to
evolve…the most successful will be those that
evolve into movements.
Success will be determined by their ability to
mobilise, inspire and support an
ever-expanding array of participants extending
far beyond their own four walls”
John Hagel, SXSW 2015
http://www2.deloitte.com/us/en/pages/center-for-the-edge/articles/john-hagel-at-
sxsw.html

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Closed innovation Open innovation
As a pilot test site , we want to
be left alone for a period of
time so we can work it out for
ourselves
As a pilot test site, we seek to
continuously get ideas and
guidance from leading thinkers and
practitioners outside our local area
We will test our new ways of
working internally “to
destruction”. When we are
confident they will work, we
will offer to share our “best
practice innovations” with
others
A wider group has contributed to
the innovation process, beyond our
host organisation; people from
other localities already feel that
they own it. Spread is more likely to
be “done with” not “done to” and to
be “pulled” not “pushed”

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The power of co-creation

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Open innovation is
a mindset, not just
a process
We would love to
share with others
but there don’t
seem to be any
takers

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#5
Even where we are able to create replicable change
concepts from the pioneering localities, if we don’t
have an implementation approach for spread that
engages different local contexts, it doesn’t work
Nine repeating patterns from pioneer/pilot type
programmes

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Innovations won’t put down roots if the ground
isn’t fertile
Source: David Fillingam
• National and regionally led
improvement initiatives have their place
• But “ sheep dipping” managers and clinical
leaders in programmes external to their local
communities is unlikely to have lasting benefit
• What’s more the learning won’t spread to
other communities (or even be sustained in its
place of origin) unless each community has its
own locally developed and owned culture and
system of improvement

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There is a tendency towards “cargo cult”
improvement
Attempts are made to
spread/replicate new models from
pilot projects without a proper
understanding of how they work.
They end up reproducing the
superficial outer appearance but not
the mechanisms that produced the
outcomes in the first instance
(Dixon-Woods & colleagues 2011)

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What is the best way to spread new
knowledge?
Source of data: Nick Milton
http://www.nickmilton.com/2014/10
/why-knowledge-transfer-
through.html
Social connection/discussion is
14 times more effective
than
written word/best practice
databases/toolkits etc.
Source of image: www.happiness-one-quote-time.blogspot.com

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#6
The pioneer localities have limited bandwidth to coach
others & spread best practices
Nine repeating patterns from “pioneer-type” programmes
in health and care in England
over the last 18 years

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#7
Local leaders are understandably much more
concerned with local change than they are with
spread
Leaders of the macro level system must act as
catalysts for spread
Nine repeating patterns from pioneer/pilot type
programmes

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“Choreographers of complexity”
Scale up efforts should be overseen by a
“choreographer of complexity”:
“An analogy can be made to the role a
choreographer takes in a dance company. Their job
is to produce a finished work that integrates many
different performance elements; music, dance, and
storytelling. This must be done by making trade offs
and finding synergies within the available resources
of the [organisation or system], and all the while
driving toward an ultimate vision.”
McClure and Gray (2015b)

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#8
The commitment, characteristics & skills of local
clinical leaders is often the crux issue for change in
specific settings
Nine repeating patterns from pioneer/pilot type
programmes

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“Perhaps the single most important influence on programme response by
individual units—either in promoting or resisting change—was the extent
of consensus and coalition among the senior medical and nursing staff….
Transforming or boosting of efforts was most likely to occur when those
locally charged with implementation were sincere in their beliefs about the
value of the programme, were able to create transdisciplinary alliances,
had local credibility among peers, were prepared to tolerate debate but
exercise firmness, and used multiple tactics including role modelling,
persuasion, sanctioning, reminders, and constant feedback….
[Consultant says] ‘I think it’s been successful because it’s a unifying
program, it’s one of the few things that we’ve done that hasn’t been just a
doctor thing, or just a nurse thing, it’s involved the doctors and the nurses
together.’”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3704826/

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Nine repeating patterns from pioneer/pilot type
programmes
#9
Sustainability of change is as much of a
challenge as spread of change. The same
receptive local contexts create the conditions
for both spread and sustainability (See
Buchanan and colleagues)

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Few evaluative studies look beyond
the pioneers to the issues of scale &
spread so empirical evidence is
limited

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Although studies in small samples provide useful
insights regarding local barriers and facilitators to
adoption, the relevance of these findings for efforts to
achieve large-scale adoption (i.e., scale up or spread)
in hundreds or thousands of institutions or
communities is limited.
Numerous practice-based efforts to scale-up and
spread evidence-based health programs have been
documented (although primarily in developing
countries), but this work only rarely employs scientific
methods for understanding and evaluating scale-up
processes and strategies, and thus offers limited
evidence and guidance for improving future scale-up
efforts.
Norton and colleagues

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What does the NHS workforce think?
14,000 contributors recently identified 10 barriers to
change:
Confusing strategies
Over controlling
leadership
Perverse incentivesStifling innovation
Poor workforce
planning
One way
communication
Inhibiting
environment
Undervaluing staff
Poor project
management
Playing it safe
Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change
Challenge” March 2015

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What does the NHS workforce think?
14,000 contributors recently identified 11 building blocks
for change:
Inspiring & supportive
leadership
Collaborative working
Thought diversityAutonomy & trust
Smart use of resources
Flexibility &
adaptability
Long term thinking
Nurturing our people
Fostering an open
culture
A call to action
Source: Health Service Journal, Nursing Times, NHS
Improving Quality, “Change Challenge” March 2015
Challenging the
status quo

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The Change Model

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How does it work and aid spread?
Zoe Lord - Improvement Manager @ZoeLord1 #NHSTform
Start with the Our
Shared Purpose
No order after Our
Shared Purpose = better chances of
success, sustainability
& spread…
Use all parts in equal
measure

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http://www.institute.nhs.uk/index.php?option=com_spread_and_adoption

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Actions supported by history#1:
Build in considerations of spread and adoption right from
the start of a major change strategy (not as an afterthought)
Make spread a
whole system
collaboration;
bottom up with top
down support
Use
adoption partners,
“sprints” for action &
Challenge Prizes to build
& sustain momentum &
interest in the wider
community
Use social
media & other
virtual channels to
keep the wider
community connecting
& learning from
each other
Encourage
social interaction
& discussion to spread
new knowledge,
rather than guidelines,
best practice
databases or
toolkits
Make
the “pioneers”
part of a wider
learning community
from the start & make
it easy for them to
interact with
others

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Use all our levers for change, both intrinsic and extrinsic, to
enable change to happen at scale
Actions supported by history#2:
Work on the deeper
environmental/cultural
factors that create a
receptive local context for
change at least as hard as
we work on the new
delivery processes
Create a spread
strategy which aligns
multiple drivers for
change & balances space
for innovation with
mechanisms for managing
complexity at
scale
Flip as many
levers as possible from
acting as extrinsic drivers
(“prods”) to acting as
intrinsic motivators
(“proactive support”) so
people want to not
have to
Align regulatory and
inspection functions to
incentivise rapid
adoption of the new
models of delivery

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Actions supported by history#3:
Create systems of support and encouragement for local leaders to
adopt the new models
Provide
targeted development
in the system leadership,
analytical & change
leadership skills needed to
implement the new models
(these are surprisingly
scarce) Don’t declare
victory too early; expect
setbacks; cherish failures
as opportunities to learn;
thank & praise those
who are working hard &
risking much
Assess & grow
the capability of the
improvement & leadership
development resources and
support leaders to
lead change from the
bottom up
Reinforce & role
model transformational
behaviours
Create the
opportunities and
support for teams to
come together
(physically & virtually) to
test, learn, develop and
improve

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What do the leaders who get the best spread
results do? They:
Source: McCannon
• Attempt remarkable things (provocation and optimism)
• Talk about justice
• Have a shared story
• Apply many levers
• Play jazz (adaptive, creative)
• Keep it simple (e.g., interventions, measurement systems)
• Model trust
• Seek affection and give recognition
• Break rules (avoid consensus, condense timescales)
• Go broad and deep
• Respect/revere logistics

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The conclusions of the very first national spread programme
in the NHS (National Booked Admissions programme from
1998) are still highly relevant
This evaluation has shown that there
are no magic bullet solutions….The main source of
change and service improvement has to come from within
each and every NHS organisation. Renewed effort now needs
to be put into developing the staff and organisations that can
embrace the kind of cultural change foreshadowed by the
NHS Plan. No amount of guidance, support, hectoring or
cajoling can substitute for the lack of capability and
understanding among the staff delivering care to patients of
the need to reshape the provision of services.
Chris Ham & colleagues, 2002