How do we ensure that we sustain the

great work from each vanguard and

spread it up and down the country?

@HelenBevan#FutureNHS

@HelenBevan #FutureNHS

Our spread goals

By 31st March 2017, to have implemented eight key elements of integrated urgent care for 20%

of the national population

By 31st March 2020, to have implemented IUC across the whole of England

@HelenBevan #FutureNHS

A story

@HelenBevan #FutureNHS

What is a theory of change?

• Created at the early stages of a spread intervention

• An explicit hypothesis that links actions with goals: “if we do this, this and this we will produce that result.”

• Likely to deliver better outcomes• Builds learning• Complements “change models” and

“methodologies”Bevan, Plsek & Winstanley

“In science, a good theory reveals compelling hypotheses that subsequent experiments will validate”

Todd Zenger

@HelenBevan #FutureNHS

Task

Draw a picture of how we will achieve the spread goals for IUC vanguards

Choose the level you want to depict:• A geographical area• Between geographical areas• Across England

@HelenBevan #FutureNHS

The theory of change for spread needs to be strongly linked to a narrative for spread

Theory of change• Roadmap for

change• Preconditions• Underpinning

assumptions• Change process• Outcomes

Story/narrative• Connecting to

bigger purpose• Creating meaning• Commitment to

change• Engagement/

mobilising• Compelling people

to act

shar

ed v

alue

s

In trying to bring people together to take action, we get the best results if we appeal to their values, rather than intellect or facts

Ted Fickes Shared values: where theory of change meets storytelling

@HelenBevan #FutureNHS

Some definitionsDiffusion: "the process in which an innovation is communicated through

certain channels over time among the members of a social system”Rogers 1962

Spread: “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

Scale up: “An enterprise with annual growth in turnover > 20% per annum over a three year period, and with more than ten employees at

the beginning of the period”Coutu 2014

@HelenBevan #FutureNHS

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 help to build a body of

knowledge

We found that the factors of sustainability are also the factors for effective

spread

Spread and sustainability

@HelenBevan #FutureNHS

5 big messages from spread efforts• Ideas do not spread instantly but flow between

groups of people• An idea or change spreads because someone

chooses to adopt it• Ideas commonly go through a process of

reinvention as they spread• “Getting to scale” beyond the initial innovators

is the hardest part• The environment and context is as important as

the idea or change and its implementation

@HelenBevan #FutureNHS

@HelenBevan #FutureNHS

Globally, we see the same challenges

With alarming regularity,

many promising pilots in the

health care improvement

and implementation field

have little overall impact

when applied more broadly”

Perla & colleagues,

Health Affairs blog,

April 2015

@HelenBevan #FutureNHS

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)

Cargo cult http://www.learningsolutionsmag.com/articles/1909/nuts-and-bolts-the-cargo-cult-of-training/pageall

@HelenBevan #FutureNHS

Components of a spread model• A spread goal• Metrics to show that the goal is being achieved• A hypothesis/change theory of how it is going to

be achieved• A spread plan, covering both anatomical and

physiological components of change• A way of assessing readiness for spread (both the

robustness of the solution and the conditions for spread)

• A spread narrative

@HelenBevan #FutureNHS

@HelenBevan #FutureNHS

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

@HelenBevan #FutureNHS

My favourite spread referencesBarker P, Reid A, Schall M (2016) A framework for scaling up health interventions: Lessons from large-scale improvement initiatives in Africa Implementation ScienceBuchanan D et al (2007) The sustainability and spread of organizational change: modernizing healthcare Clay-Williams R et al (2014) Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review BMC Health Services ResearchDe Silva D (2014) Spreading improvement ideas: tips from empirical research The Health FoundationGartner (2014) The Gartner hype cycleGreenhalgh T et al (2004) Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations Milbank Quarterly Grimshaw J et al (2012), Knowledge translation of research findings Implementation Science Kastelle T (2016) We’ve hit peak innovation (hype)McClure D & Gray I (2015a) Scaling: Innovation’s Missing Middle McClure D & Gray I (2015b) Managing the journey to scale up innovation in the humanitarian and development sectorNHS Institute for Innovation and Improvement (2012) The spread and adoption toolMcCannon J (2011) The spread problemMoore G (2015) Crossing the chasm: marketing and selling products to mainstream customersNorton W et al (2012) A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in healthPerla R et al (April 2015) Health Care Reform And The Trap Of The “Iron Law” Health Affairs blogRandall S (2015) Using communications approaches to spread improvement The Health FoundationSchall M & Schilling L (2014) An introduction to spreading effective practices and From sustainability to spread and scale up