The reading task for the session on "change programmes to change platforms" from Helen Bevan at NHS Confederation conference 3rd June 2015

1. Helen Bevan
With help from
David Fillingham
and
Steve Fairman

2. “Unless a program can be replicated and
sustained on a large scale, it will not be
transformational…..
We can no longer evaluate [change]
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

3. Over the past 18 years there have been more than 100
NHS-wide pioneer/pathfinder/pilot/demonstration sites

4. “Pioneering
is the enemy of
transformative and
systematic change”
David Albury
The Innovation Centre
Why, after
nearly two
decades,
haven’t we
created an
unstoppable,
system-wide
drive for
improvement?

5. 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
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
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)
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

6. Few evaluative studies look beyond the pioneers to the
issues of scale & spread so empirical evidence is limited
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
6. The pioneer localities have limited bandwidth to coach others & spread best
practices
7. Local leaders are understandably much more concerned with local change
than they are with spread; leaders of the “bigger system” must act as
catalysts for spread
8. The commitment, characteristics & skills of local clinical leaders is often the
crux issue for change in specific settings
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 & sustainability

7. • New models of care implemented more widely
than initial pilots tend to show limited or
negligible impact (Perla & colleagues)
• The typical effect sizes of spread activities are
perhaps 10-20% at best (Grimshaw)
• There is a tendency towards “cargo-cult”
improvement, where 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)
• When promising innovations are not adopted,
policymakers may turn to regulation to ensure
compliance; a strategy with limited impact
(Leape)

8. • Discuss the slide deck with the people around
you
• Identify some actions we should take to
address these issues and enable large scale
change across the system
• Put each idea on a separate post-it note

9. Allcock C (2015) Constructive comfort; accelerating change in the NHS The Health Foundation
Buchanan 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 Research
Damschroder J et al (2008) Fostering implementation of health services research findings into practice: a
consolidated framework for advancing implementation science BMC Health Services Research
De Silva D (2014) Spreading improvement ideas: tips from empirical research The Health Foundation
Dixon-Woods M et al (2011) Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement
Program Milbank Quarterly
Dixon-Woods M et al (2013 Explaining Matching Michigan: an ethnographic study of a patient safety program
Implementation Science
Greenhalgh 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
Ham C et al (2002) Capacity, culture and leadership: lessons from experience of improving access to hospital
services: Final report from the evaluation of the national booked admissions programme first wave pilots
University of Birmingham report
Ham C (2014) Reforming the NHS from within The Kings Fund
Hamel G (2014) Build a change platform, not a change program McKinsey Quarterly
Health Service Journal, Nursing Times and NHS IQ (2015) The Change Challenge
Leape L (2014) The Checklist Conundrum New England Journal of Medicine
Negroponte N (2014) A 30-year history of the future TED talk
NHS Institute for Innovation and Improvement (2012) The spread and adoption tool
Perla R et al (April 2015) Health Care Reform And The Trap Of The “Iron Law” Health Affairs blog
Randall S (2015) Using communications approaches to spread improvement The Health Foundation