Helen Bevan's slides on spread and sustainability of change at the urgent and emergency care vanguards quarterly forum, 19th May 201

1. How do we ensure
that we sustain the
great work from
each vanguard and
spread it up and
down the country?
@HelenBevan
#FutureNHS

2. @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

3. @HelenBevan #FutureNHS
A story

4. @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

5. @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

6. @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
sharedvalues
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

7. @HelenBevan #FutureNHS
Some definitions
Diffusion: "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

8. @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

9. @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

10. @HelenBevan #FutureNHS

11. @HelenBevan #FutureNHS
Globally, we see the same challenges

12. @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

13. @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

14. @HelenBevan #FutureNHS

15. @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

16. @HelenBevan #FutureNHS
My favourite spread references
Barker P, Reid A, Schall M (2016) A framework for scaling up health interventions: Lessons from large-
scale improvement initiatives in Africa Implementation Science
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
De Silva D (2014) Spreading improvement ideas: tips from empirical research The Health Foundation
Gartner (2014) The Gartner hype cycle
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
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 sector
NHS Institute for Innovation and Improvement (2012) The spread and adoption tool
McCannon J (2011) The spread problem
Moore G (2015) Crossing the chasm: marketing and selling products to mainstream customers
Norton W et al (2012) A stakeholder-driven agenda for advancing the science and practice of scale-up
and spread in health
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
Schall M & Schilling L (2014) An introduction to spreading effective practices and From sustainability to
spread and scale up