This document discusses innovation at scale in healthcare systems. It notes that incremental change is no longer enough and that transformative change is needed. It presents models for exploring approaches to innovation, including national versus local strategies and ordered versus ad-hoc methods. Case studies are presented showing that some innovations persist over time while others fade or change, and that sustainability depends on factors like stakeholder values and implementation quality. The document advocates learning from both successes and failures to improve innovation strategies.

1. Innovation at scale
– the development paradox
Dr Christopher Loughlan

2. Structure
• Crisis point
• Some stats
• Evidence diffusion, innovation
• Metaphor for innovation
• Innovation barometer
• Innovation manifesto
• Innovation strategy
• Case study
• Culture
• Questions please…

3. The NHS timebomb letter: 'NHS and social care
services are at breaking point.
It cannot go on‘
06 October 2014

4. Some stats…
NHS net expenditure (resource plus capital, minus depreciation)
has increased from £64.173 billion in 2003/04 to £109.721bn in
2013/14. Planned expenditure for 2013/14 is £113.035bn
In 2013 the NHS employed 147,087 doctors, 371,777 qualified
nursing staff, 154,109 qualified scientific, therapeutic and
technical staff and 36,360 managers
.
Managers and senior managers accounted for 2.66 per cent
of the 1.364 million staff employed by the NHS in 2013

6. Question
Who orders bread for (the good citizens of) London?
The Undercover Economist Harford T 2006

7. The new era of thinking and practice in change and transformation: a
call to action for leaders of health and care (2014)
‘Fundamental, transformative care…
Small scale incremental change to existing models of care is no longer
enough to deliver the scale of change that our patients and populations
will need’
It is no longer enough to startegise for large scale change solely with the
logic of the past…To deliver change quickly enough and a wide enough
basis in our current era we need to supplement this with new thinking
about how change happens

8. Levers of change
Current world is governed by Transactional Model
- performance agreements, MoUs, contracts, compliance and inspection
regimes and incentive schemes
- staff held to account
Emerging world
- through a commitment to a common cause, built on a foundation of
relationships
‘As leaders of change in health care…we need to be able to operate at the
interface of both worlds. Both are essential. Success will come from
effectively operating both in tandem’

9. ‘As Professor Don Berwick ­ who wrote an outstanding report on
improving safety in the NHS last year – said, in a unified system you
have the ability to make systematic change on a national scale’
‘Sign Up To Safety’­ The path to saving 6,000 lives
Rt Hon Jeremy Hunt MP United Kingdom Secretary of State for
Health Visit to Virginia Mason USA March 2014

10. How to Spread Good Ideas A systematic review of the literature on diffusion,
dissemination and sustainability of innovations in health service delivery and
organisation
Greenhalgh T et al
Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO)
April 2004
Diffusion of Innovation
Extensive mapping exercise
Conclusions

13. "If We Build It, Will It Stay?" A Case Study of the Sustainability of
Whole­System Change in London
Greenhalgh T Milbank Quarterly Issue 90 Vol 3 2012
Findings:
­ Some but not all services introduced were still running;
- others had ceased or been altered substantially to accommodate
contextual changes
- key cultural changes largely persisted, and innovative ideas and practices
had spread elsewhere.
- to draw causal links ..the sustainability of the original vision and capacity
for quality improvement was strongly influenced by (1) stakeholders'
conflicting and changing interpretations of the targeted health need; (2)
changes in how the quality cycle was implemented and monitored; and (3)
conflicts in stakeholders' values and what each stood to gain or lose.

14. Conclusions:
The sustainability of whole­system change embodies a tension between
the persistence of past practice and the adaptation to a changing context.
Although the intervention­focused question, What has persisted from the
original program? (addressed via a conventional logic model), may be
appropriate, evaluators should qualify their findings by also considering the
system­dynamic question, What has changed, and why? (addressed by
producing a meaningful narrative).

15. National
Local
OrderedAd­hoc
Model for
exploring
approaches

16. Metaphor – How does your garden grow?
N
S
L
R

17. National
Local
OrderedAd­hoc
­ we all look the same
+ standard/equity
­ sustainable
+ resourced
­ duplication
+ unearth a gem
­ liable to change
+ more scaleable

18. Innovation Barometer
4 criteria
a) scale (Sc)(standardisation)
b) scope (Sp) (who for?)
c) Sustainability (Sy)
d) Quality (Q) (standard)
Note
Public Health warning – this is not scientific; it is exploratory

19. National
Local
OR
Barometer
Sc Sp Sy Q
Sc Sp Sy Q
Sc Sp Sy Q
Sc Sp Sy Q

20. National
Local
OR
Barometer
Sc Sp Sy Q
Sc Sp Sy Q
Sc Sp Sy Q
Sc Sp Sy Q

21. National
Local
OR
Barometer
Sc Sp Sy Q
Sc Sp Sy Q
Sc Sp Sy Q
Sc Sp Sy Q
Case study

22. National
Local
OrderedAd­hoc

23. Innovation Manifesto!
Copy
Build
Measure
Learn
Share

24. Innovation Strategy
“On an average week, most people
come up with at least one good
idea”
Take the “pain” out of the
activity
Ease it

25. Case Study
Speakset (UK)

27. Key observations
Get good data
­ show positive results
Demonstrate economic benefit
­ save money
­ assuming no perverse incentives
Save workforce time
­ especially higher trained staff

28. To summarise…
Time
Nos

29. Entrepreneurial approach System approach
1 1
(n+1) E (entire system)
(n+1) +1
(n+1+1) + 1
Can (efficacy) Mandate (must)
Does (effectiveness) Moral (should)

30. Nothing lasts for long….
Joni Mitchell Chinese Café 1982

31. Nothing lasts forever.
NOTHING LASTS 4EVA
Unknown Philosopher and graffiti artist ,
Cambridge UK 2014

32. In the end…..
Culture, culture, culture
‘In the end, culture will trump rules, standards and control strategies
every single time, and achieving a vastly safer NHS will depend far
more on major cultural change than on a regulatory regime
A promise to learn – a commitment to act Berwick Report 2013

33. Questions please