From innovation to widespread adoption: key principles

Transformative change depends not just on innovation, but the ability to implement, adopt, spread and scale what works to new settings. Successful spread of change requires significant focus on adoption (and adopters) and sophisticated approaches to adapting innovations for different contexts. 

Adopters are individuals, teams or organisations that implement an intervention in a different setting than the one in which it was originally developed. 

Moving from pilots to embedded, wide-spread implementation will require tailored strategies, honed skills and capabilities, new forms of leadership, learning systems and wider supportive infrastructure. 

Successful change in health and care systems depends not only on innovation, but on the ability to adopt, implement, spread and scale what works. 

Meeting the transformative ambitions set out in documents such as England’s 10-year plan will require spreading both cutting-edge innovations, (for example, in genomics or artificial intelligence), and existing solutions, (for example, flow management, cross-sector working, wearables, electronic patient records and workforce interventions), much more widely.

The Explain THIS: Spread, Scale-Up, and Sustainability resources define spread as taking, ​‘interventions that have been successful in one setting and implementing them somewhere else.’

Despite much ambition and enthusiasm, few improvement efforts that succeed locally end up being spread and sustained more widely (sometimes referred to as the ​‘replicability problem’). Even good practices that see some spread rarely reach everywhere that could benefit. 

The reasons spread fails are many and varied, but two overarching factors emerge strongly in the research literature:

1. Too much focus is placed on initial innovation, rather than what is required for successful adoption.
2. Spread is seen as overly linear and straightforward, where an intervention can be faithfully ​‘lifted’ from one setting and ​‘shifted’ to another. Insufficient attention is paid to the complexity and unpredictability of adoption in different contexts.

In response, various frameworks have been developed to support adoption and spread. We share some of the most useful ones throughout this briefing. 

Based on the best evidence and Q’s experience supporting adoption and spread over the past decade, we set out here eight key principles to guide this work.

We recommend using them as supportive tools to inform the complex work of adoption – not rigid processes to be followed. Indeed, many frameworks explicitly advise adopters to use them in this way.

The Spread Challenge report defines an innovator as ​‘the individual, team or organisation that developed the idea for the intervention or that first implemented it’. Innovators must design for the adoption and spread of an intervention from the outset. 

Spread is a social and not purely technical process. It is therefore important to consider what relational work – including building trust, relationships and a shared sense of purpose – is needed for an intervention to succeed. Designing an intervention to be adaptable can help ensure it will work in other settings. 

Improvement approaches can be used to codify the intervention and think through what adopters will need to know in order to reproduce it successfully. Codification can provide clarity on what is core to making the intervention work and what is adaptable. The Medical Research Council provides useful guidance for identifying the core elements of an intervention.

Co-designing with stakeholders at all levels – from early adopters, beneficiaries, experts, commissioners to national policy makers– can also help determine what contexts and elements will enable the intervention to spread.

Adopters are individuals, teams or organisations that implement an intervention in a different setting than the one in which it was originally developed. 

Adopters, particularly those involved in the early stages (sometimes referred to as ​‘co-innovators’), are not passive recipients of interventions but active agents in shaping how they are adapted and refined through learning and experimentation. 

Leaders and policymakers need to support adopters – not just innovators – to effectively and sustainably embed change. Much like innovators, adopters need to take a test-and-learn approach. Improvement approaches such as Plan, Do, Study, Act cycles can be helpful here, along with other tools and methods.

Recognising this complexity is essential to ensuring meaningful, sustainable change that reproduces the benefits of the intervention when spread to other contexts. 

The NASSS framework helps innovators and adopters identify and understand the complexity they are operating within. It outlines seven domains for complexity:

• the nature of the health condition or illness
• the type of technology or intervention
• the value proposition
• the role of intended adopters
• the organisational capacity and support structures
• the complexity of the wider system
• the potential for continuous embedding and adaptation over time.

Throughout both the innovation stage and early adoption, it’s important to identify which elements of an intervention are core and which can be adapted locally. Tailoring implementation allows teams to respond to local needs, build ownership and integrate change into existing workflows and cultures. 

The Dynamic Sustainability Framework can help adopters with this tailoring. It considers the specific intervention alongside the implementation context (staff, organisational and technical infrastructure, learning approaches) and ecological system (including other clinical settings, the legislative and regulatory environment, market influences, and population characteristics).

Successful adoption is hard work. It requires high-level ​‘technical’ skills such as developing business cases and programme theories, and navigating governance or procurement processes. It also requires flexible leadership skills such as being able to make good judgements with limited data, managing conflict and resistance to change, dealing with unpredictability and network building. 

These skills need to be actively cultivated across the system. The reservoir of existing skills also needs to be tapped – especially from practical expertise in what makes adoption efforts succeed and fail.

Adopters need time, space and support to test and tailor interventions to their specific context. They need to consider organisational and system readiness – and assess what infrastructure needs to be in place. 

Adopters should be supported in doing so by coordination and leadership that provides strategic direction and resources, tools and training for staff as well as appropriate governance and assurance regimes.

Based on the Health Foundation’s Adopting Innovation Programme, The Innovation Unit developed the Adoption of Innovation Wheel. It highlights four categories of skills and capabilities required to support the uptake of innovation: 

1. creating authorising environments
2. supporting adoption projects
3. building capabilities
4. nurturing enabling cultures.

See also the 3S Scale-Up Infrastructure Approach, which includes three infrastructural components needed to support large-scale implementation: structure, strategy and support (including reliable data monitoring systems for regular reviews).

Leaders play a critical role in adoption. A step change in successful spread will require new leadership behaviours across all levels. NHS Horizons’ Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide sets out seven key principles for spread and adoption. 

Key among them is the need for an enabling style that shifts leadership mindsets from directing people what to do, to ​‘my role is to think about how I can facilitate and enable adaptation, emergence and change’. The guide also emphasises the need to support adopters to have a sense of agency and feel energised, focus on the benefit rather than the innovation, recognise complexity and build communities for change.

Learning is not a by-product of change – it’s a driver. Conventionally, knowledge has been seen as generated solely by innovators. But adopters generate valuable insights through adapting and testing interventions in new settings.

Adopters must be able to learn from what’s working elsewhere. This means investing in structures and spaces that enable cross-organisational learning based on evidence about how change spreads. 

These can include structured collaboration-based approaches or peer-learning-based networks such as the Q community. We provide a learning infrastructure that spans professions, sectors and geographies, creating the conditions for shared learning and collective progress.

Throughout the adoption and spread process, it is also important to learn from data. This can help adopters better understand what works and what doesn’t and adapt an intervention as needed. Learning systems with data that’s as real time as possible can help track progress, evaluate impact and share best practice.

A range of formal evaluation approaches will also be needed to inform successful ongoing adoption. This includes ongoing tracking against intended outcomes, case study approaches to really understand how and why a context is influencing adoption efforts, and longitudinal research to distil best practice for adoption across different settings over time.

System decision-makers need to work with innovators and adopters. They can help set up mechanisms to adopt innovations that benefit the health care system and patient care through funding, setting up financial or regulatory incentives and creating sustainability plans. 

Work funded by the Health Foundation and largely echoed in Roland Sinker’s review in England highlights the importance of local innovation–implementation ecosystems for supporting adoption and spread. These can provide central coordination, disseminate information and help catalyse partnerships.

The adoption and spread of digital solutions require particular attention. New technologies and digital solutions are often purchased from private companies based on vendor hype, persuasion and ​‘fail fast’ development efforts. The NHS Technology Evaluation Safety Test can help enable evidence-based choice and support the safe and effective scaling of technology.

While most key principles of adoption and spread also apply here, specific considerations around digital interventions include information governance and ethics, interoperability with existing infrastructure and the trust and confidence of staff and patients.

Many technological solutions are developed outside the UK, further complicating adoption. There is also often insufficient attention given to supporting the implementation of digital solutions, including the human factors required.

The health and care system has no shortage of successful innovation and improvement projects, but we have to get better at adopting and spreading their successes. This is demanding, skilled, complex and, sometimes, long-term work. 

We need to challenge unrealistic expectations of rapid, linear processes of spread at scale. But we also need to much more effectively draw on everything we know about spread and put it into practice, to enable change to happen as quickly and effectively as possible. 

• Explain THIS: Spread, Scale-Up, and Sustainability
• Spring Impact’s The Scaling Impact Toolkit
• NHS Horizons Resource to help you Spread and Scale Innovation and Improvement
• Sign up to Q’s community site and join Q’s Adoption and Spread Collective – Q Community