Scaling innovation in social care

Studies highlighted the importance of identifying when a problem is complex (as opposed to complicated[1]) and engaging with it appropriately. This is of particular relevance to social care, where problems are likely to be complex rather than complicated. Fenge (2015) suggests that many problems in social care bear the hallmarks of ‘wicked problems’, they have multiple contributory elements, are intractable and difficult to solve.

Acknowledging and engaging with complexity is particularly relevant when we bear in mind the social care environment, which as a number of studies noted is a particularly difficult context for innovating and scaling. Social care takes place in the context of a highly regulated system, where provision, commissioning, funding, regulation and quality assurance are distributed amongst numerous organisations from the public, private and (often) third sector. An innovation, particularly one which has a significant impact on care, is likely to have to interact with all components of that system, and if one aspect breaks down or doesn’t accept or support the innovation, that can hinder attempts to scale.

The review identified the importance of having adequate funding and resources for scaling to take place. Typically, in social care we are not going to be talking about new types of provisions, rather it will be a new way of delivering an existing provision, for example, a new model for providing accommodation, or a new way of providing personal support. As such, there will need to be a transition and some costs associated with starting up and growing the new service. In some cases, double running may be necessary to smoothly transition from one service or approach to another without negatively impacting on people’s care.

However, there is often limited funding available specifically for scaling. The idea of ‘investing to save’ may be widely accepted, but in practice authorities and other funders have limited flexibility to invest up front, particularly in the current economic context.

Recruitment and staff turnover are also an issue of significant relevance to social care. As a sector, social care has a very high staff turnover rate, 30.8 per cent in adult social care in England in 2018/19 (Skills for Care, 2019). Recruitment is also an issue, the same report found that ‘7.8 per cent of roles in adult social care were vacant, equivalent to 122,000 vacancies at any one time’ (Skills for Care, 2019). There are consequences here for scaling innovations in adult social care. Growing and spreading services will require recruitment of new staff, and high turnover rates can mean that attempts to embed and disseminate new ways of working are hindered, leading to delays and potential additional costs, for example, for recruitment and training.

Social care is a highly regulated sector, and has an association with being risk averse. There are good reasons for a high degree of regulation and risk aversion within social care. The intention is to ensure services are of good quality and to protect people who receive services from abuse. However, risk aversion can be used as an excuse to resist any attempt at change, and can limit attempts to grow and scale innovations. It is important that there is some agreement on what constitutes an acceptable risk, and how that risk should be managed amongst all parties involved in commissioning and providing care for people.

Taking a co-production approach can help mitigate some of these difficulties. Co-production should involve people who use services to design services which work for them. But it can also involve those who are delivering services, and as such provides a way to engage commissioners and the workforce, and overcome some of those potential issues with risk aversion and reluctance to change practice. Co-production is also a way of finding shared solutions to difficult problems, particularly when compromise on one (or more) sides is necessary. If all stakeholders are involved they can learn from one another, understand each other’s perspectives, and the restrictions they are under.

Many of the studies identified the importance of evidence for demonstrating efficacy and building a case for change. Studies identified that as well as evidencing outcomes, it was important to record and evaluate the process of delivering the innovation so that they can be spread effectively. It follows from this that adequate funding and resources need to be provided for evaluation of innovations, to support the scaling stage.

Greenhalgh et al. put forward a conceptual model for considering the determinants of diffusion, dissemination and implementation of innovations in health care organisations.

Greenhalgh et al. state that the model is intended mainly as a memory aide for considering the different aspects of a complex situation and their many interactions, and that it should not be viewed as a prescriptive formula.

The Sustaining Innovation in Public Services (SIPS) model (Brown, 2015) poses a set of questions that can be used to analyse and describe the context within which an innovation is going to be trialled. The intention is that the questions are asked at the beginning of the implementation process to highlight potential issues that might emerge as the innovation is put in place. These are then repeated once the innovation has been implemented to detail the process and changes (or adaptations) that have been made as time passes. It aims to both assist with implementation and to provide knowledge which can be passed on to potential second sites, therefore assisting and supporting the scaling up and sustainability process.

There are four sections to the SIPS tool:

1. Defining the project/programme/innovation
   Section 1 asks questions to produce a clear description of the main characteristics of the innovation. Importantly, this section also identifies the proposed ‘theory of change’ that the innovation employs, namely what the aims are and how it proposes to achieve them. This is perhaps the most critical and important part of the information being gathered.
2. Implementation in your environment
   Section 2 considers the governance arrangements and the readiness of the organisation and environment to adopt the innovation.
3. Resources
   Section 3 identifies the costs/resources involved in implementing the innovation.
4. Next steps
   Section 4 explores the plans for sustainability and spread of the model, including what type of evaluation is required or going to be necessary as proof of change.

NHS England (2018) sets out a ‘model of large scale change’ which focuses on the process of creating and leading large-scale change. It consists of seven related elements.

The elements interact and at the centre is an iterative process of engagement, reflection and change.

The Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework (Greenhalgh et al., 2017) considers influences on the adoption, non-adoption and take-up of patient-facing health and care technologies.

The framework identifies seven domains which relate to the innovation and its adoption or spread. Each domain is classified as:

• simple (straightforward, predictable, few components)
• complicated (multiple interacting components or issues)
• complex (dynamic, unpredictable, not easily disaggregated into constituent components).

Programs characterised by complicatedness proved difficult but not impossible to implement. Those characterised by complexity in multiple NASSS domains rarely, if ever, became mainstreamed.

Again, a key part of the framework is a continuous process of embedding and adaptation over time.

The NASSS framework could be helpful to social care organisations in considering challenges to implementation of a range of technology-supported health or care programs.

Greenhalgh et al. suggest that It could be used prospectively and in real time to predict and explore the challenges of implementing an existing technology to support a new program, or it could be used retrospectively, in reflective practice to explain failures in adoption and spread.

• Myths and mechanisms: a brief note on findings from research on scaling and diffusion (Innovation Unit, 2015)
• Against the odds: successfully scaling innovation in the NHS (Innovation Unit and The HEalth Foundation, 2018)
• A summative report on the qualitative evaluation on the eleven remodeling social work pilots 2008-2011 (Children’s Workforce Development Council, 2011)
• New models of home care (King’s Fund, 2018)
• Scaling and deepening the Reclaiming Social Work model: evaluation report (Department for Education, 2017)
• Mainstream or margin? The current use of family group conferences in child welfare practice in the UK (Brown L. (2003) Child and Family Social Work, 8(4), 331–340, 2018)
• A Lasting Legacy? Sustaining Innovation in a social work context (Oxford British Journal of Social Work)
• Adoption and spread of innovation in the NHS (King’s Fund, 2018)
• Adult social care. Ninth report of Session 2016–17 (Communities and Local Government Select Committee, 2017)
• Social innovation in health and social care (The Young Foundation, 2016)
• Barriers and facilitators to replicating an evidence based palliative care model (Davis EM. et al. (2006) Home Health Care Services Quarterly, 25(1–2), 149–165)
• What does it take to go big? Insights on scaling social innovation from the Centre for Social Action Innovation Fund (Nesta, 2016)
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• Insights from the spread of the primary care home (King’s Fund, 2019)
• ‘Wicked Problems’ in adult social care – responding through collaborative leadership (NCPQSW, 2015)
• Personalised Integrated Care Programme: sustainability, impact on hospital attendances and admissions, and lessons learned about spreading and scaling the model (Age UK)
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• Let’s talk about scale (Innovation Unit)
• Scaling new heights: how to spot small successes in the public sector and make them big (Doing What Works, 2010)
• Evaluation of the national roll-out of parenting programmes across England: the parenting early intervention programme (PEIP) (Lindsay G. & Strand S. (2013) BMC Public Health, 13, 1–32)
• Evaluation of the Homeshare pilots (SCIE and Traverse, 2018)
• Digital change in health and social care (King’s Fund, 2018)
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• Implementing large-scale quality improvement: lessons from The Productive Ward: Releasing Time to Care (Morrow E. et al. (2012) International Journal of Health Care Quality Assurance, 25(4), 237–253)
• Innovation in the public sector: How can public organisations better create, improve and adapt? (Nesta, 2014)
• Leading large scale change: a practical guide (NHS England)
• Glossary of terms pacesetter programme V4 December 2018 Final (NHS Wales, 2019)
• Spreading nursing unit innovation in large hospital systems (Pearson ML. et al. (2008) The Journal of Nursing Administration, 38(3), 146–152
• Sowing the seeds of innovation: Ideas for child and family services (Salveron M., Arney F. & Scott D. (2006) Family Matters(73), 38)
• Systemic conditions for innovation in children’s social care (Department for Education, 2017)
• Scaling-up innovations (What Works Scotland, 2015)
• The state of the adult social care sector and workforce in England (Skills for Care, 2019)
• Growing innovative models of health, care and support for adults (Social Care Institute for Excellence, 2018)
• Transforming care and support (Social Care Institute for Excellence, 2018)