Scaling innovation in social care
Rapid pragmatic evidence review: summary report
Published June 2020
SCIE undertook a rapid pragmatic literature review of publications since 2015 to provide a baseline understanding of the evidence on scaling innovation in adult social care. We were specifically interested in significant or large-scale change, and searched for examples of good practice and factors which hinder and facilitate scaling of innovations.
Examples of scaling innovation
We found few reports of specific innovations in adult social care which had scaled significantly in the time period covered by this review. We extended the remit to include health and children’s social care, but there were still relatively few published examples of single innovations which had scaled significantly in the time period covered. Across all three fields there were a number of reviews of scaling innovation which were published after 2015, but drew on examples prior to 2015. This review is based on evidence from those reviews as well as the smaller number of studies of individual innovations and innovation programmes.
What facilitates or hinders scaling of innovations in adult social care?
Across the literature we found that common themes to do with scaling innovations had been identified. Following Albury et al. (2015) we divided the themes into those which are closely related to the innovation or change itself, and are (to some extent) within the power of the innovator to influence; and those which are external to the innovation, to do with the wider context or system, and are harder for the innovator to influence directly. This latter category may be particularly relevant for commissioners, funders, policy-makers and others who wish to drive or facilitate the scaling of innovation.
Factors at the level of the innovation
- The importance of evidence for demonstrating efficacy and building demand.
- Maintaining effectiveness while adapting to context.
- Scaling is iterative and requires reflective learning.
- The need to acknowledge and engage with complexity.
- Scaling is different from innovating and may require different leadership/teams.
- Leadership is necessary, but it is important to scale groups or teams rather than lone champions.
- Acknowledging that change takes time and commitment.
- Engagement and co-production with people who use services is key.
- The need to plan for scaling.
- Having a clear vision and building shared understanding.
- Having adequate resources, both financial and human.
- The impact of recruitment and turnover of staff.
- Professional and management risk aversion.
- Reluctance in the sector for partnership working.
Factors external to the innovation
- Acknowledging that social (and health) care is an inherently difficult environment for innovating and scaling.
- The need to provide funding to support scale and spread.
- The importance of networks for spreading innovations and sharing knowledge.
- The importance of support from leadership and management.
- The need to allow time for scaling and embedding.
- The use of policy and financial levers to encourage adoption.
- The need to capitalise on national and local priorities.
- The importance of commissioning for sustainable spread.
We suggest that all of these factors are important for scaling innovations and large-scale change in adult social care, but there are seven which are of particular relevance in the context of adult social care, and which innovators and those wishing to encourage scaling of innovations in adult social care should pay particular attention to.
1. Acknowledging and engaging with complexity Open
Studies highlighted the importance of identifying when a problem is complex (as opposed to complicated) 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.
2. Social care is an inherently difficult environment for innovating and scaling Open
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.
3. Having adequate resources and funding to support scale and spread Open
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.
4. Recruitment and turnover of staff Open
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.
5. Risk aversion Open
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.
6. Engagement and co-production with people who use services Open
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.
7. The importance of evidence for demonstrating efficacy and building demand Open
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.
Models and frameworks for planning and understanding scaling
The review identified a number of frameworks or models for scaling and spreading innovations. These models may help innovators and supporters of innovation by providing a framework for planning and understanding scaling which incorporates the factors identified above. The review identified four in particular that have potential for further exploration and use in adult social care because they explicitly engage with the complexity and difficulty of scaling innovations in contexts like this.
To see illustrations of these models, please download the full PDF.
Greenhalgh’s conceptual model Open
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.
Sustaining Innovation in Public Services (SIPS) Open
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:
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.
Implementation in your environment
Section 2 considers the governance arrangements and the readiness of the organisation and environment to adopt the innovation.
Section 3 identifies the costs/resources involved in implementing the innovation.
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.
- Defining the project/programme/innovation
NHS Model of Large Scale Change Open
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 framework Open
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.
The evidence reviewed suggests that all the factors identified are important for successful scaling of innovations. Innovations in social care may need to pay additional attention to seven factors which are of specific relevance to social care:
- Acknowledging and engaging with complexity
- Social care is an inherently difficult environment for innovating and scaling
- Having adequate resources and funding to support scale and spread
- Recruitment and turnover of staff
- Risk aversion
- Engagement and co-production with people who use services
- The importance of evidence for demonstrating efficacy and building demand.
Using of one of the models identified above, or a similar framework, can help innovators to identify potential areas of difficulty when planning and designing an innovation. Use of formal models also allows innovators to record and analyse progress in a systematic way which can help increase scale and spread.
About the Social Care Innovation Network
The Department of Health and Social Care is funding SCIE, Think Local Act Personal (TLAP) and Shared Lives Plus to develop the Innovation Network to help local areas take innovative approaches to social care which work.
The Innovation Network will bring together:
- innovative providers
- interested citizens
The Network will support them and local authority commissioners, local partners, care providers and others to test new ideas and share learning and support with others.
Further reading Open
- 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)
- Delivering digital health and well-being at scale: lessons learned during the implementation of the Dallas program in the United Kingdom (Devlin AM, McGee-Lennon M, and O'Donnell CA et al. (2016). JAMA, 23(1), pp.48–59)
- 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)
- Diffusion of innovations in service organizations: systematic review and recommendations (Greenhalgh T, Robert G, and Macfarlane F et al. (2004) The Milbank quarterly, 82(4), pp.581–629
- Beyond adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologie (Greenhalgh T, Wherton J, Papoutsi C, and et al. (2017) Journal of Medical Internet Research 19 (11) e367)
- 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)
- The concept of scalability: increasing the scale and potential adoption of health promotion interventions into policy and practice (Milat AJ. et al. (2013) Health Promotion International, 28, 285–298)
- 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)