The nuts to crack when scaling innovation in end of life care

By Gina Mirow, Analyst at Social Finance

In 2018 the Health Foundation published a seminal report called The Spread Challenge, which addressed the challenges of successfully spreading innovation in health care. As the report explained:

“while the invention of new […] models of care are exciting moments in health care, invention itself is only half the story. People sometimes fall into the trap of thinking that when an idea has been successfully demonstrated or piloted then the hard work is done. But exploiting the full potential of a new idea requires successful replication at scale — and this takes time, skill, resources and imagination.”

The report concluded that change at scale is a hard nut to crack and adds that in the current political environment the problem is that there are many hard nuts. Worse, we’re trying to crack them with chopsticks.

Social Finance has been working on this problem through the End of Life Care Integrator for the past four years. We felt it was time to share: what have we learned that makes a difference? Have we cracked any nuts?

After working with stakeholders across 11 Clinical Commissioning Groups, perhaps our biggest discovery is that impact at scale may be less about which nut you crack, and more about the way you go about cracking it. While we may not have developed one model that works for all areas, we have seen trends emerging across our developing partnerships. Recognising them early has allowed us to take a more adaptive and targeted approach to developing, mobilising and implementing services at scale.

Commitment is what allows impact to stick

“Spread programmes need to be designed in ways that build and maintain adopters’ commitment to implementation, including seeking consensus on both the problem and the proposed solution.”

Core to our approach in developing services is understanding that people across the local system, who are working on improving care for the same patients, need to have relationships with one another from start to finish.

We know that this can be hard when working on projects that might last for five years, especially within the current NHS and third-sector context, but we’ve found that indicators of strong partnerships include:

• early commitment from change leaders with decision-making power across clinical, commissioning and finance teams to drive the project forward
• a thoughtful approach to the project’s governance, which ensures that the right guidance and support is available to the delivery team, while enabling the project manager to optimise the service
• well-managed handover of projects in the face of staffing changes. This should include a thorough induction of key historic documents, critical decisions, and familiarisation with the project team

Data is dynamic, and services need to mirror this with agility

Data sets will never be able to paint a fully accurate picture of reality. This need not be a hindrance to the launch of a new service, but the right measures should be in place to understand new data as it is collected, and for the service to be able to respond as it gets a better understanding of the population’s needs.

For example, one of the hardest data points for commissioners to identify is whether or not the people who are likely to use the service would otherwise have had a good death. By prioritising data collection and rigorous project management, one of our London services was able to develop a better understanding of its cohort as the service went live. After six months it was recognised that more patients who were already receiving support through palliative care services were linking into the service. As a result, we developed a new referral strategy, particularly focusing on harder to reach cohorts.

“It requires mechanisms such as peer networks to capture and share the learning that adopters generate as they tackle implementation challenges.”

Perhaps most of all, what we have been energised by is the drive and insight from people in the sector. From forward-thinking project managers to groups of clinicians meeting on Thursday afternoon at the End of Life Care Big Rooms in Charing Cross, London, people are thinking about how to improve care at the end of life.

In order to scale the change we need to ensure that learnings are shared and partnerships are built, especially outside of London. To this end, and beginning with this blog, we are hoping to share our findings through various media channels.