In working on the upcoming NHS Horizons White Paper on spread I have read many papers, reports and articles. Each one provides an insight or potential explanation as to why spreading innovations, even when evidence of their benefits exists, is a challenge. The recent paper from Greenhalgh and Papoutsi (link at the end) is very helpful in providing an explanation of the three main theoretical lenses in use when studying, planning and trying to enable spread. Each of the three lenses is based on a different logic of change.
- Implementation science (mechanical)
- Complexity science (ecological)
- Social science (social)
The authors outline and describe the three lenses:
Implementation science takes a structured and phased approach to developing, replicating and evaluating an intervention in multiple sites. It tends to be linear and top-down and reliant on quality improvement methodology such as using rapid cycle change. This approach has matured over time shifting from a highly structured approach (based on mechanical logic) where standardisation and replicability were important to a more adaptive approach closer to that of the complexity science approach.
Complexity science utilises a flexible and adaptive approach to change in a dynamic, self organising system. A complex system is defined as a set of things, people, and processes that evolve dynamically and are defined in terms of their relationships and interactions. Important characteristics of such systems are uncertainty, unpredictability and emergence. Our healthcare system is complex and many of the innovations we aim to spread are also complex (see my blog Spread and Complexity in the NHS), so the complexity science approach has much to offer our understanding of spread.
Social science approaches consider why people act in the way they do, especially the organisational and wider social influences that inform and constrain people's actions. How individuals act in an organisation is shaped by their practical situation but also by routines. Routines are the expected or usual pattern of behaviour effected by both formal influences such as regulation and standard operating procedures and by informal influences such as customs, usual practices and traditions.
There are synergies and overlaps between these three lenses, many successful spread programmes utilise one of these lenses but include elements of the other two.
As the authors conclude '.... the larger, more ambitious and more politically contested the spread challenge, the more the ecological and social practice perspectives will need to supplement (or replace) 'mechanical' efforts...'
In producing the forthcoming spread White Paper we have utilised all three lenses to inform our thinking and writing.
If you would like to be involved in helping shape the White Paper, thank you to those who have already volunteered, please contact Diane.firstname.lastname@example.org.
'...there is no simple or universally replicable way of implementing change at scale in a complex system'