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Sciana Fellow Marc Augustin investigates the difficulties behind scaling projects and the skills required by leaders when seeking innovation

Why does a best practice model in health care so often remain just that - a single model? Why do healthcare projects succeed at a local level but fail when scaled across the nation? Sciana Cohort 4 Fellows from the UK, Switzerland, and Germany explored these questions at their fourth meeting in Salzburg in November and reflected on what leadership is needed to change the fate of the best practice example.

A working group of Fellows discussed innovative projects that do things differently, focusing on three questions: what defines best practice examples? How does scaling happen? How can leaders meet the challenge of scaling up innovative approaches?

It is difficult to give a precise definition of best practice models in health care, but it is easy to group them into broad categories. There are approaches that change the way a service is organised, such as Buurtzorg, which gives nurses complete autonomy. There are models that provide a holistic service, such as the Bromley-by-Bow Centre, which combines health and social services to meet the needs of its community. And there are innovations in service delivery, such as social prescribing in the NHS, which links patients with non-medical community resources. Each category scales differently.

In health organisations, scaling is usually understood as increasing the size or impact of a service. For a best-practice model in one community, scaling could mean extending it to a whole region or country so that more people benefit. Research in health care management distinguishes three types of scaling: copying, transferring, and translating. Similar tasks in similar health care contexts can be copied with little adaptation. Similar tasks in different contexts, however, require modification of the organisational framework and are therefore transferred. Translation is the highest level of scaling of knowledge and practice, when different tasks are performed in different settings. This requires a complete restructuring of the organisation.

This sounds theoretical, but it helps to understand why many good practice models fail when scaled up. A Cohort 4 working group visited Geko in Berlin, a community health service that combines "general and pediatric practice, counselling, self-help programs, social activities and a café under one roof". It serves the diverse neighbourhood of Neukölln and has built strong community links over the years. Any attempt to scale this approach falls into the category of highly complex translation: serving a different community in Berlin just a few kilometres away requires completely different tasks in a different context. Simply copying the Geko approach is likely to fail if it is not adapted to the new conditions.

It seemed difficult to draw conclusions for leadership when the Fellows continued to compare experiences to learn from each other. What works in the NHS offers little guidance for Swiss and German health systems, which include stronger state and cantonal levels. Any international translation has to take into account the social, economic and political differences of the UK, Switzerland, and Germany, as well as their unique histories and cultures. Common ground was found at the local level. Across countries, innovative projects succeed because they adapt to local conditions. They also thrive because of passionate leaders who pursue goals beyond the requirements of their organisations. You can copy a service, but you cannot copy a leader.

A common leadership feature at innovative projects such as GeKo or Bromley-by-Bow was that what started as a small group became a movement over time. Leaders had a clear vision of how they wanted to deliver care and brought people together with shared values to tackle the problem together. Leaders listened to the community and provided what the community wanted, not what they thought was necessary. If service users wanted line dancing as a daytime activity, the service provided line dancing. Actually, we rarely heard the word “service user” because, in one project, leaders referred to them as “members”. And inclusive leaders immediately understand that it changes the culture and deeply affects those who are part of a project, whether individuals are addressed and thought of as “a member” rather than “a user”.

While these were common elements of the leadership that made these projects successful, the type of leadership required to scale them up appears to be different. Part of this challenge is how well each system accommodates and enables innovation. Does the system incentivise change? At GeKo in Berlin, providing excellent care, improving health outcomes and reducing costs in the Neukölln community may go unnoticed in a fragmented German health system with about a hundred independent health insurers. If the incentives for delivering excellent care are not aligned with the system, innovation will not be rewarded and encouraged.

For leaders, this means thinking about how the system incentivises change more broadly. The Health Foundation in 2018 published the report “Against the odds: Successfully scaling innovation in the NHS”, which emphasised the need for leaders to create the right conditions for innovation to spread. They need to articulate the clinical benefits of change to create strategic opportunities. Leaders must convincingly show how change will lead to better outcomes. As another resource, they can turn to the World Health Organization’s practical guidance for scaling up health service innovations. It concludes that the challenge of scaling up the most complex health interventions is “both an art and a science; it involves the heart as well as the mind”.

This article was authored by Sciana Fellow Marc Augustin. The views and opinions expressed in this article do not necessarily represent the views of their organisation(s), Sciana: The Health Leaders Network, nor those of the Sciana Network's three funding foundations.