There are a number of reasons why things fail to spread in the public sector. It is helpful at the outset to be clear about what we are attempting to scale or replicate. It might be an idea (what we do), a process (how we do it), a product (what we do it with). The following barriers to scale will be different dependent on which of these we are trying to scale.
Perhaps the most fundamental is that of the governing philosophy. This states that value for money, and impact, is achieved when an innovation (idea, service, product, solution etc) is replicated from one ‘test’ site to all localities across the country. Government – and national politicians – love pulling policy levers that impact everyone. In a health sense, locality can mean hospitals, CCGs, ICS’s, GPs and so on. To assume that such replication is helpful is to define every problem the same, that it shows up the same in every locality, and that the challenge is therefore to overcome barriers to adoption. Thus national schemes are born of small-scale pilots, as in the 50 ‘vanguards’, test sites under the five year forward view. It’s a bit like the challenge of taking a new medicine to market. Once you’ve proved its efficacy, all that remains is to ensure all commissioners are aware it exists and to ensure its take up.
Barriers to adoption run deep though, as they relate to our own individual agency and practice. Who really wants to be told that the solution is something that was tested in Kent? There is no individual sense of ownership compounded by an instinctive distrust that what works for the population of Kent will also work for the population of Newcastle.
This leads to the next major challenge. Most interventions, innovative or not, tend to fail to take adequate account of contextual and personal factors. In other words, the reasons why one person continues to smoke will be different from the next, and therefore will require nuanced approaches that recognise and take account of these subtle differences.
This is compounded by temporal challenges. Someone who has smoked 20-a-day for 20 years will need a different approach to a social smoker who has a few a month. These fluctuations over time represent they dynamism that local interventions need to take account of.
Different places will also have different traditions, processes and cultures. These mean that the mechanisms through which new things are brought to life will be different everywhere.
Where we are dealing with a complex challenge, there is no solution whose adoption will fix things. We have to keep working on it, test, learn and step. Should we be dealing with a complicated issue, we are able instead to identify best practice and figure out how to adopt it in our own domain and circumstances. In other words, we have to know the nature of the presenting problem.
There are a range of additional behavioural challenges to be aware of too. The fear of failure runs deep in the public sector, largely because politicians don’t want things to be seen to ‘go wrong’ on their watch, and politicians and managers alike are cautious of things that might not offer value for money to the taxpayer. Linked to this is the very public way in which such failings play out in the media (such as Baby P or Winterborn View care home) leading to very real fear of reprisals. These can be categorised as relating to ‘risk tolerance’.
The proceeding challenges are often compounded by a range of activities and processes collectively known as immune responses: the self-serving mechanisms through which the status quo is reinforced. Thes might be the regulatory framework, procurement, legacy IT systems, competing incentives and market readiness. All forms of immune response can be activated in order to crowd out the innovation, whether it is something new that a member of staff has designed or tested, or whether it is parachuted in from afar.
Finally, one of the biggest and most overlooked challenges is system capacity. The failure to invest in capacity or margin leaves our systems and services highly vulnerable to shocks. Worse, austerity and efficiency measures effectively squeeze it out. We overload existing and often archaic practice with pilots and tests without realising that there is no capacity to adopt these innovations even if they manage to show promise. Staff take on such ‘projects’ on top of the day job, compromising their ability to do either fully.
For the new to be adopted we need to create space and time, and this means we have to let some things go. Not necessarily whole services, but perhaps there are too many steps in a process, sign-offs and gateways, hand-offs, old tech, and the like. All because the default is known and comfortable. To create the space for new things we have to stop doing something otherwise the sums simply don’t add up. It is impossible to overstate how difficult it is to land innovations on old systems without some surgery first. In turn, where we are dealing with systems that are complex and dynamic, no amount of attempting to land someone else’s innovation will work. Instead we need to put time and energy into understanding the system as a living ecosystem and proceed from there. There are often no solutions, only journeys.