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Executive summaryExecutive summaryThe NHS Innovation Accelerator (NIA) is an NHSEngland initiative, delivered in partnership with thecountry’s 15 Academic Health Science Networks(AHSNs) and hosted at UCLPartners. Created tosupport delivery of the Five Year Forward View, theNIA supports spread of innovation for demonstrablepatient and population benefit and provides realtime practical insights on innovation scaling toinform national strategy. Since its launch in 2015 ithas supported 36 Fellows to spread 37 innovationsacross the NHS.To deliver this research, a representative selection ofthe 37 NIA innovations were chosen, covering thebreadth of innovation ‘type’ - digital, device, modelof care, workforce - as well as including a rangeof commissioning and purchasing organisations NHS Trusts, Clinical Commissioning Groups (CCG),GP Federations, Sustainability and TransformationPartnerships (STP). Geographical coverage andensuring the innovation had spread successfullybeyond its initial site were also criteria for selectionof the innovation and adopting site.Each year the NIA has a research focus to informhow to scale innovations successfully in the NHS.The focus of the research to date has concentratedon the innovator and innovation - the supply sideof innovation.In total nine of the NIA innovations were selected,with interviews taking place with representatives from13 of the NHS organisations that had adopted them.These have been written into the case studies thatinform this report. The case studies can be viewedfrom page 28.This research, in contrast, focussed on the role ofadopting organisations. It aimed to understand thekey factors enabling the uptake of innovation and todetermine how decisions are made withinNHS organisations.The areas it aimed to address were: 6How and why organisations take up aninnovation The enabling factors which facilitate the uptakeand embedding of the innovation The impacts of adopting the innovation onorganisational practicesThe approach to the research included an examinationof the theoretical literature on innovation adoption.Eight theoretical perspectives were reviewed and usedto guide the interview questions, and provided a lensthrough which to view the data gathered from theinterviews. The data for each innovation was analysedthematically and then themes compared acrossinnovations. This approach allowed themes to emergefrom the data. In total more than 80 interviews wereconducted across the nine innovations which provideda level of confidence in the key themes identified.The study offers insights related to how organisationalcontext plays a significant part in adoption as well ashighlighting recurrent themes in innovation spreadNHS Innovation Accelerator: Understanding how and why the NHS adopts innovationacross the NHS. The analysis is organised into threesections: the adoption journey, the adoption network,and common tasks in the adoption journey.The key themes emerging from the adoptionjourney included:and innovator - referred to as the negotiation space.All nine innovations demonstrated complexity,non-linearity, iteration and longer timescales thanoriginally expected to achieve a level of embeddednessand sustainability. Complex nature of adoption: The dynamic andnon-linear process of adoption within organisationsTwo key points arise from the understanding generatedfrom this research: Need for mutual adaption and iterationbetween the organisational context and theinnovation to facilitate adoption, referred to in thisreport as ‘the negotiating space’The first is that the adopter sites should be applaudedand celebrated for their resilience, commitment andtenacity in adopting innovation. The findings from thecase studies highlight just how difficult and challengingadoption is in a complex organisation. Interaction with the adoption network tofacilitate the negotiation and adoption The interplay of push and pull factors that supportimplementation and build the capabilities both forthe adopting organisation and for the innovatorThe analysis of the adoption network highlightsthe role of multiple champions operating insideand outside of the adopting organisation, who aredrawn from multiple professional groups. The setof traits commonly displayed by these championsare summarised, including being reflective, skilled inchange, well-connected and focused on improvement.A set of common tasks were identified across theNHS sites adopting NIA innovations: Getting to know the innovation: the tasksundertaken to better understand the innovation,which involved a significant focus on trials The activities required to build the case foradoption of the innovation The ways in which adaption of the innovation andthe adopting site were achieved The emergent process followed to achieveembedding and sustainability of the innovationThe second is that because the iterative and nonlinear nature of the adoption process is not generallyrecognised as a critical journey for all adopter sites,generalisable learning is not often captured for othersto benefit from. Each organisation faces negotiatingthe adoption process with a new NHS site with noor limited knowledge of how it was achievedsuccessfully elsewhere. There is an opportunity tobetter capture learning that incorporates the emergentnature of the adoption journey, and then providethis as part of the push factors to assist adoptingorganisations in their negotiation process. There arealready indications that networks are forming aroundparticular innovations where learning can be shared,for example, through the AHSN National Programmes.Further developing this approach may be of greatassistance to new adopters.The eight theoretical perspectives provide insight andguidance to the interview and analysis stage of thestudy. There is an opportunity to further synthesisethe theoretical work to provide better understandingof the organisational pull factors as well as capturingthe unique and generalisable learning around theorganisational contexts impacted by the innovations.A better understanding of the negotiation processcould underpin improved translation of adoptionbetween contexts and give a home to the valuablelearning generated by each adoption journey.Drawing on the findings and to assist others workingin this field, two sets of ‘top ten tips’ have beendeveloped for innovators and adopting organisations.These can be viewed on page 26-27.In summary, the recurring experiences across all theadopter sites, as captured in the case studies, detailthe need for iteration and adaption between adopterNHS Innovation Accelerator: Understanding how and why the NHS adopts innovation7

IntroductionThe challenges facing the National Health Service(NHS) are immense including a rise in the prevalenceof long-term conditions associated with precipitatinglifestyle factors and demographic shifts, alongsidethe escalating costs of increasing expectations andtechnological capacity.NHS England and the Office for Life Sciences (OLS)have increasingly highlighted innovation as part ofthe solution. This has been demonstrated recentlythrough plans (e.g. Next Steps on the NHS Five YearForward View), commissioned reports (e.g. AcceleratedAccess Review, Life Sciences Industrial Strategy)and consultations (e.g. Topol Review, Long TermPlan for the NHS), alongside investment in enablinginfrastructure, such as Academic Health ScienceNetworks (AHSNs).However, the adoption of innovation by NHSorganisations is challenging - multiple studies haveshown it to be slower than in other Europeancountries. This means the potential benefits ofinnovation in the NHS are delayed. These benefitsinclude: eliminating unwarranted variations in healthindicators and the outcomes of care, improvingequitable access, giving the best possible experiencefor patients and carers, more cost-effectivelyintegrating care and resources around the needs ofpatients and populations.Study aims and methodologyTo help inform understanding of adoption, the NHSInnovation Accelerator (NIA) has focused its year threeresearch on capturing insights from some of those NHSsites who have adopted NIA innovations.The NIA is an NHS England initiative, delivered inpartnership with the country’s 15 AHSNs and hostedat UCLPartners. Created to support delivery of theFive Year Forward View, the NIA supports spread ofinnovation for demonstrable patient and populationbenefit and provides real-time practical insights oninnovation scaling to inform national strategy.Since its launch in July 2015, the NIA has supported36 innovators to scale 37 high impact, evidence-basedinnovations to an additional 1,483 NHS sites acrossEngland and to raise 60 million in external funding.In its first year alone - according to an independentevaluation - adoption of NIA innovation savedEngland’s health and care system over 12 million(Institute for Employment Studies, March 2018).AimsEach year the NIA undertakes research to further theunderstanding as to what enables innovation spread inthe NHS. In previous years, the research has focussedon the supply side - examining the characteristics andimpacts of the innovation and innovator.This year, recognising the amount of work required byNHS organisations to adopt and implement innovation,this research focuses on them: the demand side. Itaims to determine how decisions are made within NHSorganisations, and in doing so understand: How and why organisations take up an innovation The enabling factors which facilitate the uptakeand embedding of the innovation The impacts of adopting the innovation onorganisational practicesThis research recognises that with limited resourcesand time, only a selection of the innovations andcorresponding adopting sites could be interviewed.Therefore, whilst this work cannot claim to be acomprehensive analysis of every enabling factor thatsupports innovation uptake in the NHS, it aims to shinea light on some of these factors. It is also intended tohighlight and recognise the hard work of each of theadopting NHS organisations highlighted through thecase studies.MethodologyAn Evaluation Advisory Group (EAG) was set up toprovide strategic direction and leadership for theevaluation and to ensure that key learning wasidentified and extracted for dissemination. Memberswere drawn from NHS England, the AHSNs, The HealthFoundation, patient and NIA Fellow representatives.A list of members of the EAG can be viewed in theAcknowledgements on page four.8NHS Innovation Accelerator: Understanding how and why the NHS adopts innovationA representative selection of the 37 NIA innovationswere selected for the research. The EAG advised thisshould cover a breadth of the types of innovationsupported by the NIA: Digital Device Model of Care WorkforceIn addition, that it should cover a representativeselection of the typical types of organisationimplementing or commissioning the innovations: NHS Trust Clinical Commissioning Group (CCG) GP Federation Sustainability and Transformation Partnership (STP)NHS sites were selected to reflect the geographicalspread of the innovations across England. The researchalso aimed to include sites where the innovation hadspread from at least one initial site and where it wassuccessfully implemented. In total, nine of the NIAinnovations were selected to take part, with interviewstaking place with representatives from 13 of the NHSorganisations that had adopted them. Nine of thesehave been written into the case studies that informthis report.The innovations selected can be viewedon page 15.Each NHS organisation was formally invited to takepart in the research. Interviewees who had played arole in the adoption of the innovation were identifiedvia interviews with the NIA Fellows, the local AHSN,and through recommendations from the NHS sites.Interviewees represented the economic, operational,clinical and organisational aspects of the innovationNHS Innovation Accelerator: Understanding how and why the NHS adopts innovation9

Study aims and methodologyInterviews were undertaken between June andSeptember 2018 by members of the BayswaterInstitute team with support from the NIA team andfour MSc students from the London School of Hygieneand Tropical Medicine. The inherent complexity of the structure of NHS andprovider organisations and the competition betweenthem due to the purchaser/provider split The potential for unintended incentives related toreimbursement modelsThe role of theory and study methodology The impact of procurement processes The challenges to effective communication betweenindependent NHS organisations and lack ofintegrated datasetsThe questions that were explored in the interviews andthe analysis of the data gathered were informed by avariety of theoretical perspectives on the processes bywhich innovations are adopted.Theory has a role to play in forming an ‘approach to’and an ‘analysis of’ the learning from the NIA casestudies. However, any intervention in healthcare issubject to complexity. This complexity arises frommany aspects of the context, including: organisationaldynamics, psychodynamics and the job roles of thepeople impacted, development of the innovation,economic factors, and the fit between the innovationpush and the system pull. It is therefore necessary todraw on a range of theories to support understandingand to explain innovation adoption of a range ofinterventions in such a complex system. Theoryinformed several aspects of the approach to analysingthe case studies in this report. These included: Theories that underpinned the collection andanalysis of data that provided understanding abouthow individual innovations have been adopted bythe NHS and other organisationsTheories that provided insight into understandingthe common themes and learning that can bedrawn from the similarities and differences betweenthe innovations and their adoptionBroader theories relating to innovation adoption ingeneral and the impact of context and policy on thesuccess of innovationsEach of these aspects has significant amounts ofpublished literature, often from different academicdisciplines, that provide insight. A number of thesetheories of innovation and adoption are rooted inthe private sector and in diffusion of consumer andindustrial products and processes. The healthcaresector presents a particular set of challenges to the useof such theories. Some of the factors that differentiatethe healthcare sector include:10 The complexity of the internal and externalenvironments of healthcare caused bycontinual changeThe application of innovation and adoption theoriesthat apply in the private sector are somewhatconfounded by these factors. Theories that addresshealthcare directly often struggle with aspects such asthe complexity of the context. Some of the theoreticalunderpinning of the approaches adopted in this reportare reviewed.Collection and analysis of dataThe approach to the research included an examinationof the theoretical literature on innovation adoption.Eight of these perspectives are presented below.These perspectives informed the interview questionsand provided a lens through which to view the datagathered from the interviews.Where themes emerged regarding specific aspects ofthe innovation, further stakeholders were sought torepresent that experience in the data. The data foreach innovation was analysed thematically and thenthemes compared across innovations. This groundedtheory approach (Charmaz, 2006) allowed themesto emerge from the data. In total more than 80interviews were conducted across the nine innovationswhich provided a level of confidence that key themeswere identified.NHS Innovation Accelerator: Understanding how and why the NHS adopts innovationPerspectives on theadoption of innovationsThe literature on adoption of innovations is complexand varied. In their 426-page systematic review ofdiffusion, dissemination and sustainability of healthcareinnovations, Greenhalgh et al quote one reviewer assaying: “[it is] a conceptual cartographer’s nightmare”(Greenhalgh, 2004). There have been contributionsfrom many different disciplinary backgrounds eachusing their own language and concepts. Some of theperspectives focus on a particular kind of adoptionprocess but there is also overlap in what is covered bythe approaches.Eight perspectives are reviewed here and the way theyinfluenced the acquisition and analysis of the datais described. It is beyond the scope of this report toexplain each of the different perspectives in detail asthey represent significant areas of study in themselves.The goal is to provide an overview of how thecomplexity of healthcare interventions may be mappedonto many areas of theoretical thinking.1. The diffusion of innovation approachThis theory developed by Everett Rogers, a professorof communication studies (Rogers, 1962 and 2003),has been very influential. Adoption typically followsan S curve through early adopters and the earlymajority to the late majority and the laggards. Thesignificant mechanisms for diffusion are the relevantsocial systems and the communication channelsavailable within them. The theory has developed agreat deal over 40 years of its existence, but the mainfocus remains the way consumer products diffusethrough the population. Its applicability to healthcareinterventions is confounded by the types of factorsmentioned previously. Diffusion of consumer productsis dependent upon resources to acquire the productand communication of the benefits, and more recently,aspirational value. This is why communication is theunderpinning theme. In a scoping review produced bythe Social Science Research Unit of University CollegeLondon it was stated that, for NICE guidance: “Overall,there is growing recognition across disciplines thatgetting evidence to influence and change practice is acomplex undertaking.” (Kneale, 2016).The research team used this perspective to explore withinterviewees the communication channels by whichthey had heard about the innovation and whether, asadopters, they became part of the process of diffusionacross the healthcare sector.2. The evidence-based adoption modelThis approach, derived from medical research, sees theprimary driver of innovation in organisations as thegathering of good quality scientific evidence of thevalue of an innovation to provide a convincing clinicaland business case. The gold standard has been doubleblind randomised control trials to provide quantitativeevidence. Again, even where this evidence exists,the quote from the scoping review above points tocontextual challenges. There are now wider interestsin, for example, (a) understanding what kind ofevidence case is required in different contexts, and (b)other kinds of evidence. The Health Foundation reporton scaling innovations, Against the Odds, for example,draws attention to the value of qualitative evidence inproducing compelling narratives that ‘capture heartsand minds’ (Albury, 2018).The research team used this perspective to explore withinterviewees the kind of evidence base that influenceddecisions at the beginning of the adoption journey,what further evidence was collected within the adoptersite and what influence local sources of evidence hadon subsequent developments.3. The organisational readiness modelThis approach comes from organisational developmenttheorists and examines how ready an organisationis to embrace a specific innovation. ‘Readiness’ mayhave many dimensions, from the very specific (theinnovation meets a specific need of the organisation)through to the organisation’s capacity to take it onNHS Innovation Accelerator: Understanding how and why the NHS adopts innovation11

Perspectives on the adoption of innovationsboard (the ‘organisational slack’ available to dothe extra work involved), to the general climate inthe organisation.A popular development of this line of thinkingis ‘the learning organisation’. The approach wasdeveloped by Peter Senge and colleagues, andpublished in The Fifth Discipline (Senge, 1990.) Fiveaspects of a learning organisation are identified:systems thinking, personal mastery, mental models,shared vision and team learning. The challenges inbecoming a learning organisation are identified inThe Other Side of Innovation (Govindarajan, 2010.)Although this publication focuses on private sectorinnovation, it identifies some universal issues withadopting innovation. It describes the daily operationof most organisations as the “performance engine”recognising that: “business organisations are notbuilt for innovation; they are built for efficiency.” Aquote from Ray Sata, founder and chairman of AnalogDevices is revealing: “The limits of innovation in largeorganisations have nothing to do with creativity andnothing to do with technology. They have everythingto do with management capability.” It is here thatthe innovation push and the system pull meet in theability of the organisation to engage with the changenecessary to adopt the innovation.The research team used this perspective to exploreorganisational capabilities of the adoption site withinterviewees. Aspects such as ‘pull factors’ thatfacilitated adoption were explored. Examples includeda pre-recognition, for example, that a need exists thatthe innovation may be able to meet. Exploration ofthe recognition and experience in the disruption ofinnovation was also discussed.4. The project management approachThis approach is concerned with the phases of worknecessary to put an innovation in place and have it ‘upand running’. Project management methods are mostadvanced in the construction industry and in IT wherePRINCE2 is a widely used tool. Historically, projectshave been defined as a linear sequence of activities(the ‘waterfall model’) but in a complex, uncertainand risky world there is now a lot of interest in moreiterative and agile approaches based on action research(Stringer, 2014) that facilitate learning and guide theprocess towards effective solutions. Agile softwaredevelopment has a focus on self-organising teams with12Perspectives on the adoption of innovationscross-functional capabilities. The approach is iterative,incremental and evolutionary, and incorporates a lotof the test and learn thinking that has arisen out ofsocial media and eCommerce technology platforms.Purposeful Program Theory (Funnell, 2011) is anexemplar of an approach that factors in context to thedevelopment of programme and project planning. Ina complex, continually changing world, linear projectmanagement is being augmented by rapid cycletest and learn approaches that incorporate learningand understanding.The research team used this perspective to explorethe kind of project management approach adopted.Attention was paid to the ability to undertake linear,well-planned stages or whether there was need foriteration, and what learning was derived from theproject management experience.5. The ‘transitional system’ or temporaryorganisation approachThis is not so much an approach as a set of findingsthat recur in case studies of innovation. For innovationsto diffuse and be adopted, relationships need to bebuilt between the innovators and all the key agentsin the adopter system. A recent systematic literatureanalysis of current research on innovation champions,from both an individual and an organisationalperspective (Reibenspiess, 2018) identified a total of56 traits, 26 skills and 11 knowledge types that wererepresentative of innovation champions. The mostimportant of each of these were considered to beas follows: Traits: creativity, enthusiasm, self-confidence, risktaking, persistence, optimism, and proactivity Skills: supportive skills, innovation skills,networking skills, transformational leadershipskills, and social skills Knowledge: technical knowledge andorganisational knowledgeA common characteristic across all the casesstudied was that the adoption process required theengagement of many members of the adoptingorganisation. There is a network of people who cameinto play at different stages of the adoption process,here defined as the ‘adoption network’. ReibenspiessNHS Innovation Accelerator: Understanding how and why the NHS adopts innovationet al point to the complete lack of research lookingat the individual or organisational factors that areimportant in encouraging effective enabler networksfor adoption to develop. Many types of championmay be needed in an adopter site for the adoptionprocess to gather and sustain momentum. Fordiffusion across sites, facilitation may be required bythe networks that link significant players in the relevantdomain. Each innovation nee

NHS Innovation Accelerator: Understanding how and why the NHS adopts innovation NHS Innovation Accelerator: Understanding how and why the NHS adopts innovation 3 Foreword Innovation is regularly highlighted as part of the solution to the challenges facing our National Health Service. However, adoption