By Aoife Keohane PhD, CLAHRC South London short course coordinator
NIHR CLAHRC South London (@CLAHRC_SL) recently held a #impscichat to explore the theme of our 2nd UK international Implementation Science conference ‘Advancing the science of scaling up: Improving efficiency and effectiveness of implementation strategies in healthcare’ on 27 June 2019. We briefly discussed the general understanding of the term ‘scale up’, some possible methods and interventions we could use to scale up complex health interventions to large populations and the barriers posed.
Q1: What do you understand by the term ‘scale up’?
Ruth Louise Poole (Senior Health Services Researcher in Wales @RuthPoole) reflected that this ‘usually applied to quality Improvement projects which have demonstrated effectiveness at a small scale (e.g. single site), scaling up tests the effectiveness of the same intervention but broadens the context (e.g. multiple sites, other populations).’
John Ovretveit (Director of research for the Medical Management Center at the Karolinska Medical University in Sweden and Professor of health improvement, implementation, and evaluation, @jovret) defined scale up as ‘taking a change that was found to be effective elsewhere and copying it in another one place or population: either copying the specification of the change precisely, or copying the principles of the change for adaption.’
This understanding was supported by Sarah Birken (Assistant Professor at UNC at Chapel Hill Gillings School of Global Public Health-Health Policy and Management Department @birkensarah) emphasising the ‘importance of adaptation’ and Alexandra Ziemann (Senior Researcher, City University of London Centre for Healthcare Innovation Research @_aziemann) indicating ‘the challenges of finding a balance with fidelity’.
Health Services Research at BMC (@HSRatBMC) wondered if implementation Science professionals ‘use (scale-up) in the same way as policymakers and does this vary between healthcare professionals and non-medical social scientists?’ While CHIR Centre for Healthcare Innovation Research (@CHIR_City) believe that ‘Scale up’ involves ‘spreading innovations across different organisations, across different professions, across different sectors, across different contexts’.
Q2: What are the barriers to effective scale up in your experience?
Alexandra Ziemann described external contextual factors as a barrier to effective scale up context giving many examples of ‘policy and legal context, resources, geography and physical environment, health/social care system organisation, demographic characteristics (socio-economic, socio-cultural factors), historical developments’. This was supported adamantly by Thekla Brunkert ( @TBrunkert) and Sarah Birken reminding us to consider ‘that sometimes identifying core functions can be done prospectively (e.g., researchers providing clear description), but sometimes it must be done retrospectively.’ Ruth Poole stressed that communication is key, emphasising that the ‘lead team need to clearly explain their aims, and gain buy-in from a wider group of stakeholders’.
Q3: What methods or interventions have people used to overcome these barriers?
John Ovretveit underlined the importance of ‘adequate infrastructure’ and the the need for researchers to provide ‘a clear description of the improvement change they evaluated, conditions that helped and hindered their implementation’ and ‘recommendations for implementation elsewhere’. Alexandra Ziemann highlighted ‘adaptation’ and stressed the importance of identifying ‘core components… and better supporting innovation adopters rather than enabling innovation inventors or researchers to do adaptation’. Ruth Poole reinforced the importance of communication where they have ‘explored with different stakeholders which methods of communication suited them best (e.g. email, social media, newsletters)’.
Sarah Birken highlighted work by her colleague Stephanie B Wheeler (@StephWheelerUNC) who investigated ‘different communication strategies to promote scale-up of an intervention to promote colorectal cancer screening and advocated the use of ‘theory to which researchers can map onto as we evaluate scale-up so we don’t end up reinventing the wheel when studying barriers to scale-up with the objective of addressing those barriers’. This was vehemently supported by the Centre for Healthcare Innovation Research (@CHIR_City) ‘We couldn’t agree more!’.
Q4: Can high-income countries learn anything from the practice of scaling up in low- and middle-income countries?
The unanimous answer from our tweeters seems to be yes! Health Services Research at BMC highlighted that ‘Reverse innovation (high income countries learning from LMICs) has been going on for years, https://www.biomedcentral.com/collections/reverseinnovations’. This was supported by Bella Starling (Wellcome Trust Engagement Fellow, Director of Public Programmes at Manchester University NHS Trust @bellastarling) who maintains her ‘experiences of working in community engagement in the global South has informed and enriched my practice in the UK’.
Shalini Ahuja (Post doc Researcher at the Centre for Implementation Science, King’s College London @shals_ahuja) believes the ‘scale up of clinical interventions are coupled with horizontal and vertical scale up of the implementation strategies’. While John Ovretveit believes it can be useful for ‘scaling up more complex delivery models and multiple-component improvement changes’ while providing ‘the infrastructure necessary to support scale up’ and help ‘simplify and adapt the improvement changes for the man different situations’.
Jane Sandall (Professor Jane Sandall CBE, Chair in Social Science and Women’s Health, King’s College London @SandallJane) was interested to know if in ‘low income settings there is more attention to health system strengthening’. Meerat Kaur (PhD student in quality improvement, Imperial College London and NIHR CLAHRC North West London, @kaumee) found that ‘various and very different community health workers models in both sub-Saharan Africa and across the UK (are) being used to tackle very similar issues regarding access to appropriate, responsive healthcare with community health workers being more advanced in low and middle income countries’. Dr Liz Hoffman (Journal Development Manager at BioMedCentral @LizHoffmanbmc) interjected with ‘can we learn how to do scale up in high income countries (HICs) more cheaply and efficiently by copying low income countries (LMICs). Are there things done better in low income countries?’. Shalini Ahuja believes ‘implementation science methods should be taught across high income countries and low income countries as they pay attention to the urgent global needs while at the same time remaining sensitive to the local needs, priorities, and capacities.’
Q5: Have you got any examples of good scale up in health or social care?
Many examples were highlighted by the tweeters including ‘Community health worker models to help people manage specific health conditions’ from Meerat Kaur. Shalini Ahuja highlighted a paper from Petersen and colleagues (2019) that investigates ‘scaling up of mental health interventions in LMICs using the Consolidated Framework for Implementation Research’. Ruth Poole mentions the ‘The Health Foundation Scaling Up Programme’ and her CFT PROMISE Project @PROMISECPMCFT that her team is working on at Cedar, Healthcare Technology Research Centre, Cardiff.
What next?
This topic was further discussed at our oversubscribed 2nd Annual UK Implementation Science Conference ‘Advancing the science of scaling up: Improving efficiency and effectiveness of implementation strategies in healthcare’ held on 18 July.
Why not join us next year for our 3rd Annual UK Implementation Science Conference in London on 17 July 2020. Please email clahrcshortcourses@kcl.ac.uk to register your interest.
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