By Aoife Keohane PhD, CLAHRC South London short course coordinator<\/p>\n
NIHR CLAHRC South London<\/a>\u00a0(@CLAHRC_SL<\/a>) recently held a #impscichat to explore the theme of our 2nd<\/sup> UK international Implementation Science conference \u2018Advancing 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 \u2018scale up\u2019, some possible methods and interventions we could use to scale up complex health interventions to large populations and the barriers posed.<\/p>\n Q1: What do you understand by the term \u2018scale up\u2019? <\/strong><\/p>\n Ruth Louise Poole (Senior Health Services Researcher in Wales @RuthPoole) reflected that this \u2018usually 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).\u2019<\/p>\n 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<\/a>) defined scale up as \u2018taking 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.\u2019<\/p>\n 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<\/a>) emphasising the \u2018importance of adaptation\u2019 and Alexandra Ziemann (Senior Researcher, City University of London Centre for Healthcare Innovation Research @_aziemann<\/a>) indicating \u2018the challenges of finding a balance with fidelity\u2019.<\/p>\n Health Services Research at BMC (@HSRatBMC<\/a>) wondered if implementation Science professionals \u2018use (scale-up) in the same way as policymakers and does this vary between healthcare professionals and non-medical social scientists?\u2019 While CHIR Centre for Healthcare Innovation Research (@CHIR_City<\/a>) believe that \u2018Scale up\u2019 involves \u2018spreading innovations across different organisations, across different professions, across different sectors, across different contexts\u2019.<\/p>\n Q2: What are the barriers to effective scale up in your experience? <\/strong><\/p>\n Alexandra Ziemann described external contextual factors as a barrier to effective scale up context giving many examples of \u2018policy and legal context, resources, geography and physical environment, health\/social care system organisation, demographic characteristics (socio-economic, socio-cultural factors), historical developments\u2019. This was supported adamantly by Thekla Brunkert ( @<\/strong>TBrunkert<\/a>)<\/u> and Sarah Birken reminding us to consider \u2018that sometimes identifying core functions can be done prospectively (e.g., researchers providing clear description), but sometimes it must be done retrospectively.\u2019 Ruth Poole stressed that communication is key, emphasising that the \u2018lead team need to clearly explain their aims, and gain buy-in from a wider group of stakeholders\u2019.<\/p>\n <\/p>\n Q3: What methods or interventions have people used to overcome these barriers? <\/strong><\/p>\n John Ovretveit underlined the importance of \u2018adequate infrastructure\u2019 and the the need for researchers to provide \u2018a clear description of the improvement change they evaluated, conditions that helped and hindered their implementation\u2019 and \u2018recommendations for implementation elsewhere\u2019. Alexandra Ziemann highlighted \u2018adaptation\u2019 and stressed the importance of identifying \u2018core components\u2026 and better supporting innovation adopters rather than enabling innovation inventors or researchers to do adaptation\u2019. Ruth Poole reinforced the importance of communication where they have \u2018explored with different stakeholders which methods of communication suited them best (e.g. email, social media, newsletters)\u2019.<\/p>\n Sarah Birken highlighted work by her colleague Stephanie B Wheeler (@StephWheelerUNC<\/a>) who investigated \u2018different communication strategies to promote scale-up of an intervention to promote colorectal cancer screening and advocated the use of \u2018theory 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\u2019. This was vehemently supported by the Centre for Healthcare Innovation Research (@CHIR_City<\/a>) \u2018We couldn’t agree more!\u2019.<\/p>\n <\/p>\n Q4: Can high-income countries learn anything from the practice of scaling up in low- and middle-income countries? <\/strong><\/p>\n The unanimous answer from our tweeters seems to be yes! Health Services Research at BMC highlighted that \u2018Reverse innovation (high income countries learning from LMICs) has been going on for years, https:\/\/www.biomedcentral.com\/collections\/reverseinnovations<\/a>\u2019. This was supported by Bella Starling (Wellcome Trust Engagement Fellow, Director of Public Programmes at Manchester University NHS Trust @bellastarling<\/a>) who maintains her \u2018experiences of working in community engagement in the global South has informed and enriched my practice in the UK\u2019.<\/p>\n Shalini Ahuja (Post doc Researcher at the Centre for Implementation Science, King\u2019s College London @shals_ahuja<\/a>) believes the \u2018scale up of clinical interventions are coupled with horizontal and vertical scale up of the implementation strategies\u2019.\u00a0 While John Ovretveit believes it can be useful for \u2018scaling up more complex delivery models and multiple-component improvement changes\u2019 while providing \u2018the infrastructure necessary to support scale up\u2019 and help \u2018simplify and adapt the improvement changes for the man different situations\u2019.<\/p>\n Jane Sandall (Professor Jane Sandall CBE, Chair in Social Science and Women’s Health, King\u2019s College London @SandallJane<\/a>) was interested to know if in \u2018low income settings there is more attention to health system strengthening\u2019. Meerat Kaur (PhD student in quality improvement, Imperial College London and NIHR CLAHRC North West London,\u00a0@kaumee<\/a>) found that \u2018various 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\u2019.\u00a0 Dr Liz Hoffman (Journal Development Manager at BioMedCentral @LizHoffmanbmc)<\/a> interjected with \u2018can 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?\u2019. Shalini Ahuja believes \u2018implementation 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.\u2019<\/p>\n \u00a0<\/strong><\/p>\n Q5: Have you got any examples of good scale up in health or social care? <\/strong><\/p>\n Many examples were highlighted by the tweeters including \u2018Community health worker models to help people manage specific health conditions\u2019 from Meerat Kaur. Shalini Ahuja highlighted a paper from Petersen and colleagues (2019) that investigates \u2018scaling up of mental health interventions in LMICs using the Consolidated Framework for Implementation Research<\/a>\u2019. Ruth Poole mentions the \u2018The Health Foundation Scaling Up Programme\u2019<\/a> and her CFT PROMISE Project @PROMISECPMCFT<\/a> that her team is working on at Cedar, Healthcare Technology Research Centre, Cardiff.<\/p>\n <\/p>\n What next?<\/strong><\/p>\n This topic was further discussed at our oversubscribed 2nd<\/sup> Annual UK Implementation Science Conference \u00a0‘Advancing the science of scaling up: Improving efficiency and effectiveness of implementation strategies in healthcare’<\/a>\u00a0held on 18 July.<\/p>\n Why not join us next year for our 3rd<\/sup> Annual UK Implementation Science Conference in London on 17 July 2020. Please email clahrcshortcourses@kcl.ac.uk<\/a> to register your interest.<\/p>\n <\/p>\n Harris, M., Weisberger, E., Silver, D., & Macinko, J. (2015). ‘They hear “Africa” and they think that there can’t be any good services’–perceived context in cross-national learning: a qualitative study of the barriers to Reverse Innovation.<\/strong>\u00a0Globalization and health<\/em>,\u00a011<\/em>, 45. doi:10.1186\/s12992-015-0130-z<\/a><\/p>\n Milat, Andrew & Newson, Robyn & King, Lesley & Rissel, Chris & Wolfenden, Luke & Bauman, Adrian & Redman, Sally & Giffin, Michael. (2016). A guide to scaling up population health interventions.<\/strong> Public Health Research & Practice. 26. 10.17061\/phrp2611604.<\/a><\/p>\n Ovretveit, John & Mittman, Brian & Rubenstein, Lisa & A Ganz, David. (2017). Using Implementation Tools to Design and Conduct Quality Improvement Projects for Faster and More Effective Improvement.<\/strong> International Journal of Health Care Quality Assurance. 30. 00-00. 10.1108\/IJHCQA-01-2017-0019.<\/a><\/p>\n