In this blog, CEI's Managing Director in the UK and leading implementation science scholar and practitioner, Jane Lewis, shares three elements of successful scaling up.
This content was presented at a session on ‘scaling up’ for the Implementation Science Masterclass, organised by the NIHR Applied Research Collaboration South London.
Jane Lewis delivered this session with two expert collaborators with leading roles in the scale-up of parenting programs in the UK: Sarah Tyndall from the Family Nurse Partnership and Jo Nicoll from the Empowering Parents Empowering Communities program.
The ultimate challenge
The challenge of scaling up can seem huge: very little in the way of evidence-based intervention actually gets scaled up, even when there is long-term intensive support for scaling.[i] [ii] Sadly, this is one of the many ways in which inequality becomes entrenched: uneven scale-up means that state-of-the-art care isn't available to the most disadvantaged groups.[iii] [iv]
There is, in fact, a direct tension between scaling in a way that reaches the largest numbers, and scaling in a way that reaches those with greatest need.
Focus on the endgame
We often see 'getting the program right' as the first stage of work in scaling up. It's certainly true that it’s important to have all the program components in place: materials, implementation support strategies such as (but not limited to!) training, quality assurance, and a well-evidenced theory of change. But a more vital starting point is deciding what the 'endgame' is.[v] This is about what the structure will be for delivery at scale. This might for example, be continued delivery by the program developer, replication (e.g. under a licensee or train-the-trainer model), forming a partnership, the program being passed on to a (commercial or other) organisation, government adoption, open-source availability, or some other form.
Knowing who will be the 'doer-at-scale' (and the 'payer-at-scale') should shape program improvement and evaluation.[vi] An early judgement on this means a program can be evaluated and developed with the endgame in sight, for example building train-the-trainer or partnership delivery into early evaluation, rather than evaluating a form of delivery that is unscalable.
Focus on users
Scaling also requires a focus on market viability. There's a tendency to see scaling as being about 'push' by developers and intermediaries, but a much more powerful force is the 'pull' from users.[vii] This requires work to really understand the value of the intervention to the market, as well as market, pricing and competition analysis.
Adaptation is key
Finally, scaling also necessarily involves mobilising and aligning with the wider public service system to provide funding and incentives, to dovetail with sector improvement and workforce development initiatives, and to build momentum and wider support. Since this wider system is in a state of constant flux, successful scaling involves a never-ending dance of adaptation and calibration. This means that scaling is far from linear and predictable: it's an adaptive process of change requiring attention to the ecology of systems.[viii]
Learning from two UK parenting programs
The need to work within complexity is well illustrated by two parenting programs overcoming the challenges of scaling up.
Family Nurse Partnership (FNP, the UK version of Nurse Family Partnership) is used widely following a government-led program to introduce it and is now showing very promising results.[ix] The Empowering Parents Empowering Communities program (EPEC) at South London and Maudsley NHS Foundation Trust is a peer-led parenting program where parents who have been EPEC group participants are trained and supported to lead parenting groups in their own communities.[x]
FNP and EPEC both needed to be improved and adapted so they were better aligned with needs and practice. Core values and principles were a lodestar in this work. It also involved building relationships with delivery agencies based on co-ownership of quality and data rather than on rigid compliance, working with the complexity of fast-changing contexts, and the need for a very human-centred and relationship-based approach.
More than evidence
Studies of what has scaled up highlight that evidence from a phased pipeline of evaluation is often not a key driver[xi] [xii], and that political and system alignment are more often at play. This doesn't mean evidence isn't important, but it is not enough – and this is what makes scaling challenging.
At CEI, we're embracing this challenge. We recently worked with the Education Endowment Foundation to support their scaling work, and we're working with the men's mental health charity Movember to assess and support the scalability of projects they fund. We have also authored a chapter in a forthcoming book about What Works Centres, which encourages them to see scaling as the new frontier in their work.
With thanks to Sarah Tyndall (Nurse Consultant in the FNP Maternity Unit, Office of Health Improvement and Disparity), Jo Nicoll (UK Hub Lead for the Empower Parents Empowering Communities program at South London and Maudsley NHS Foundation Trust) and the Implementation Science Masterclass.
References and further reading
[i] Fagan, A., Bumbarger, B.K., Barth, R.P., Bradshaw, C.P., Rhoades Cooper, B. Supplee, L.H. and Klein Walker, D. (2019) Scaling up Evidence-Based Interventions in US Public Systems to Prevent Behavioral Health Problems: Challenges and Opportunities. Prevention Science (2019) 20:1147-1168.
[ii] Waterman, C. (2021) Evidence-supported interventions for children in care: Does Treatment Foster Care Oregon (TFCO) fit within the UK context? J Fam Ther 2021:43 392-413
[iii] Scarbrough, H. and Kyratsis, Y. (2022) From spreading to embedding innovation in health care: Implications for theory and practice Health Care Manage Rev July-Sept 2022 43:3 236-24
[iv] Dearing, J. W., & Cox, J. G. (2018). Diffusion of innovations theory, principles, and practice. Health Affairs, 37(2), 183–190.
[v] Gugelev, A. and Stern, A. (2015) What's Your Endgame? Stanford Social Innovation Review Winter 2015: 41-47
[vi] Starr, K., & Hattendorf, L. (2015). The Doer and the Payer: A Simple Approach to Scale. Stanford Social Innovation Review. https://doi.org/10.48558/ET3G-NY28
[vii] Proctor, E.K., Toker, E., Tabak, R., McKay, V.R., Hooley, C. and Evanoff, B. (2021) Market viability: a neglected concept in implementation science. Implementation Sci (2021) 16:98
[viii] Greenhalgh, T. and Papousti, C. (2019) Spreading and scaling up innovation and improvement. BMJ 2019: 365:I2068
[ix] Robling, M., Lugg-Widger, F., Cannings-John, R., Sanders, J., Angel, L., Channon, S., Fitzsimmons, D., Hood, K., Kenkre, J., Moody, G., Owen-Jones, E., Pockett, R., Segrott, J. and Slate, T. The Family Nurse Partnership to reduce maltreatment and improve child health and development in young children: the BB:2–6 routine data-linkage follow-up to earlier RCT. Southampton (UK): NIHR Journals Library; 2021 Feb. Public Health Research, No. 9.2. doi: 10.3310/phr09020
[x] Day, C., Michelson, D., Thomson, S., Penny, C., & Draper, L. (2012). Evaluation of a peer led parenting intervention for disruptive behaviour problems in children: community based randomised controlled trial. BMJ 2012;344:e1107 doi: 10.1136/bmj.e1107.
[xi] Koorts, H., Cassar, C., Salmon, J., Lawrence, M., Salmon, P. and Dorling, H. (2021) Mechanisms of scaling up: combining a realist perspective and systems analysis to understand successfully scaled intervention. International Journal of Behavioral Nutrition and Physical Activity (2021) 18: 42
Koorts, H., Cassar, C., Salmon, J., Lawrence, M., Salmon, P. and Dorling, H. (2021) Mechanisms of scaling up: combining a realist perspective and systems analysis to understand successfully scaled intervention. International Journal of Behavioral Nutrition and Physical Activity (2021) 18: 42
[xii] Indig, D., Lee, K., Grunseit, A., Milat, A. and Bauman, A. (2018) Pathways for scaling up public health interventions. BMC Public Health (2018) 18:68