To support better practice, THIS Institute has collaborated with Ipsos and The Health Foundation to develop a framework for designing large-scale complex change programmes in health and care – major initiatives run by national organisations aimed at securing improvement or service change.

This framework is designed to guide early-stage planning (“the front end”) of large-scale change programmes in health and healthcare. It helps programme teams think rigorously and systematically before major decisions are made, with the aim of reducing avoidable failure and improving chances of success. It draws on evidence from the literature on large projects across multiple sectors, national guidance and reports, interviews with experienced programme leaders, and stakeholder testing with real policy teams.

During a session at our annual event, THIS Space 2025, a panel chaired by Sarah Hardy from the Health Foundation, including Mary Dixon-Woods, director of THIS Institute, Charles Tallack, a senior fellow at the Health Foundation, Michael Lawrie, a director at Ipsos UK, and Ron Agble, an improvement and innovation advisor at THIS Institute, were asked how they could see the framework supporting large-scale programmes, including those that may come from the 10 year health plan. These are some of their insights.

Learning from failure and success

From improving cancer care to digital transformation, national programmes have been a key feature of how change is made in the NHS. Successful introduction of new care models such as social prescribing, closer integration with community pharmacy, and the infection control programmes of the 2010s are just some of the examples of how large-scale programmes can play a valuable role. “Ministers and national policymakers will always want to make improvements for patients through changing service models”, says Charles Tallack, “and national programmes are an important part of their toolkit.”

But not everything works. History is littered with programmes which have not been successful in achieving their aims, despite significant investment of time, money, and political capital. “There was a nagging thought that we could do better,” says Charles. This led to the idea of creating a practical framework that combined previous learning to help policy teams with effective design and planning.

Conducted by Ipsos, interviews with 17 senior leaders of previous large programmes produced some powerful insights. The Ipsos report clearly shows that these types of programmes are often designed and delivered in a complex and highly politicised environment, and Mike Lawrie noted that making decisions isn’t straightforward. “We heard from senior programme leads – one said to us the triangle between the treasury, the minister in question, and the programme team is where the decision- making happens.”

One key challenge is that big programmes often tend to try to come up with a solution before they fully understand the problem they are trying to solve. “It can be quite easy to run very quickly at standing up a programme to deploy a particular solution without thinking about whether that is genuinely the right way of solving the problem,” says Mike Lawrie.

Once options for possible solutions have been identified, engagement with stakeholders is essential to designing a programme that can deliver it. But that kind of engagement can be done in highly practical ways.

Future large-scale programmes

Looking ahead, the next phase of NHS reform is likely to need rigorous design and planning if the ambitions of the 10 year health plan are to be realised. The challenge is not whether to use them, but how to design and deliver them more effectively. Here’s where the framework is intended to help, by supporting teams to:

• Clarify the case for change, goals, scope, and theory of change.
• Understand contexts, stakeholders, and develop a credible implementation strategy.
• Strengthen programme management, governance, costing, scheduling, risk management, and evaluation plans.

It is intended for teams designing and planning large-scale NHS programmes but will be relevant to anyone likely to have a role in them or likely to be charged with implementing them.

“Having seen national programmes over many years,” adds Charles, “This framework is designed to bring in some consistency, to stop us failing in the same ways.”

An example is the NHS App. As Mary Dixon-Woods noted: “It’s been positioned as the digital front door to the NHS which means there’s an awful lot to think though there – not just technical issues, but also social issues that will need to be resolved.” Here’s where the framework may be helpful, since it directs attention to the many possible issues that need to be considered.

Having learning systematised into a framework in this way, Ron Agble suggests, means we are in a better position to know what we should do, identifying deficits both of knowing and of doing.