An effective approach to change

• Implementing the ambitions laid out in the 10-Year Health Plan for England, the Health and Social Care Service Renewal Framework in Scotland and similar agendas in Wales, Northern Ireland and Ireland will require both wholesale transformation and incremental improvement.
• To effectively achieve the scale of transformation required, the health and care system needs to adopt more structured and coherent approaches to change. Effective approaches will likely draw on a range of existing methods and frameworks to fit specific goals and contexts.
• Leadership is essential in setting vision and purpose, mobilising capability and resources and creating the necessary conditions. New forms of leadership behaviour and mindsets are needed that are more distributed and networked. 
• Effective measurement and evaluation are crucial but should be accompanied by systems for learning. This will allow organisations to evaluate impact over time, adapt approaches and build on what’s been proven to work.
• Mobilising the energy, commitment and diverse perspectives of staff and co-developing change with patients is necessary to navigate major change.
• Successful adoption and spread depend on tailored strategies, relational support and learning systems that empower both innovators and adopters to adapt interventions to local contexts.
• Maintaining the quality of care while effectively delivering transformation will require a shift in how many organisations operate. Embedding a Quality Management System approach can support this.

We need to respond to the scale of challenges and opportunities. Health and care face many stark challenges: rising demand, workforce pressures, health inequalities and financial constraints. The sheer level of change needed to positively transform care is set out in the 10-Year Health Plan for England and the Health and Social Care Service Renewal Framework in Scotland – with similar ambitions in Wales, Northern Ireland and Ireland.

These documents call for radical shifts towards community, population and preventative health; digital transformation (including AI); increased productivity; and integration across the system. These shifts will require both wholesale transformation – fundamentally rethinking how care is delivered, how people are involved and how systems learn and adapt – and incremental improvement to support sustainable implementation.

Change is difficult and has often failed. Change can be inhibited by many underlying factors such as a lack of human and financial resources, structural barriers, political instability or stifling regulatory requirements. However, efforts can also fail due to an ineffective approach to change itself –be it unclear or unrealistic priorities, ineffective engagement of staff and patients, insufficient capacity, lack of rigour, misaligned metrics or incentives and inattention to complexity. 

But we know a lot about effective change. There are many well-established frameworks and tools to support change, as well as curated resources such as NHS IMPACT, Scottish Approach to Change and Explain THIS. But evidence consistently shows that we don’t properly learn from previous success or failure when it comes to change. 

Overall, the health and care system needs to adopt more structured, coherent and effective approaches to change – drawing on a range of methods, frameworks and capabilities. Based on the best evidence and Q’s experience supporting change over the past decade, we set out here some key elements of such an approach. The core elements are applicable at multiple levels of change – in services, organisations and whole systems – although exactly how they are applied will differ. The final section also sets out some specific considerations at the system level. 

This resource aims to condense and consolidate what is already known rather than be exhaustive or create new resources. This is an ever-evolving field, and we will regularly update it with new content.

Three well-established and evidenced frameworks that offer valuable foundations are:

• The NHS England Change Model, published in 2018, outlines eight essential elements for planning and implementing change.

• The Scottish Approach to Change, launched by Healthcare Improvement Scotland in 2025, integrates multiple change methods into a practical, unified tool.

• NHS Impact is the single, shared NHS improvement approach for England. Although not strictly a change framework, it outlines the conditions required for continuous improvement and for organisations and systems to respond to key challenges.

Regardless of what overarching framework(s) is used, it is also important to apply a specific method for change. This could be one established method or drawn from multiple. Indeed, to deliver large-scale change within the complex health and care system, we likely need to bring together a mix of methods and approaches from different disciplines. This will help connect macro redesign with more incremental process improvement. The many possible change methods include: 

• Improvement approaches and methods: for example, Model for improvement, Six Sigma, Lean and Define-Measure-Analyse-Improve-Control 

• Design and systems thinking: for example, human-centred design, rapid prototyping, system mapping, experience-based co-design and human factors
• Agile and adaptive management and delivery methods: for example, sprints, continuous feedback, Theory of Change and rapid improvement events
• Human dimensions of change: for example, Behavioural insights, appreciative inquiry
• Collaborative approaches: for example, Breakthrough Series Collaboratives, flow coaching, liberating structures and communities of practice

The key is to select an approach that fits specific aims and context. The ability to make this selection is a vital skill those with improvement and change experience can bring to change efforts. The system needs to draw on these skills much more intentionally for the changes ahead. 

Also important is ensuring teams have the skills and support to apply the method(s) effectively. 

A compelling vision and purpose underpinning the change process helps align efforts, motivate action and sustain momentum. Those leading, delivering and affected by change should be involved in developing this vision. It should also take sufficient account of the complex context of health and care – but not get bogged down in it. And it should allow for flexibility on how overarching goals are delivered in different contexts. 

Leadership has a crucial role to play in change. It is essential in setting vision and purpose, mobilising capability and resources (including breaking down traditional silos and avoiding unhelpful duplication of effort) and creating the necessary conditions. 

Change needs to have leadership buy-in (including at the executive and board levels). Those managing the process should actively identify and build leadership support and capability. 

Change also needs leaders at all levels – including middle managers and clinical and administrative staff with the skills and agency to effect change. Change processes should actively foster psychological safety and openness to challenge throughout.

We also need new forms of leadership behaviour and mindsets. These should be more distributed, where leaders share responsibilities across multiple stakeholders. They should also more networked, with leaders actively nurturing and mobilising connections to support change – often beyond organisational boundaries.

Good data help track progress, inform decisions and surface what’s working (or not) in real time. But measurement should do more than monitor performance – it should support improvement and learning. 

By embedding systems for learning into change programmes, organisations can evaluate impact over time, adapt approaches and build on what’s been proven to work.

Effective measurement and evaluation should draw on multiple sources, including existing evidence, outcome and process data, staff and patient feedback, qualitative research, management data and more informal stakeholder engagement. Crucially, effective evaluation doesn’t necessarily mean more measurement. Improvement approaches help identify what measures really matter (often leading to streamlining of indicators) and encourages focus on both the technical and human infrastructure required to make the best use of data. 

People, not plans, drive transformation. Mobilising their energy, commitment and diverse perspectives is essential to navigate major change. 

Engaging staff is both more challenging and even more necessary in the current climate of restructures and redundancies. Staff need space, time and agency to shape, design and deliver change and improvement. 

Effective and inclusive co-development with patients is also crucial, including to better address longstanding inequalities. There are lots of good practice guides on how to do this.

But as well as applying established methods, true co-production also requires a substantial transfer of power to people and communities. 

In many cases, the desired future is out there, somewhere. Examples of good practice are widespread, but they often remain isolated and localised. To deliver the change required, we must get better at identifying good practices – and using adaptive approaches to implement these in other contexts. 

Adoption and spread are complex processes that require tailored strategies, not one-size-fits-all approaches. We need to focus on adaptability, not just fidelity. 

Innovators must design for spread from the outset, clearly identifying what is core and what can be adapted. Adopters must play an active role in adapting interventions to local contexts through testing and learning. Tailored strategies, infrastructure and support are essential. 

By investing in shared learning and supporting both innovators and adopters, systems can move from isolated good practice to embedded, sustainable transformation. 

Periods of transformation often risk declines in quality – driven by staff turnover, stretched resources and poor communication. Recognising, and acting on, this risk is important. 

Effectively delivering transformation while maintaining quality of care will require a shift in how many organisations operate day to day. Quality Management Systems (QMS) offer a structured, organisation-wide approach to planning, improving, controlling and assuring performance. They can also provide an operating system for quality-driven learning. While traditionally used to manage ​‘steady state’ business as usual delivery, there is growing interest in applying QMS to support change. The Scottish Approach to Change is one such example, proposing a framework that integrates QMS into transformation efforts.

Successful transformation also means stopping doing things that no longer deliver value. This process of ​‘de-implementation’ requires proactive management that ensures stopping doesn’t have implications for quality. 

When aiming for sustainable improvements at the system level across multiple organisations and hierarchies, leaders need to come together to plan and deliver work holistically. This complex work can be hard to navigate. Q’s cross-system improvement framework outlines six different modes of action that are necessary for successful change at this level. They largely overlap with those at the service and organisation levels, but this framework includes some specific considerations for system-wide improvement efforts.

The framework can be used by those developing strategies to improve health and care across systems. It supports leaders to recognise and navigate the improvement landscape, and to holistically plan and deliver large-scale change. 

• Explain THIS is a collection of short, accessible resources designed to help people working in health care improvement understand key concepts and approaches
• Leading Improvement in Health and Care podcast shares the stories and explores the challenges of people making changes across systems
• A framework to guide the design and planning of large-scale change programmes in health and health care developed by THIS Institute
• Q members’ Quality Coach Development Programme and Systems Quality Improvement Practitioner Programme
• Transformational change in health and care is a King’s Fund report that provides examples of staff’s and community’s experience of change
• Improving health and care at scale is an NHS Confederation/​Q report exploring the early work of integrated care systems at the forefront of improvement at scale
• Implementing the 10-Year Health Plan: ensuring an effective approach to change is a joint statement from Q, NHS Confederation, NHS Providers, The King’s Fund, National Improvement Board and National Voices