Spread and Complexity in the NHS

Posted by: Diane Ketley - Posted on:

Why, if an innovation makes an improvement in one clinic, don’t all similar clinics do the same? This is a much asked question. There are many different factors for why innovations don’t always spread across the NHS – and one important factor is complexity.

A complex scenario may be similar to a complicated one in that there may be many components involved, but what differs is the level of predictability. For example, building a rocket is complicated with many components but has largely a predictable outcome. Compare that with raising a child: that’s complex because it is dynamic, has multiple interacting elements and is unpredictable (Greenhalgh, 2018).

When considering spread, we need to consider three aspects of complexity: that of the context, the innovation, and the process:


Healthcare is a complex adaptive system, meaning that it changes over time. It cannot be understood by looking only at its individual components: we need to look at the bigger picture. 

We also have the challenge of considering many different organisational scenarios e.g. primary care, secondary care and different levels from national to frontline. The interface of the adoption or implementation of an innovation with business as usual is often a particular challenge.


An innovation may have been a local initiative or a ‘top down’ requirement. The innovation may have multiple components and relational elements which may not be well understood or well described – innovations often change with use and over time, too. 

Gaining insight and understanding of the impact of an innovation is always an important part the process of spread. It is important that this is done in a way that reflects the complexity of the system. NHS Horizons is exploring the use of Sensemaker© for this purpose – my colleague Rosanna Hunt is writing a post about this next week, so please do watch out for it.


Finally, the process of spread itself requires change by organisations and by individuals in their behaviour and their routines. How do individuals find the energy and motivation to change what they do while still delivering a service? The School for Change Agents offers the opportunity to learn about this – sign up now for the online course that starts on 16 May. It’s free to join!

There is a dynamic relationship between these three aspects of context, innovation and process as they reciprocally interact and evolve.

What we know is that spread is a developmental, contextualised, adaptive learning and social process. However, we have traditionally used models of spread that are linear and mechanistic. 

We need to match the complexity of the challenge of spread with complexity. We need a new mindset and approach to spread. Braithwaite argues we need to move to a learning system that applies a more nuanced systems thinking approach and that factors in knowledge about the system’s complexity. 

In planning for spread and improvement understanding the limits of what is predictable and what is not is essential. Complexity means less predictability in implementation and outcome.

Understanding complexity is important because it allows us to plan and organise better for successful spread and improvement. We’re developing this as part of the forthcoming Horizons White Paper. Thank you to everyone who has already been involved in helping shape the White Paper – there’s still opportunities to be involved, and if you’d like to help please contact Diane.ketley@nhs.net.

If you’re interested in how to spread innovation in healthcare, there’s further blogs to follow. Please do subscribe to this blog; and follow @DianeKetley @horizonsnhs#nhsspread.