The Five Enablers of Sustainable Change: Creating better outcomes for people, staff and services
Change is part of everyday life in health and social care. Needs are becoming more complex, expectations are shifting and services remain under pressure. That makes improvement harder, but it also creates opportunities for improvement to make an even bigger impact.
Good ideas are not enough on their own. Lasting change depends on the conditions around them. The Scottish Approach to Change describes five connected enablers which create the conditions for change. These enablers work best together. If one is missing, improvement is much harder to create and sustain.
- Clear vision and purpose A shared reason and direction for change.
- Process rigour A structured way to plan, test and learn.
- Leadership and culture An environment where improvement can thrive.
- People-led approaches Change shaped with those affected by it.
- Learning systems Ways to capture, share and spread learning.
1. Clear vision and purpose: Why change matters
People are more likely to get involved when they understand why change is needed, what difference it could make and what success looks like. A shared vision gives everyone a common direction while leaving room for different skills, initiatives and contexts. It is also important in reducing confusion later, allowing teams to test new ideas against the same goal and explain decisions consistently.
Example from practice: People with a diagnosis of personality disorder often face significant barriers to accessing care and treatment, with access to dedicated services and interventions frequently limited or unavailable. People with a diagnosis are more likely to experience poorer social, physical and mental health outcomes and are more likely to present in crisis and experience multiple inpatient admissions.
The Identifying and understanding the evidence for change: National recommendations section of this toolkit provides access to key reports from the Royal College of Psychiatrists and the Mental Welfare Commission. These reports highlight the scale of the challenges faced by people with a diagnosis and provide evidence-based recommendations for improving access to care and support.
“There are many real-life issues that can challenge how unified senior clinicians and managers are day to day, for example, different perspectives on the diagnostic complexities, varying clinical approaches, and staff shortages alongside the increasing volume and complexity of clinical work. However, joint ownership of such complexity remains an essential ingredient for positive change. Healthcare Improvement Scotland has witnessed innovative and sustainable service developments in many parts of the health and care system when there is a shared commitment to working towards a common goal.”
Michele Veldman, Consultant Psychologist and Clinical Lead for Mental Health Renewal, Healthcare Improvement Scotland
2. Process rigour: Ideas into action
Sustainable change needs more than enthusiasm. Teams need a practical way to plan, test, review and adapt. Small tests can reveal what works, what needs to change and whether an idea can succeed on a wider scale. This does not mean creating unnecessary paperwork. It means using enough structure to make decisions visible, evidence-informed and repeatable.
Example from practice: Within NHS Dumfries and Galloway, Structured Clinical Management was identified as an effective approach to meet the needs of people with a diagnosis of personality disorder whilst also building the skills, confidence and capability of staff. Initially delivered by the developers of Structured Clinical Management, training has now evolved into a flexible, locally led model, with key team members providing training, supervision, mentorship and peer support.
As a result, staff have reported greater confidence in delivering structured clinical management and to support their service users, alongside a sense of ownership of the approach and shared culture of learning in the team. The case study in the Defining and testing changes: Designing and refining pathways of care section of the toolkit provides more detail.
3. Leadership and culture: Key factors in creating the conditions for successful change
Leaders and organizational culture shape how we do change, through what they priorities, the behaviours they model and what is made possible. A positive change culture gives people permission to speak up, test ideas and learn when things do not go to plan.
Collaboration, curiosity and recognition of progress then become part of everyday work, rather than an extra task. Leaders also need to create the space for improvement, removing barriers that teams and colleagues cannot solve on their own.
“Effective clinical leadership in a health board has a direct influence on the culture of the service and its capacity for compassion. In my experience, busy teams should have access to consultation with visible leading clinicians, to support difficult decision making and individual case management.” – Michele Veldman, Consultant Psychologist and Clinical Lead for Mental Health Renewal, Healthcare Improvement Scotland
Example from practice: NHS Greater Glasgow and Clyde drew upon strong clinical leadership to develop its dialectical behavioural therapy service. Supportive clinical leadership created a culture which brought people together and encouraged a multidisciplinary approach focused on improving outcomes for people with a diagnosis of borderline personality disorder. Development of the service was informed by an assessment of local needs, the evidence base for DBT and workforce skills and training requirements.
Following the award of time-limited funding, the service worked with a multidisciplinary steering group to test and refine the service. Implementation began with a small, motivated clinical team with a clear vision for the service, supported by active engagement with stakeholders to build and maintain commitment.
This approach led to full implementation of the service, the establishment of permanent roles within the team and stronger links with wider mental health services. Through continued leadership, learning and workforce development, the service has evolved over time and is now fully embedded within the local area. The Implementing Changes and Making the Business as usual: reviewing and embedding changes section of the guide contains a visual depiction of this process.
4. People-led: Change that is designed with people
The people who use and deliver services often see things that plans and data miss. Involving them from the start helps teams understand what matters, spot practical barriers and create solutions people are more likely to trust and use.
Lived experience and professional expertise should carry equal value. Good involvement is ongoing, accessible and honest about what can change. It includes families, carers and communities where appropriate. Taking a people led approach involves:
- Actively listening to diverse perspectives
- Involving people from the start
- Valuing lived and living experience expertise alongside professional and clinical expertise
- Creating and fostering opportunities for genuine partnerships
People led approaches mean that change and improvement are designed around what matters to the people who use services, understanding their needs and designing solutions for them rather than what they system thinks will work.
Example from practice: NHS Dumfries and Galloway sought to improve their structured clinical management pathway following an internal review. For the programme to succeed where others hadn’t, they knew they had to better understand a traditionally under served group. To do this, service user interview packs were developed to gather insights into people’s experience moving through the pathway.
The findings from these interviews informed the creation of a patient experience map, providing valuable insight into the pathway from the perspective of those accessing the service. Combined with learning from the pathway review, this informed revisions to the patient information leaflet, which was shared with service users across all five CMHTs for feedback. This helped ensure information about the pathway was clear, accessible and set realistic expectations around the support available.
“We often hear from employee surveys (such as iMatter) that staff feel removed from decision making and have little confidence in influencing their organisations. Genuine engagement of staff, at all levels, is essential to fostering motivation and participation, and ultimately improved patient care”
Michele Veldman, Consultant Psychologist and Clinical Lead for Mental Health Renewal, Healthcare Improvement Scotland
5. Learning system: Collaborating, sharing and spreading change
Improvement takes root when teams regularly reflect, use data well and share learning. A learning system is not only asking whether something worked. It explores how it worked, what others can use and what needs adapting in a different setting. Regular spaces for reflection help teams pause, compare experiences and act on learning to enable change ideas to develop and grow in response to changes and new ideas.
Example from practice: West Lothian HSCP worked with the Mental Health Renewal Team at Healthcare Improvement Scotland to review and support implementation of its complex post-traumatic stress disorder and emotionally unstable personality disorder pathway. This process brought together staff from inpatient services, psychological therapies, community mental health teams and service leaders to explore how the pathway and its interfaces worked in practice.
There were regular forums to enable honest conversations about where the pathway was working well, where it could be improved, and learning based on her personal clinical experiences. This led to the development of an updated pathway visualisation and a set of service user personas to support understanding and training in the pathway.
The pathway visualisation (along with Dumfries and Galloway’s Structured Clinical Management pathway) is available in the Designing and testing changes: designing and refining pathways of care changes section of the toolkit. Personas will be added to the toolkit when available.