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 barriers to accessing timely care and treatment, leading to poorer health outcomes, frequent episode of crisis and inpatient admissions. The Identifying and understanding the evidence for change: National recommendationssection of this toolkit brings together key reports from the Royal College of Psychiatrists, the Mental Welfare Commission and the Psychological Therapies Matrix. These resources highlight the scale of the challenges faced by people with a diagnosis, the services that support them 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.
“Implementing SCM as a core function within CMHT’s required not only strategic commitment, but key individuals to own and lead on changes, whilst supporting staff to adapt to new ways of working. CMHT workload remains fast paced and complex, which re-enforces the need to embrace clearer and more effective models of delivering care. Feedback from service users and staff highlights the importance of process rigour in ensuring positive patient outcomes and staff experience. ”
Jeanie Gallagher, Lead Nurse – Mental Health and Learning Disabilities, NHS Dumfries & Galloway
Example from practice: within NHS Dumfries and Galloway, Structured Clinical Management was identified as an effective approach for people with a diagnosis of personality disorder whilst also building the skills, confidence and capability of staff. Initially, training was delivered by the models’ developers, but this has now evolved into a flexible, locally led model, with key team members providing training, supervision, mentorship and peer support. This has increased staff confidence in delivering care and to support, fostered ownership of the approach and promoted a culture of shared learning. The case study in the Defining and testing changes: Designing and refining pathways of caresection 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 Board directly influences how a compassionate service culture is shaped. This means senior clinicians with credibility and experience of working with the most complex clinical situations being in key positions where they can lead on productive discussions and developments over a sustained period of time. It is important that there are mechanisms for communication with colleagues at all levels in the organisation to try to spread and embed a culture of curiosity and collaboration. This can be challenging in busy services with competing demands, and it takes a lot of energy to maintain the momentum. Leadership is best held by a group of motivated clinicians and managers who can build, share and sustain a clear vision across multiple strands of work”
Dr Andrea Williams, Personality Disorder Lead in NHS Greater Glasgow & Clyde.
Example from practice: NHS Greater Glasgow and Clyde demonstrate how strong group leadership and a supportive culture can support sustainable change. The implementation of the dialectical behavioural therapy service was informed by an assessment of local needs, the evidence for dialectical behavioural therapy and workforce development requirements. Following organisational commitment to time-limited funding, the service worked with a multidisciplinary steering group to test and refine the service. Implementation began with a small, motivated 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, permanent roles within the team and stronger links with wider mental health services. Through continued buy in from the organisation, 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 changessection of the toolkit 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: Following a review of their Complex Post Traumatic Stress Disorder and Emotionally Unstable Personality Disorder pathway, West Lothian Health and Social Care Partnership sought to develop tools to explore the shared understanding of staff of the people using their service. Using clinical knowledge, expertise and experience, a series of personas were developed that aligned to each part of their matched care pathway. These personas provide valuable insight into the clinical presentations that staff experience in their day to day working, including common patient backgrounds and referral information as well as treatment goals and interventions. Combined with learning from the pathway review, these personas provide a more relatable way of understanding a pathway and the people who will be supported by it. The Designing and testing changes: staff development and training section of the toolkit contains the personas developed for the service.
“Large documents of text are not the best way to communicate a new pathway and philosophy of care. Staff need to be able to recognise the system and new information in a visual way and from the starting point of how patients present to the system. Working on the personas felt like a meaningful way to achieve this”
Dr Amal Al Sayegh, consultant psychiatrist West Lothian.
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: NHS Highland’s Personality Disorder Service Awareness, Education and Training website brings together learning materials, training, evidence and perspectives from people with lived experience to provide practical guidance on improving understanding of personality disorder. The approach taken by NHS Highland aims to make specialist knowledge more accessible, supporting workforce development and helping staff build confidence and capability while also challenging the stigma and misconceptions that surround personality disorder diagnosis. NHS Highland demonstrate how learning can be translated into practice and their platform supports the spread of evidence-informed approaches and exemplifies how shared learning can create the conditions for lasting change that benefits people. The Designing and testing changes: staff development and training section of the toolkit contains more information and resources on staff development and training.
“Education and awareness is a crucial component of an effective approach in supporting those people who have been given a diagnosis of personality disorder, their friends and families, and those professionals who work with them. High quality, accessible educational materials form a key part of promoting self-management and in supporting self-management through the delivery of consistent, high-quality services”
Dr Tim Agnew Consultant Psychiatrist and Psychotherapist, Clinical Lead NHS Highland Personality Disorder Service.