About Nesta

Nesta is the UK's innovation agency for social good. We design, test and scale solutions to society’s biggest problems. Our three missions are to give every child a fair start, help people live healthy lives, and create a sustainable future where the economy works for both people and the planet. For over 20 years, we have worked to support, encourage, and inspire innovation. We work in three roles: as an innovation partner working with frontline organisations to design and test new solutions, as a venture builder supporting new and early-stage businesses, and as a system shaper creating the conditions for innovation. Harnessing the rigour of science and the creativity of design, we work relentlessly to change millions of lives for the better. Find out more at nesta.org.uk

Who is this publication for?

This paper is a practical guide, sharing lessons and insights from the experiences of health and social care innovations backed by Nesta and partners over the last five years as they sought to increase the impact of their work. The innovators leading the change were largely organisations working outside and alongside mainstream public services, although a number were very much embedded within this context. It is intended for both social innovators and their potential partners and supporters: funders, commissioners, evaluators, and policy leads.

Acknowledgements

Thanks to our partners in designing the programmes that helped support the scaling of great innovation, particularly The National Lottery Community Fund for our work together on Accelerating Ideas and the Cabinet Office and Department for Digital, Culture, Media and Sport through the Centre for Social Action Innovation Fund from 2013 to 2020.

Thanks to our Nesta colleagues who have been involved in these innovation programmes over the last ten years – too many to name. Thank you to the Bright Harbour and & Good teams, who carried out some of the research that fed into this paper.

Lastly, our particular thanks to the health and social care innovations for being generous with their time, ideas, expertise and incredible work in reaching and supporting many more people. It has been an absolute privilege to be a small part of your innovation journey, and we can't wait to see what you will achieve in the years to come.

We particularly want to thank the teams at: Absolutely Cultured • British Lung Foundation • British Red Cross • Carers UK • The Cares Family • City of York Council • Compassionate Neighbours • Equal Arts • GoodGym • GoodSAM • Kinship • Plymouth City Council • The Reader • Shared Lives Plus • Stroke Association • Volunteering Matters

We draw particularly from their honest reflections, learnings, and insights in this paper. However, there are dozens of other innovations we have journeyed with in scaling who together show that another future is already here – it's just not evenly distributed.

Authors

Alice Clay, Amy Solder, Carrie Deacon, Chris Norris, and Sarah McLoughlin

November 2021

1. About this paper

This paper catalogues some of the key learnings from the experiences of a group of innovators scaling their health and care innovations over the last five years. It has been produced in close collaboration with the innovations themselves, drawing on their practical learning and experiences, and is aimed at helping others seeking to get to grips with scaling people-powered health approaches. Whilst aimed at innovations scaling impact in health and social care, it will likely have broader resonance for those scaling in other fields too.

It should also be noted that COVID-19 has affected the 16 innovations in different ways. Some had greater demand than ever before, some had to pause much of their activity at the height of lockdowns, and others pivoted to digital. We don't yet know the medium to longer term effects of the pandemic, or what this will mean for the role of person- and community-centred health innovations, but it has been clear that these approaches are needed more than ever. The learnings here are therefore not pandemic-specific.

Beyond sharing an account of the key insights and learnings from health and social care innovations, this paper also looks to the future, examining what needs to shift to enable more people-powered health innovations to move from margins to mainstream, creating the transformative change needed to support happier, healthier, and more equitable lives in the coming years.

1.1 A quick note on language

Where possible we have avoided technical jargon. However, there are some areas where we think it is appropriate to use a specific term. Here, we outline how we are using such terms.

Co-production When citizens are actively involved in the development of new services, projects or programmes. Contrasts with a more traditional and transactional model of service design in which citizens are merely seen as users of services, projects or programmes.

People-powered and person- and community- centred health and wellbeing This paper uses the term people-powered and person- and community-centred approaches for health and wellbeing to describe a wide range of approaches united by a common purpose: to genuinely put people and communities at the heart of health and wellbeing. This happens by focusing on what is important to people, what skills and attributes they have, and on the role of their family, friends and communities. See longer definition on page 10.

Scaling When we talk about scaling, we're not just interested in growth and numbers we are also interested in growing impact, the conditions needed to successfully scale, and scaling up to change policy. See page 15.

Social innovation Social innovations are new products, services or models that both meet social needs and create new social relationships or collaborations. They are 'social' both in ends and means. Social innovations can be generated from within any sector – public, private or social or from citizens and social movements. They may generate financial value, but don't have to.

Systemic innovation There is no precise definition of systemic innovation. We see it as an interconnected set of innovations, where each influences the other and with innovation both in the individual parts of the system and in the ways they interconnect.

'Upstream' approaches Interventions and strategies that focus on creating the economic, social and community conditions that enable citizens to live healthier and happier lives. Simply put, public services that solve problems before they happen: preventing people feeling lonely, for example, or working to promote healthier approaches to end of life care.

2. Executive Summary

Our starting point is that health and care needs to work alongside and be created with and by individuals, carers, families, social networks and thriving communities, to enable us to live healthier, happier lives. Over the last decade, Nesta has worked to make the case for this more people-powered health revolution, supporting some of the best people-powered health and care innovations to scale their impact and demonstrate the value and potential of these approaches to the mainstream. We have sought to nurture these innovations as the seeds of change - experimenting with ways to scale this type of work.

Although innovations spanned different sectors and geographical locations, operated on different business models, and focused on different outcomes, they all worked towards shifting health and care approaches centred on individuals and communities, and support people to have greater control over their own health and wellbeing. The experiences and insights of the innovations reflected a number of common characteristics that underpinned their success in how they were able to scale their impact, focusing on four key areas:

• Ways of thinking that innovations were based on, including having a deep understanding of the challenge, a big, audacious idea, and viewing themselves and the challenge as networked and interconnected.
• Ways of building that supported their scaling ambitions, including understanding the importance of context and building for 'local', putting people and relationships at the heart of the innovation, investing in core infrastructure, and building skills, capacity and culture to support growth.
• Ways of acting that enabled them to effectively scale their innovation, including how they lived and embedded their values, how they used evidence well and valued learning, how they continued to innovate but knew when to say no, how they experimented with their business models, and how they used powerful narratives to amplify and influence change.
• Enabling context that created the conditions to support innovations to scale, including the role of field-building and systems leadership, better integration of new approaches, effective longer term funding relationships, and partners who valued people-powered approaches that worked upstream of issues to turn the tide.

Whilst scaling innovation is often associated with simply growing an organisation and reaching more people, the success of these innovations relied on a wider understanding of scaling. They 'scaled out' in a whole host of ways, including growing their delivery through networks or in partnerships and growing core organisational capacity through large-scale digital delivery. But they also 'scaled up' and 'scaled deep' to create broader change, both themselves and through working with government, local government, funders, a range of civil society organisations, media, and people and communities more broadly. They could often only do this when the right scaling conditions were present, enabled particularly when funders and public services could play a role in fostering and enabling the context for the work and wider change. Through the examples in this paper, you will see how they 'scaled up', 'scaled deep' and 'scaled out', and the conditions that enabled this.

To tackle problems entrenched in our societies, including widening health inequalities, increased loneliness and isolation, and spiralling costs of supporting people to live well with long-term health conditions, we need more people-powered health and care innovations to mainstream and become the new normal. We hope this paper provides valuable practical insights to enable innovators, commissioners, funders and policymakers to make this a reality.

3. Introduction: Scaling people-powered health and care innovations

Imagine you have recently had a stroke. You receive great emergency care, and ongoing support from doctors, nurses and healthcare professionals. But it's not until you talk to someone in the same position as you that you find a way to cope with, recover from and live with the short- and longer-term effects of the stroke in a way you could never have done simply by getting medical support.

This is the simple yet amazingly powerful experience of peer support. Peer support is obviously by no means a new phenomenon: it is a well-tested and long-established part of the care and health system, and also a core part of how we organise our basic social structures of family, friendships and communities. Yet in spite of an array of powerful evidence and examples, the power of peer support is not available for all, and has still rarely been systematised or used at scale in the health and care systems.

To tackle problems entrenched in our societies, we need more impactful social innovation that creates a new normal. Peer support at scale, available for all people when they need it, could have profound societal effects for individuals, communities, and the health and care systems. Peer support is just one example of an innovation that should be a normal part of all health support, and there are a wide range of other person- and community-centred innovations that could also make a huge difference to our health and wellbeing. In many of these cases, we don't lack inspiration, but frequently fail to scale the ideas, behaviours, principles and practices needed to defuse, embed and redesign those systems that will make way for the new and adapt or replace the old.

Over the last decade, there has been a growing focus on how to empower and engage communities in their own health and care, with a wide range of initiatives from social prescribing to new approaches to personalised care. However, despite increased interest and growing action, policymakers and commissioners often struggle with what they can do to make this vision a reality. Around the country there are many ideas and initiatives that together could spell out the answer: promising pilots, new operating models and approaches developed within public services, and social enterprise and community innovations showing huge promise and potential. Whilst these innovations may grab attention and be cited as a source of inspiration by many, too often it's difficult to sustain them, and even harder to adopt into the mainstream.

So why, in spite of a mounting case for more personalised and community-focused health, and a growing support for people-powered health innovations from communities, policymakers, and civil society alike, do many of the high potential innovations like peer support remain on the margins? Why do they often struggle to scale beyond a small number of people? And why do so many of these innovations get caught, unable to cross the 'scaling chasm'?

There are many reasons that account for these challenges. We have seen, for example, that there can be systemic and organisational immune responses which seek to protect the status quo, entrenching resources, mindsets, capacity and processes in ways that create little space for growing new approaches. We know that we are often caught in shorter-term thinking, and can find it difficult to shift horizons from the current dominant paradigms to new possibilities and what may be required to get there. Some people have shared that ways of commissioning can favour large scale providers, drowning out space for growing newer innovations.

In spite of an ecology of new ways to support social innovations, from accelerator programmes to new forms of investment and finance, many feel we do not yet have the full range of support structures and funding to support innovators to scale. We also know that not all social innovations have scaling potential, and that not all innovators want to grow their activity.

We also see that the way funders and investors have thought about and supported scaling may be too narrow, often backing individual unicorn ideas rather than building fields of actors who together can make the change. There is also much more still to learn about how we make the scale of change needed.

For more than ten years, Nesta has been researching, funding and championing people-powered health, a vision of health created by people, with people, for people. Through a variety of tactics and innovation methods, alongside a fantastic cadre of partners, we have sought to support some of the best approaches to enter the mainstream. We've worked to understand and create the policy conditions for these approaches to become mainstream, with learning around people-powered health being used to shape Chapter 2 of the NHS England's Five Year Forward View, as a founding partner of the Coalition for Collaborative Care, and working to influence people-powered health to become recognised as a key operating model in health as seen in NHS England Long Term Plan and Universal Personalised Care strategy.

We've researched approaches to scale and what needs to shift in the system with programmes such as People Powered Health, Realising the Value, or Social Movements for Health. Through Nesta's impact investments, we have invested over £12 million in 26 commercially viable health innovations to fuel their scaling ambition. Our People Powered Results work has pioneered approaches to achieving change and innovation in complex systems. These approaches are smarter, faster, more collaborative and inclusive of citizens and people working at the frontline, and accelerate ideas to mainstream practice and create cultures for innovation.

Nesta has also been seeking to learn about scaling people-powered health innovation through programmes using longer-term grants which support high-impact social ventures to scale over a period of time. Through both grant finance and non-financial support, the approaches aim to accelerate the scaling journey for social innovations, enabling them to reach more people and fulfil their potential, achieving greater influence. This paper builds on work in this area, drawing from some of the health and social care innovations from the Centre for Social Action Innovation Funds in partnership with the Office for Civil Society, which ran from 2013 to 2020, and the Accelerating Ideas Programme, in partnership with the National Lottery Community Fund, which ran from 2016 to 2021. This paper aims to share the learning and insights from the experiences of the 16 people-powered health innovations who have been scaling their work.

What is people-powered health?

The health and care system we rely on today was created for a very different time. With a focus on treating people in the short term, it's simply not set up to support and enable people to be healthy in the long term. The limits of a 'treat and cure' model are well and truly established; excellent clinical care is both essential and absolutely not enough for the complex issues we face. A confluence of factors are challenging the boundaries between formal health institutions and the environments where health is developed and experienced, including people desiring deeper involvement in choices related to their health and wellbeing, the traditional medical model falling short of addressing the wider determinants of health, and increasing recognition that hierarchical institutions alone can no longer adequately address local and global health challenges.

There is a consensus that we need to move upstream to prevent ill health. But this requires a whole set of actions that are beyond the reach of traditional formal services and which move into the social sphere; indeed, into the private lives of people.

We have worked to support a health and care system that empowers people to lead healthier and happier lives – people-powered health. We know that people are healthier and recover faster when their social health needs are met alongside their clinical needs. There are a whole spectrum of new approaches, relationships, networks and technologies which empower people to improve their health and wellbeing.

3.1 A snapshot of innovations

The social innovations whose experiences we draw from in this paper were a range of high-impact approaches, selected for their scaling readiness and ability to impact the lives of many more people. Each innovation had already been developed and tested, and could demonstrate positive signs of transformative impact.

They came in a broad range of forms some were start-up ventures such as GoodGym or The Cares Family, some were from larger established charities such as British Red Cross or Carers UK, and some were from within public services but in partnership with civil society such as City of York Council's Community Health Champions. Whilst all were ready to scale, some had developed their approach over many years, whereas some were scaling early on in their journey through approaches such as digital roll-out. The innovations were also highly varied – from peer support networks for people experiencing long-term health conditions to social groups to support reduced loneliness and isolation. They had different audiences, and operated in different parts of the country. Yet their work and ways of scaling showed clear patterns – common insights into what successful scaling can look like and consist of.

Absolutely Cultured

Absolutely Cultured built on the foundations of the citywide volunteering they established as part of the 2017 UK City of Culture to mobilise the time and talents of the people of Hull to achieve key city priorities, including reducing loneliness and supporting communities to develop their own ideas for change.

They adapted and scaled their approach through developing strengths-based, geographically-focused action with communities. This included a series of projects ranging from a film on loss and dying to a campaign to encourage random acts of kindness. From 2018 to 2020 they mobilised 923 volunteers, who supported over 4000 local people.

British Lung Foundation

British Lung Foundation's Integrated Breathe Easy peer support groups connect people living with chronic lung conditions with each other and healthcare professionals.

From 2016 to 2019, British Lung Foundation grew from running 43 Integrated Breathe Easy peer support groups for around 3,000 older people, to 219 groups supporting 8,289 people. This is set to continue to grow.

British Red Cross

British Red Cross' 'First Call' service supports people as they recover from a crisis and helps them remain independent at home for longer.

From 2016 to 2021, First Call's offer grew from five areas of the country to nine. Through First Call they have now supported 6,495 people in their recovery at home, with 63 per cent of referrals coming from hospitals. They, too, are set to continue to grow in the next few years.

The Cares Family

The Cares Family creates community networks of younger and older neighbours who hang out and help one another in our rapidly changing cities.

From 2016 to 2021 The Cares Family grew from supporting 2,000 people in North and South London to 5,430 older and 4,827 younger people in North, South and East London, Manchester and Liverpool. They are now spreading best practice and examples of community connection through their Multiplier programme.

Carers UK

Carers UK's national volunteering programme enables people with experience of caring to provide valued support to help others better manage their caring role.

From 2016 to 2021, Carers UK's volunteering programme grew from around 500 volunteers who were almost all based in England to a national volunteering programme, with 1,568 volunteers recruited and 150,000 carers supported.

City of York Council

City of York Council focuses on improving the health and wellbeing of citizens by recruiting Community Health Champions who develop and lead key activities to encourage participation amongst underrepresented groups in the city.

From June 2018 to January 2020, the programme trained 75 Health Champions who supported 1,810 community members. The Health Champions have played an essential role in joining the dots between different community initiatives and embed a city-wide health and wellbeing agenda.

Compassionate Neighbours

The Compassionate Neighbours approach, originally developed by St Joseph's Hospice, encourages and equips volunteers to support vulnerable neighbours who are in the last years of life.

Compassionate Neighbours established a network of hospices to replicate the model, growing from one to eight hospices. By the summer of 2019, over 1000 Compassionate Neighbours had been trained, supporting 617 community members.

Equal Arts

Equal Arts' 'HenPower' is an asset-based relational care model that aims to empower older people to build positive relationships through henkeeping with improved wellbeing, reduced loneliness and reduced depression.

Equal Arts scaled HenPower through growing geographic clusters of care homes. From 2017 to 2019, Equal Arts expanded HenPower from 20 to 60 care homes, engaging over 6,000 residents in creative workshops and henkeeping.

GoodGym

GoodGym is a new way of supporting older people. It's powered by a growing community of runners who work to reduce isolation among older people and bring communities together.

In 2016, GoodGym was in 24 areas with 3,500 active members and 700 older people engaged: it now operates in 58 different cities and boroughs across England and Wales, involving almost 30,000 runners and older people.

GoodSAM

GoodSAM is a collaborative platform and community of first responders that can increase the chances of survival after a cardiac arrest.

In September 2017 there were 1500 GoodSAM Cardiac Responders and 600 GoodSAM Cardiac Alerters in the UK. Only one ambulance service was integrated into the system. In 2020, there were 100,000 GoodSAM Cardiac Responders in the UK, 180,000 Cardiac Alerters in the UK and 11 Ambulance Services integrated.

Kinship

Kinship's Connect programme brings together Kinship carers to help themselves and each other through building strong and sustainable peer networks, addressing social, geographical and technological barriers to establish resilient kinship communities.

From 2016 to 2019, Kinship set up 35 new peer support groups, increasing their reach to 61 groups. They scaled across 17 local authority areas, including two new regions, supporting over 360 Kinship carers. They are set to continue to grow, with increasing demand from public sector partners to support Kinship carers across the country.

Plymouth City Council

Plymouth City Council's 'Our Plymouth' focused on energy saving and growing healthy food. The council focused on challenging traditional power structures and modes of working with citizens and existing voluntary organisations.

From January 2019 to March 2020, Our Plymouth delivered food bags to 84 households, supporting over 400 people to eat healthier, and delivered healthy eating cooking sessions to 126 people.

The Reader

The Reader runs 'shared reading' sessions aimed at people at risk of isolation, where participants read works of literature aloud to one another.

They scaled by creating a new volunteer-led group model, starting in the Liverpool City Region and North West. By September 2019, The Reader had established 115 new shared reading groups, growing from 141 to 256. This enabled them to support an additional 1,700 people to participate in shared reading groups, reducing isolation and improving wellbeing and social connections.

Shared Lives Plus

Shared Lives Plus is a national membership organisation supporting an innovative form of social care based around sharing home and family life. The scheme involves a Shared Lives carer sharing their home and family life with an adult in need of care or support.

Over the last five years, they have grown to support many more people. 150 Shared Lives schemes connect nearly 15,000 people living ordinary lives with over 10,000 carers sharing their home and community across the UK. Between 2016 and 2021, one of the scaling priorities for Shared Lives was to expand in Scotland and Northern Ireland, and over the last five years they grew from no older people supported in Northern Ireland and only 65 in Scotland to 246 total new clients using Shared Lives across these areas.

Stroke Association

Stroke Association's peer support network brings people living with the effects of stroke together to reduce isolation and promote recovery.

From 2016 to 2021, the Stroke Association's Hand in Hand peer support groups grew from 140 across the UK to 216 groups, reaching 6,530 people affected by stroke.

Volunteering Matters

The Volunteering Matters Grandmentors programme matches volunteers aged 50 and above to mentor young care leavers on a one-to-one basis, focusing on supporting them in their journey out of care and into independent living.

They scaled Grandmentors through organisational growth, with a new staff member in place in each new area, embedded within local authorities. By the summer of 2019 they had scaled from three to nine local authority areas, with a strong pipeline of interest, having connected almost 400 young people with a grandmentor.

3.2 What we mean by scaling and how it works in practice

Social innovations can be said to have scaled when their impact grows to match the level of need¹. However, scale can be achieved in many ways – innovations can be diffused, grown, copied, replicated and adapted. Organisations can be grown to deliver directly for more people; partnerships can be formed to help deliver or spread innovations drawing on the strengths of different people; innovations can be spread through policy or legal change; innovators can licence materials and training for others to deliver and spread. We outline more on this in the report Making it Big, and if you are looking to explore options for how you might want to grow or scale something, this would be a great place to start.

Health and social care innovations are often using multiple routes and tactics to scale their innovation at any one time. The Cares Family, for example, have replicated their model in different geographic areas through partnering with a collection of locally rooted organisations, worked to create large-scale cultural and policy change, and are now sharing their experiences by supporting other organisations to build bridges in their own communities. The British Lung Foundation, on the other hand, have grown their capacity to support peer support groups, taken a networked approach to local delivery, and partnered with health services across the country to integrate their model and draw from their expertise.

Taking an innovation from new idea to new normal involves distinct actions that we outline simply through seven stages of innovation (see Fig. 1). This means that scaling often requires a change in tack and focused strategy, and can require new skills, new ways of organising, new governance, new partnerships and more.

There is lots of debate as to whether 'scaling' really reflects the process of growing social innovations to create a new normal, or if this is even what is needed. Scaling is seen to imply linear growth, standardisation and economies of scale, which runs counter to the core of people-powered health and the relational approaches it requires. Some believe that, rather than scaling individual innovations, we need to spread lots of smaller ideas through what is referred to as 'mass localism'. Others have identified that scaling individual innovations is never enough.

This has led to greater calls for and attention to more systemic innovation, recognising the complexity of many of the social challenges we face. Systemic innovation looks to address both the root cause of issues through legal, policy and institutional shifts, with bottom-up networked approaches weaving together interconnected innovations alongside greater attention to the conditions, practice, mindsets and behaviours that underpin systems.

3.3 Field building for people-powered health

In this paper, we consider scale in four ways (see Fig. 2). These categorisations were inspired by the work of Darcy Riddell and Michele-Lee Moore.

As we have highlighted, successful scaling is rarely a matter of simply scaling out to greater numbers of people. The 16 health and social care innovations highlighted in this paper scaled out in a whole host of ways, including growing their delivery through networks or in partnerships, and growing core organisational capacity through large-scale digital delivery. But they also scaled up and scaled deep to create broader change, both themselves and through working with government, local government, funders, a range of civil society organisations, media, and people and communities more broadly.

They could often only do this when the right scaling conditions were present, enabled particularly when funders and public services could play a role in fostering and enabling the context for the work and wider change. Through the examples in this paper, you will see how they scaled up, deep and out, and the conditions that enabled this throughout.

It is important to note that the scaling of these innovations was not done in isolation. As well as scaling individual innovations, Nesta, alongside a range of other organisations including The Health Foundation, National Voices, #SocialCareFutures, The Innovation Unit, RSA and many others, have been building and taking action to develop the case for more people-powered health and care. Indeed, these innovations were part of a wider piece of work, in which we were aiming to field build, support innovations to grow, and connect as an ecosystem to scale out people-powered health and care approaches.

These insights have helped us understand more about how you practically sow the seeds to support both individual innovations to scale and the wider fields they're situated in, and to better shape the supporting environment for change.

4. Learning from scaling

Ways of thinking, building, acting and enabling to scale health and care innovations

There is no perfect roadmap to scaling person- and community-centred innovations for health and wellbeing. Yet when exploring the learning from 16 people-powered innovations scaling out their impact, and scaling deep and up systems change, a number of patterns emerge in how they think, build and act, and what conditions are helpful to support their work.

Through sharing these patterns, we hope some of the less discussed elements of scaling innovations become more visible. These are not hard and fast rules, but common factors that appear to have helped the success of people-powered health innovations.

How they were applied or used varied enormously. The innovations that have informed these patterns, although all operating within the people-powered health context, are working in different geographies, with different types of innovations, different types of people, and different relationships to formal public services. Yet the common features that emerge speak to ways of thinking, building, and acting that we believe are useful characteristics for other innovations to consider in their journey. They also speak to what is needed within an enabling context to support more of these types of innovations to succeed. Here, we break down these patterns to help other innovations benefit from their learning.

4.1 Ways of thinking

The vision and mindset of the teams leading the scaling innovations were vital to their ability to scale. Their ways of thinking about their goals, about scale, and about the innovation's purpose was the North Star that helped guide them through their scaling journey, particularly when they hit challenges. These were often underpinned by a core set of values about how they saw the world, their work, and the power of people.

The innovations were often based on:

• A deep understanding of the challenge
• A big audacious idea
• A view of themselves and their challenges as networked and interconnected.

A deep understanding of the challenge

Health and social care fields are complex, with multiple actors and entrenched ways of doing things. The most successful scalers have a deep understanding of the challenge what the issue is, what people's experiences are, what current approaches are, and where the opportunities lie. For example, what are the issues with adult social care? How many people in total across the country need access to formal social care services? What needs to change nationally or in frontline practice?

They were adept at bringing together personal experiences with the bigger picture, valuing co-production, and drawing from a variety of sources of data. They often brought together perspectives from different experts, surrounding themselves with critical challenges and staying close to people's experiences to continue to connect with the issues and lived experiences as they scaled.

IN PRACTICE

The Cares Family understood the scale of loneliness in the UK and its impact on people's lives². But they also recognised that much of the narrative when they started their work ten years ago was focused solely on the experiences of older adults. Their experiences indicated that it was not just older people experiencing 'disconnection', but many younger people too. They also believed that the answer to disconnection was not in service delivery but in community, drawing from the assets and interests of that community.

They spent time talking, listening and developing the approach with each community they worked with, connecting individual, community and national stories to make a compelling case for change.

IN PRACTICE

The British Lung Foundation is dedicated to improving the lives of people affected by lung conditions. For over 20 years, a cornerstone of this activity has been the development of a network of people-led groups known as Breathe Easy. Groups promote self-care via peer support, education and information. With an average of 6,000 regular attendees each year and overall membership of 17,000, the popularity of Breathe Easy groups has remained high.

Despite this, groups were often seen as useful ad hoc opportunities to healthcare pathways but not always integral to them. This sometimes resulted in varying levels of engagement from healthcare professionals, fluctuating referral rates and differing levels of delivery. Integrated Breathe Easy Groups were set up to address this, keeping the best elements of peer support and combining them with a new focus on engagement with commissioners and healthcare professions to ensure sustainability and integration with respiratory pathways.

IN PRACTICE

Kinship identified that kinship carers (grandparents and siblings, aunts, uncles, and family friends who step up to raise children when their parents aren't able to), weren't getting equal support and recognition to others forms of care, meaning over 200,000 children were in families at risk of breaking down. Through their research and experience Kinship were also aware that kinship carers needed more connections with other people living as kinship families experiencing and understanding the highs and lows of what this can involve.

By creating peer support groups and connecting directly with local authority social care services, Kinship were able to both reduce isolation and build resilience for kinship carers. They were also able to work to improve local authorities' capacity to support kinship carers and promote a greater understanding of kinship carers and their support needs.

A big audacious idea

Underpinning many of the innovations' scaling journeys was a narrative an audacious vision for change that often breaks with the established discourse. Innovations could not only say why what they were delivering was different, but also had a philosophy and view of how the system at large could and should be changed to create healthier, happier lives. They dared to dream, and could see a new future. But they weren't just going to talk about this alternative – they were going to play a part in creating it.

With each phase of growth, innovations invested time consolidating their purpose and aims, keeping an eye on both the long-term vision and the shorter-term tactics needed to structure their position and keep the momentum for change.

Mindset was critical to this journey. Innovations navigated and balanced being entrepreneurial and systemic, delivering effectively within the current system whilst making the case for larger scale change that was often bigger than their work. They were focused pragmatically on impact and changing lives now, but many did not simply seek to scale themselves as a new solution but as an embodiment of the new system and world they were trying to create.

IN PRACTICE

Over a ten year period the Cares Family built five charities that tackle disconnection in Manchester, Liverpool and London. These organisations were built locally, with a wide range of contacts and connections that helped forge their success.

But they recognised that disconnection isn't exclusive to those areas. In partnership with UnLtd, The Cares Family have now set off on a journey over the next five years to invest in 50 people to build bridges in their own communities in their own ways and adapt, grow and multiply their initiatives. The ‘Multiplier' approach aims to create more connected, cohesive communities, helping to accelerate action across the country.

“By working together, we can make a greater impact than we would alone.”

Alex Smith, CEO, The Cares Family

IN PRACTICE

The Compassionate Neighbors programme replicated the learning from St Joseph's Hospice to eight other hospices. But this aims to work beyond providing a service. The underpinning philosophy and approach is about social connection, strong community, and grief, loss and dying as a normal part of our lives. Inspired by a model of participation in Kerala, India and the Compassionate Communities Movement, it aims to challenge institutional norms and re-socialise end-of-life experiences as community experiences.

By demonstrating how this could work in different contexts, they learned what this refiguration would take, and could build a narrative to help unlock this bigger change.

A view of themselves and their challenges as networked and interconnected

"If you want to go fast, go alone. If you want to go far, go together.”

This proverb certainly was a path well-travelled for the scaling innovations. Whilst there is much that drives competition in the health and social care fields, especially when looking to secure funding, many of the innovations removed themselves from this kind of mindset and from seeing themselves as single organisations. Instead, they focused on a view of themselves as networked, part of an ecosystem of actors making the large-scale change required. Even if their scaling strategy went to plan, and they reached many more people, they knew their innovation alone was likely insufficient.

Whilst the innovations used different organisational forms and routes to scale, they also commonly drew from expertise, experiences, and the strength of communities to enable them to scale.

"Before I joined this programme, I never really viewed end-of-life as an ecosystem; it was about commissioners, providers and 'service users', a hierarchy. But an ecosystem is how you get the best out of people in tough times, as proven by what we have achieved together [in mutual aid groups] in the pandemic." Hospice CEO, Compassionate Neighbours

IN PRACTICE

City Of York Council's Community Health Champions approach worked predominantly with older adults to lead activities that they were most interested in. Health Champions spoke to their friends, neighbours and networks to engage them in their health and get involved in activities and events in their communities.

This built on an asset-based approach, drawing from the strengths of the whole community with a 'people helping people strategy'. This was made possible by a focus on relationships and bringing together the community with organisations including the Council for Voluntary Services, GoodGym, the University of York, and hundreds of people within communities. Together, the city is working to create a culture change to support better health outcomes for all.

IN PRACTICE

A number of the innovations including Shared Lives Plus, British Red Cross, the Cares Family and Good Gym work together with a range of other organisation to support #SocialCareFutures, a growing movement of people with a shared commitment to bringing about major positive change in what is currently called 'social care'.

It's for those who want to take part in imagining, communicating and creating a future where 'social care' makes a major contribution to everyone's wellbeing and which, as a result, will enjoy high levels of public – and hence political – support.

4.2 Ways of building

The most successful innovations had ambitions to scale from the start, not for the pursuit of growth or income but because they knew the challenge required greater impact and a bigger social shift. Whilst they may have used very different scaling strategies, from fast growing digital approaches from GoodSAM to more distributed networked approaches from Shared Lives Plus, Compassionate Neighbours, or the Stroke Association, there was still a number of similar patterns and tactics that contributed to their success.

The innovations learned to build in ways which:

• Understood context and built for 'local'
• Put people and relationships at the heart of the innovation
• Invested in core infrastructure
• Recognised the need to build skills, capacity and culture to support growth.

Understood context and built for 'local'

While many of the innovations were replicating, spreading, or growing delivery to new parts of the country, each innovation understood the significance of their project reflecting the local context, actors, and what local people may want. These local innovations were not built as cookie-cutter replications, but took core lessons from what worked and adapted and flexed them to the context.

Many co-produced with local communities, individuals, civil society and public service leaders to better understand how to build the work in a local context. Time also had to be invested in building relationships, and creating contacts to lead the local work authentically and in partnership.

Whilst we often refer to the NHS and social care systems as monolithic units, they are made up of many different components in different public sector, private sector and civil society institutions. Getting to understand these and how they work in different parts of the country was key. Some innovations such as Shared Lives Plus moved to grow work in devolved nations, where policy on health and social care differed from England. This meant even greater adaptation, and building relationships and being able to understand the context was absolutely critical. The time needed to do this well should not be underestimated.

IN PRACTICE

GoodGym works in 59 areas of the country, with many more keen to get going. GoodGym has central digital infrastructure to support the work in every area of the country, and consistently encourages areas to provide three main approaches – one-on-one coach runs with older neighbours, group runs where people meet to undertake a community task such as cleaning up a garden, and one off mission runs for people who need help.

However, there first needs to be demand in an area from founding members, local people committed to help set up and organise the approach, at least 100 local people who want to be runners, and establishing relationships with local public services. The team recruit a local coordinator and develop a hub for people to meet in, and spend time developing relationships with local organisations. This means that people, places and organisations shape the local GoodGym to work for that area.

IN PRACTICE

British Red Cross' First Call service is in multiple locations across the UK, and in each area the model has to be adapted to meet the needs and ways of working of the local community. In the Scottish Borders, the First Call team works across a large geographic area, is embedded in the local community through hubs, and runs recurring drop-in sessions in community settings. In Bristol, the team offers people the same support, but works as part of a busy and pressured NHS system so also needs a constant hospital-based presence with strong and trusted referral partner relationships. They are therefore co-located next to discharge teams in hospitals.

Both approaches achieve comparable outcomes, but go about things differently. Giving First Call teams flexibility and autonomy to make decisions has been core to its success.

IN PRACTICE

Volunteering Matters' Grandmentors approach works with over 12 local authority areas across the country. Over the last few years, as they developed their approach, the team learned what was absolutely essential for the approach to work, such as the team being embedded with the local authority, and what can be flexed or adapted to each local area. The team recognises that each local authority, each young person, and each mentor has very different contexts, ways of working and needs.

The team takes time to establish relationships and build each delivery model to respond to these circumstances. In Milton Keynes this meant that locally recruited staff members worked closely with the local authority over a number of months to develop specific approaches to make it work most effectively, and embedded deeply into the local team. In this way, they could raise the profile of the work and help in the process of assessing which young people were best suited for the support, but also keep the council team in the loop on progress and issues. This close partnership greatly contributed to the success of the implementation.

Put people and relationships at the heart of the innovation

As person- and community-centred innovations, it was essential to focus on ways to put relationships at the heart of the scaling process. But this can seem like a contradiction – can you really scale relationships? Relationships are by their very nature small, personal, and need to be carefully knitted together.

Many of the innovations were conceived through deep co-production with people who could benefit from their work, alongside key actors such as commissioners, researchers and others. As projects grew, this level of connection was hard for many to maintain, and innovations told us that without careful design they could go through periods of 'forgetting' how critical it was. The innovations had to learn when and what to co-produce along the journey, and how to centre relationships in everything they did.

To overcome these growing pains, organisations tried new approaches to co-production, developed new ways of involving and listening to their communities, adapted their governance to centre relationships and people's experiences, and looked at how to continue to build the skills within the team to ensure this remained a core practice. Many innovations shared that they were thinking less of scaling an 'intervention' and more of scaling stories, culture and relationships between people. They had to learn to build with this in mind.

Many had to carefully consider people and relationships in designing the very structure of the innovations, with some creating more decentralised, locally-led approaches to enable this. Shared Lives Plus is the membership organisation for locally-based Shared Lives schemes across the country but is not delivered by a national organisation, helping centre local relationships and connections at the heart of the work. The Cares Family also created a family of organisations to deliver locally, rather than one central organisation, to orient delivery around relationships and partnerships that were based on the communities where they worked. British Lung Foundation's Breathe Easy groups were all locally based, with local and regional structures to support them. Scaling was never a juggernaut of centrally controlled growth.

IN PRACTICE

Compassionate Neighbours was originally developed in East London, through a process of listening to communities. Working with a skilled community engagement team, they reached out to communities across East London to understand what would support better experiences of end of life. This greatly informed the design of every element of the Compassionate Neighbours approach.

As the team replicated to new hospices, though each area learned more about the model and how it worked, the original co-production process was not seen as a core element of replication. This meant the approach developed very differently in different communities, with some becoming much more service-oriented.

Following evaluation and learning from the first stage of replication, the team looked to establish a much greater role for co-production and community leadership to guide the approach in the future. They are also looking to build on the involvement they continued to have with the Compassionate Neighbours themselves, and recognised it was key to continue to build multiple ways for neighbours to shape and lead more of the work in the future.

IN PRACTICE

The British Lung Foundation supported groups to work with local authority partners to help commissioners better understand local needs and capabilities. This co-production took different forms: in Portsmouth, three local groups joined together to hold a mini conference.

The British Lung Foundation designed a new delivery plan in January 2020, creating a closer local partnership between the Clinical Commissioning Group, local authorities, and people with lung conditions. This aims to define everyone's roles and responsibilities to further embed co-production.

IN PRACTICE

The Stroke Association shows the benefits of taking a relational and flexible approach to growth. Rather than focus on creating a number of groups per region, the Stroke Association grew from 126 to 226 groups over the course of a year by following local signals on readiness, relaxing control, creating space to develop the best relationships, and keeping track of emerging opportunities.

This impressive scale was achieved without focusing staff on 'targets' that might have diluted their focus on the people and communities they worked with. Instead, their approach to scale helped build listening and partnership skills that allowed growth but also will benefit teams more widely.

Invested in core infrastructure

Getting the core enabling infrastructure right was absolutely critical. Innovations invested in databases, digital infrastructure, websites, and business development, communications and engagement capacity, which all proved essential. Such infrastructure can often be seen as hard to fundraise for, but was a key component of many scaling strategies.

"We started by thinking about all the things we were supposed to do – impact, evidence, infrastructure, culture, process. You can't assume that commissioning will follow evenly on this basis, but you need to have it in place as it is an easy excuse not to commission you." Alex Fox, CEO, Shared Lives

Some innovations, such as GoodSAM Instant Help, were conceived as a digital innovation with scale in mind at the start. GoodSAM used an approach to test and develop a digital platform that could be tailored to the needs of each ambulance service area, meaning integration to new areas could often be done quickly, speeding up the test and implementation process in each place.

Other innovations could be smarter, faster and more effective when using a range of different digital support technologies. This grew in magnitude in the early stages of the pandemic, where lots of work was moved digitally to sustain or grow. Organisations with core digital infrastructure were often well placed to adapt and work more flexibly to changes in needs and demand. For some, this also allowed a clearer view of what can and should be delivered digitally in the future, and what should be done in person. This could potentially enable further scaling in the future.

"It's certainly worth investing time upfront to achieve long term results. The Cares Family's new CRM scoping and implementation and our evaluation design took almost a year. We're relaxed about that... That's a better approach than rushing." Alex Smith, CEO, The Cares Family

IN PRACTICE

As part of Hull's year as the UK City of Culture in 2017, the Absolutely Cultured team recruited and mobilised thousands of volunteers across the city, and invested in the Better Impact platform to enable them to create and allocate opportunities. When the team scaled their model to other areas of involvement, they adapted the platform to enable the right volunteers to be allocated to different projects; they also gave ownership and control directly to volunteers to manage their own time.

This core infrastructure also came in useful at the start of the COVID-19 pandemic, with Absolutely Cultured able to respond to the dramatic rise in the need for volunteers in Hull and becoming a key volunteering partner in Hull City Council's Covid response. Even in these challenging circumstances, they were able to quickly scale up their work, ensuring residents all over the city got the support they needed with shopping, prescriptions, telephone support and more.

IN PRACTICE

GoodGym has also used technology as the backbone of how they organise their work from their very inception. Their platform had enabled them to build communities, communicate with runners, and allow runners to sign up to activities, but in 2020 felt that it was holding them back, particularly in light of learnings from the early stages of COVID-19 when managing the huge increase in demand for support.

The most significant change was the introduction of a new type of task referral, created to meet the needs of older people unable to get to the shops or pharmacy. This new referral journey allowed them to quickly and easily collect the information needed, and as a result were able to complete 2,088 delivery tasks and 670 prescription delivery tasks during the early stages of the COVID-19 pandemic.

GoodGym also decided to introduce two new technologies to vastly improve the user experience for runners, particularly those on the way to completing a task and therefore not on a computer. These small changes allowed GoodGym to act more efficiently and effectively during a time of high demand.

IN PRACTICE

Back in 2017, the Stroke Association looked at how they could more efficiently collect data about the people using their groups and the way their groups are run. They consulted with volunteers and designed a digital data capture application that links with their CRM to collect live membership data from volunteers leading the groups. 19 active groups using the app have created 159 new member records – without needing to fill out paper forms and post them back to staff.

Based on volunteer feedback, they also added a register function, so volunteers can track who is attending the group and reach out to those who are not. Through the app, they can also get a picture of what type of external expertise groups are inviting in to support their members, for example sessions with choir facilitators or cookery instructors. This helps better understand the quality and variety of delivery.

Recognised the need to build skills, capacity and culture to support growth

As innovations grew, ensuring people working on the innovation had the skills, capabilities and capacity to enable impact was an important consideration. Ways to assess the skills and capabilities needed, and a grasp of how things will be delivered, was key. Some organisations, such as GoodGym or GoodSAM, needed to grow greater knowledge and skills around business development and health commissioning processes, whilst others such as Compassionate Neighbours or The Cares Family needed to think about deep community development skills.

It wasn't just the skills of staff that innovations needed to consider. Teams also found it beneficial to have specialist advice and expertise to help them, including advice around business models, evaluation, and designing new engagement processes. Many of them also considered the skills, experience and insights they could access through mentors, advisors, trustees, advisory boards, or volunteers, weaving together different resources to help them build for success.

Critically, beyond skills and capabilities, innovations often had to consider the culture and leadership that would support success. For some, such as Shared Lives Plus, this involved thinking about the organisational structure and leadership models that would embed the core values, care and distributed power needed to enable the work to flourish.

"For a time, social care got very uncaring, it was all about numbers of returns and outputs. But it didn't really feel like it cared very much, I think. And how people care about their teams – that will impact on the care that gets out to people who need social care. I look back and we have changed so much about how we work – making structures more flat, being vulnerable and honest with ourselves when things are hard, making space for a bit of fun... people say we've ruined them for other employers!" Shared Lives Plus

Others recognised the perils of burnout and maintaining culture through stages of growth. The Cares Family, for example, recognised that they needed to ensure they had the energy and time to embody how they delivered the work in the way they built the organisation, seeing time for fun, joy and connection as key ingredients – easy to overlook, but so important to the success of the work.

This also meant recognising that growth isn't linear: at times, it may be important to pause to consolidate and ensure the culture and values needed to enable the quality of delivery to continue are in place.

"I've learned from colleagues and from leaders across sectors and the world that those joys and moments of fun, especially in that context of change, give vital oxygen to the mission. Because fun is important. Fun is energising, galvanising. Fun is not a woolly add-on to the serious business of progress; it is a necessary ingredient for it. It creates endorphins that give us energy and keep us happy. And it creates oxytocin – the human connection hormone. Even better: fun, and positivity, are infectious." Shared Lives Plus

4.3 Ways of acting

It is often assumed that innovations move to simple 'roll out mode' once they start scaling: in reality, there was still much to do. They needed to consider whether what they were doing still worked as it scaled, whether it was truly representative of the values and ways of working core to the approach, whether the business model would work into the future, and build a powerful narrative to get people on board.

The innovations learned to act in ways which:

• Lived and embedded their values
• Used evidence well and valued learning
• Continued to innovate but knew when to say no
• Experimented with their business model
• Used powerful narratives to amplify and influence change.

Lived and embedded their values

Whilst values are often core to ways of thinking and conceiving, the hard part can often be living them. As they scaled, many of the innovations grappled with how they could continue to live their values, especially when they grew beyond a small team. They frequently needed to work out how to model and embed values in organisational structures, leadership practices, and ways of working and delivering.

This can be even harder when working in partnership, or when innovating in larger organisations where different values can come into play. A number of innovations found their values tested when working with or embedding within more mainstream health and care systems; as they looked to implement person- and community-centred approaches, they often found incompatibilities with more traditional public service models. When this is combined with inequities in funding and power, it can be particularly difficult. Those innovations who were clear on their values were often best able to navigate this tricky terrain.

Carers UK, Shared Lives Plus, British Lung Foundation, Stroke Association and Kinship were incredibly conscious about putting people in charge of shaping the work, enabling their stories and experiences to be at the forefront. They sought to embed the philosophy of 'nothing about us without us'.

IN PRACTICE

Innovations used a whole host of ways to embed their values internally and externally. GoodGym drew inspiration from sports in their culture, specifically creating a club atmosphere for runners. Their digital platform enables individuals to recognise and applaud each other's efforts, with the intention of creating a fun, open, and supportive community not only for those receiving support but those giving it.

“Like a sport, the culture of GoodGym is the most important factor in our success; whether it's cheering new people, supporting all who turn up or reviewing biscuits, each area has its own characteristics and approaches the task of running to help their community in a slightly different way... as we expanded across the UK it has, and continues to be, critical to maintain an open and inviting culture that leaves room for its players to define it.” Ivo Gormley, CEO, GoodGym

Used evidence well and valued learning

Some of the innovations shared that they had to 'unlearn' dominant, hierarchical practices prevalent in the health and care systems. This can be an uncomfortable and taxing process, with costs to time, energy and emotion. Heather Richardson, CEO and one of the core developers of Compassionate Neighbours, shared that the programme built a stronger foundation for scale once she challenged her own 'default' hierarchical leadership models enabling the organisation to embed values and approaches that ran counter to the prevailing ways of working.

"The best bits happen when people act with their own authority in a confident and creative way," she says. "It's easy to want to jump in and set parameters and guidelines, but the moment you do that you are taking control. This is now how I learned to do things in the NHS!" Heather Richardson, CEO, Compassionate Neighbours

Others found that it was important to challenge hegemonic forms of monitoring and evaluation, using previous learnings to rethink what evidence is considered 'meaningful'.

"You [need to] combine the vision and human story with the attention to detail of what the system needs, and have the data to make the case." Alex Fox, CEO, Shared Lives Plus

Typically, when innovations start their work to scale, they tend to focus on trying to 'prove' themselves to funders and stakeholders. But this is really only one element of why evidence is used. Rather than seeing monitoring and evaluation as a means to an end (e.g. an impact evaluation to please funders or commissioners), innovations have been encouraged to think more broadly about the value of evidence and how they can use this information on an ongoing basis.

The innovations were encouraged to really think about their evidence, and to invest in establishing a learning culture that could be embedded in how they deliver. They explored evidence around three main questions: does the innovation work and can it make a positive difference to people's lives?; how does the innovation actually work?; how can the innovation work best at scale?

Scaling innovations often worked to draw from existing evidence and expertise, connecting with academics, research professionals and others in the field who had a good grasp of what worked. They also found that when evidence and learning was embedded and meaningful for supporting delivery it was easier to see its relevance. Many of the innovations worked to build a culture around knowledge and learning, getting everyone involved including people who use services, frontline staff and senior management. This approach was powerful in shaping meaningful and useful tools and approaches.

Whilst using and generating evidence is often seen as a key part of the scaling journey for any social innovation, even when an innovation is demonstrably impactful, it does not automatically get adopted by the mainstream – evidence is one part of the jigsaw.

IN PRACTICE

In a world dominated by clinical outcomes, the Compassionate Neighbours team took a more inclusive approach to evaluating the impact of their model. They focused on exploring the extent to which people involved with the programme, both the Compassionate Neighbours and the community, perceived and experienced impacts, rather than aiming to measure impacts more objectively.

The team commissioned a new evaluation to build on those that had previously been done to enhance their insights into the programme; these included a PhD study and a national evaluation of befriending in the end of life context. While taking a more realistic approach meant that they could not 'objectively' attribute impact to the programme, the team was able to explore the different types of value that the programme created and put neighbours in the lead in shaping the evaluation.

"As a hospice we are trying to reach people who live on the margins...The way we are commissioned by government is so narrow, the outcomes measured are so narrow and numerical (e.g. bed days), that it means those on the margins are easily forgotten.” Heather Richardson, CEO, Compassionate Neighbours

IN PRACTICE

The Cares Family identified that many of the existing evidence tools and ways of carrying out evaluation clashed with the values, ethos and nature of their work. They were not afraid to challenge the status quo, and worked with Renaisi to develop an approach to evaluation and learning which was authentic and useful for them. They did not neglect evidence, but instead could make the case for why, for many complex social issues, simplistic, top down, quantitative and extractive measures were unlikely to help them understand the difference their work was making.

"Tools for measuring loneliness are validated by academics and universities and governments, but when it comes to applying them in local communities they are horrible. Questions asked like 'When was the last time you felt chronically lonely?', 'Are you more or less lonely since your wife died?'. If you weren't feeling lonely before these questions you certainly will after! It's counterproductive. You have to be able to discuss which tools feel appropriate and safe, and will still get partners what they need." Alex Smith, CEO, The Cares Family

Continued to innovate but knew when to say no

Whilst it is often essential to stabilise some elements, innovations also needed to ensure they were able to keep innovating to ensure that the work was responsive, that it delivered impact, and was effective for different contexts, opportunities or challenges. Getting this balance right was often tricky, but was most effective where a strong learning culture and practice was established.

For many, it was important to discuss what was stable and core to implementation and what may require further innovation. For example, even when Volunteering Matters had established their core Grandmentors practice, they worked to experiment with a 'Great Grandmentors' approach, asking more experienced mentors to take on additional responsibilities to support new mentors and develop relationships with key partners. They approached this by co-designing and experimenting, testing how it could work before rolling it out more fully.

As innovations became increasingly successful and attracted greater attention, they found new demands, ideas and opportunities. This could mean commissioners or public sector organisations asking for new types of work, or participants and partners suggesting new services or approaches.

Organisations like GoodGym were encouraged to roll their approach into cycling or other sports, which led them to adapt their model. GoodSAM were approached by the government to help support the coordination of NHS volunteers during the pandemic. Knowing when to say yes to an opportunity or idea, and when to say no, was a significant area of learning.

IN PRACTICE

Each local Cares Family charity works with people to understand what activities they want, from dancing to quiz nights and more. This is about genuine friendship, connection and fun.

Early on in the development of their work, when liaising with statutory services, there was a lot of interest in the Cares Family helping with delivering services. While there were clearly overlapping interests, the Cares Family were conscious that they did not want this work to become a service, and instead supported outreach work from local authorities, so older neighbours could be connected to the right support.

To date, the organisation has said no to many opportunities for service delivery, as they simply don't want to conform to 'public service' delivery culture.

IN PRACTICE

Shared Lives schemes support a whole range of people, including those with learning disabilities or mental health challenges and older people. As the work has grown, schemes have been supported by Shared Lives Plus to innovate and push the boundaries of what they can support.

Shared Lives Plus constantly assesses new opportunities to keep shaping the care landscape. They support Homeshare, an approach that brings together those with spare rooms with people who are happy to lend a hand around the house in return for affordable, sociable accommodation. Alongside this, they have recently been supporting the development of Family by Family in the UK, a new model of peer support for families from Australia.

All of these models centre the core value of people living well with the support of communities. This helps the team know when and where to focus innovation and development.

Experimented with their business model

Most innovations fail to grow not because of lack of will or potential but because of insufficient resources or a non-viable business model. Innovations often had to start the scaling process whilst exploring and innovating these models. They may start with certain assumptions about who might pay for their work, but testing that in reality was key – many found that who might pay was very different in different geographies and contexts, with public service health and care budgets allocated differently in different parts of the country. Innovations developed mixed income streams of grants, commissioned income, donations, sponsorship and commercial partnerships: there was no one-size-fits-all or easy answer.

Having initial bridging grant funding was without doubt essential for many to test viable business models. Grant funding could be used to incentivise initial commissions and demonstrate the value to potential partners and sources of income. Many had to treat the development of the business model as an innovation process in itself, experimenting with approaches and income streams to get the mix right.

IN PRACTICE

Over the years, GoodGym experimented with blending different sources of funding to enable them to reach towns and cities across the UK. Initial grant funding enabled them to develop and test the core model that focused on working with local authorities. After testing a variety of business development approaches, they decided to demonstrate to local authorities that there was demand for this kind of approach by enabling at least 100 people to pledge support for GoodGym and request £25,000 to roll out GoodGym within that area. This was key in making a compelling business case to the local authority or health public services.

However, this income stream was not going to be sufficient to run all aspects of the organisation they had learned it was more challenging to ask for high amounts. Based on the suggestion of GoodGym members, they also created ways for members to donate a monthly amount - like paying a gym fee - to enable activities to happen. Alongside this, sponsorship and partnerships with commercial organisations, most recently Saucony, helped build the brand and provided an income source. Developing this model took a clear vision, but also experimentation to try different things and pursue different opportunities.

IN PRACTICE

The British Red Cross' approach to funding their scaling plan demonstrates the need for a mixed approach. In the first instance, they utilised Red Cross general funds to pump-prime the scale plan. In 2016-17, they began securing funding from private funders and trusts to support the expansion of First Call into new areas, as well as one-off donations.

In order to plan statutory partnerships strategically, the team mapped the key priorities of various CCGs across England to highlight those with a strong strategic fit. They then approached the relevant CCG to explore a commissioned contract, working in a flexible and adaptive way, based on the specific CCG they were engaging with.

Used powerful narratives to amplify and influence change

Many barriers to scaling are simply out of innovators' control. But what they can control is how they strategically shape perceptions of their work to encourage bigger changes in the field. As organisations scaled, a narrative for change and clear communications strategy was often a key way of acting. Innovations consistently use language that reflects their work, their values, and those big shifts, working to share incredible stories of personal and community change.

Shared Lives Plus, for example, collects stories from their community, demonstrating the power of this approach. It is a deliberate strategy based on their vision of a kinder, stronger society built on sharing our lives and our homes. Their narrative focuses on the simple fact that our lives are better when they are shared and they put the stories of families sharing their homes and their lives at the forefront of the work. This has been very powerful, helping them expand the model into new local authorities, but also influence the national agenda on health and care. Activities such as Shared Lives Week, annually celebrate and shine a spotlight on the work, helping to elevate these approaches with policy-makers, commissioners and ministers as well as reaching the general public. This narrative is helping challenge the dominant approach to care in the UK.

By creating narratives for change alongside partners, many innovations made it everyone's responsibility to make the case for people-centred approaches. This wasn't simply a communications strategy, but the fostering of a wide network of advocates who could see how these approaches could be transformative at scale and spread the word.

IN PRACTICE

The Cares Family have developed an outstanding narrative, helping create a rallying cry of the power of connection in a disconnected age. Through the stories and spirit of neighbours coming together each week to socialise and share lives and experiences, they can demonstrate the power of this work in action. Yet the Cares Family have done more than this. They weave these stories to help diagnose the wider symptoms and issues driving the disconnected age, and through shaping their narrative they have worked to scale deeply. Their work informed the National Loneliness Strategy, has fed into the APPG on Social Integration, and received extensive media coverage.

To help strengthen and spread the narrative they have also brought together others in the field. For example, the team published a pamphlet of 12 stories from a variety of people to paint a rich, varied picture of loneliness and disconnection, and sharing ways to inspire people to act. They have also recently worked with UnLtd to create the 'Multiplier' to forge a connected narrative with 50 people building bridges in their own community. Together, they aim to amplify the stories of disconnection, but also the brilliant yet simple solutions in communities across the country.

4.4 Enabling conditions

If we want to see these innovative approaches become the new normal, we need to scale the conditions that produce and nourish them. While we often focus on the actions of innovations themselves, the conditions that funders, commissioners, public services and policymakers create can mean that innovations are either swimming with or against the tide. It requires systemic shifts, weaving together innovations and creating better experiences for individuals and communities.

Innovations felt that commissioners, policymakers and funders acted and supported in four key ways:

• Field-building and systems leadership
• Decommissioned or better integrated new approaches
• Effective long-term funding relationships
• Valued people-powered approaches working 'upstream'.

Field-building and systems leadership

Every innovation had examples of partnerships which enabled scale even when other barriers were present – and of partnerships which looked 'great on paper' but had failed to deliver in practice. Often, success was enabled by partners who were willing to listen, collaborate and create space for a shared vision. Time and again we heard about the power of relationships in unlocking the innovation potential.

"Critical analysis and a homogeneity is often what people strive for, for good reasons like quality assurance, but more often than not it's relationships which make or break a project." Alex Fox, CEO, Shared Lives Plus

For many of the innovations, stand out individuals in public services particularly enabled a pathway to scale. These relationships were very often the transformative ingredient, but can be hard to develop in new geographies or areas. Funders, connectors, and on-the-ground relationship developments were key to searching out these people.

Critically, these leaders were often field-builders, skilled at weaving together sometimes disparate actors, connecting innovations, frontline staff, funders, commissioning partners, delivery partners, and policymakers at every level of the health and wellbeing system. They valued the power and potential of individual innovations, but recognised that single solutions were rarely the answers they were looking for. By galvanising actors around a shared vision, scaling innovations found a connection that enabled their work to go further. These leaders understood what evidence would be needed to convince others and help ideas move from margins to mainstream.

IN PRACTICE

City of York Council, GoodGym and the York people-helping-people ecosystem: York has a long tradition of working with citizens and communities in innovative ways. In recent years, the local authority has been seeking to make a step change in its work, building a place with strong, resourceful and connected communities. To support the health and wellbeing of the city, the team adopted a number of new practices including a focus on social prescribing that supports people to contribute to their community through 'peer to peer' leadership as healthy living champions, through Local Area Coordination that supports people to take action, build relationships and join new social networks, and a People Helping People strategy that mobilises the talents and energy of citizens and civil society organisations around key city-wide challenges. Together, this helped galvanize citizens and a range of civil society organisations to work together with the local authority and health public services.

As part of this approach the team commissioned GoodGym to play an important part in the strategic shift they were seeking to make. The strategic leadership and underpinning cultural change that had been taken forward by City of York Council enabled them to work in true partnership with GoodGym.

“York Council sees the opportunity, they worked with us truly, are very active and really understand. We have shifted from a service to an embedded provider with communication at a local level.” Ivo Gormley, CEO and Founder, GoodGym

"As a commissioner, it's about bringing certain strategies and initiatives deliberately together. It involves grappling with parts of the policy framework nationally and locally so one thing complements another... Once you have these programmes, it's about helping them link up with other assets and reminding leadership that these social innovations are helping them meet their health and wellbeing priorities.” Joe Micheli, City of York Council

Decommissioned or better integrated new approaches

Opportunities for transformative innovation can be removed through the weight of the status quo and entrenched ways of doing things. This can be through favouring incumbents and preserving organisations or projects that already deliver, but also more passive actions like not integrating or redesigning current approaches to enable the best to come from innovations. Innovations would often be able to achieve greater scale where partners, particularly public sector organisations, actually stopped doing things, or redesigned processes fully to integrate new approaches. We know decommissioning remains challenging, with many public services open to new models and innovations but at the same time hampered by an inability to stop the old or integrate new approaches³.

Many of the people-powered health approaches we have worked with cannot be fully embedded or reach their potential because of incumbents or legacy approaches. However, where new models of commissioning also unpick the legacy system, mindset and culture, people-powered health innovations found they had the fertile conditions to embed and flourish.

For example, Volunteering Matters' Grandmentors approach was entirely embedded in the children's social care directorate, with staff co-located to ensure it became a core part of the local authority approach. In Plymouth, recognising the complexities driving food inequalities in the city, the local authority worked to create partnerships to grow a support system and network of volunteers, civil society organisations and public service partners to link the growing and cooking of food to those who could benefit most. It is now an embedded and recognised way of working across local authority and health services and provided critical foundations of support for vulnerable citizens to get food as the first wave of the COVID-19 pandemic hit in March 2020.

An additional challenge many innovations encountered was risk avoidance a dominant feature in the way public services are designed, managed and reviewed. Whilst attention to organisational risk is clearly required to support well-functioning public services and ensure accountability to citizens, an overemphasis often obstructs the adoption of people-powered health innovations. It can also be common to push the burden of risk elimination onto individual innovations, resulting in overly burdensome processes, undue emphasis on scrutiny, and focus on proving they can meet dominant clinical evidence standards.

Skilled commissioners were able to build a case for the work beyond narrow, traditional clinical measures that may never be suitable for person or community-centred outcomes, and manage the tension between what evidence is needed at a local level with meaningful outcomes for individuals and innovations.

IN PRACTICE

As the Compassionate Neighbours approach was adopted by new hospices around London and the South East, a key question arose around how safeguarding risks would be managed in a much more diffuse and community-led model. In clinical outcome-focused environments, with processes and procedures being designed to eliminate risks, this required teams to think differently about how they would work with communities.

To support neighbours and community organisations, the hospice needed to adopt mindsets that firstly examined the risk of not supporting their communities, and think how best to support community members to escalate and manage the challenges they might encounter. This enabled them the freedom to support and empower communities to grow and develop the model, whilst enabling the hospice to hold the risk.

IN PRACTICE

GoodSAM was originally conceived as a person-to-person alerting system. However, it quickly emerged that ambulance services would be willing to integrate the technology into their Computer Aided Dispatch (CAD) systems – the technology that powers 999 – and that this could drastically increase GoodSAM's impact. When a 999 operator in an ambulance center determines a call is related to cardiac arrest, their CAD automatically interacts with GoodSAM through an API to see whether any responders are nearby.

There was a lot of interest across ambulance trusts in GoodSAM and the possibilities it offered, but integrating represented a huge shift in ways of working and was deemed to be difficult.

GoodSAM took key steps in order to address this. Investing time in building trust came first: establishing the project with London's Ambulance Service required more than 30 meetings. Removing funding and finances as a barrier was the next step: GoodSAM offered the app to trusts for free for the first year and then, with support from Nesta and The Office for Civil Society, offered all ambulance services in the country up to £15,000 to cover the cost of integration.

In addition, once GoodSAM had partnered with a trust, the roll-out process was gradual and phased, with the ambulance service only alerting their most trusted groups (their staff and formal volunteers) in the first instance and only in a radius of 200m from an incident, with the view to increasing it as their confidence in the system grew.

Effective long term funding relationships

Access to funding is, of course, critical for scaling journeys. In particular, innovations who had stable, longer-term funding relationships were best placed to undertake intentional, effective growth. There remains too few long-term funds that can walk the journey with innovations, social investment is not designed for many of these models, and public service commissioning is often operating on very short timeframes.

"Longevity and a willingness to back the innovation and the organisation through the ups and downs is key. It's important for funders to challenge the thinking, challenge the delivery, but create certainty of sticking with you for a longer period. Without this you can't get the transformative level of innovation needed." Alex Fox, CEO, Shared Lives Plus

Effective funding relationships provide much more than money. Innovations also need counsel, challenge, and social support from their funding partners to help them scale effectively. Innovations shared that the most effective funding relationships had sped up and smoothed their scaling journey by helping them tackle challenges and look ahead to new opportunities and challenges on the horizon. This included having bespoke support from field experts, connecting innovations to the policy agenda, expertise about evidence in the field and challenges around rigorous research and relational, holistic and complex innovations, and being a close but critical friend available to critique approaches. Trust and understanding how funders can hold the risk for innovations is key to this too.

"If you've got a longer funding agreement, things will change in these timeframes, you'll have targets or goals that become less relevant over time. Being able to speak with a funder honestly is important in order to make the changes needed." Ivo Gormley, CEO, GoodGym

Funders and commissioners need to question assumptions with innovations, and understand the journey that may be ahead. It's all easy for innovations to over-promise, setting off on hugely ambitious scaling journeys that risk missing the impact, threaten core values, or prove unsustainable. This can have huge costs.

IN PRACTICE

A Shared Lives Plus carer shares their home and family life with a person who needs support to live everyday life. This enables a dramatically different approach to social care support, founded in real relationships between community members willing to share their homes and lives together. The results are impressive, enabling not just provision of care but enhanced connection to friends and community, improved physical and emotional health, and more dignity and choice for cared-for people.

However, Shared Lives placements can't be set up overnight, and as the scheme embeds in more local areas it's critical to invest upfront in early foundations. Commissioners that value and commit to this upfront investment, whilst leaving enough time for the innovation to mature and embed, experience much more return on investment and results that enable further scale.

“If we work with a local authority for a year at a time, and maybe also they are afraid to put out money upfront and invest, you only have one person making relationships with social workers, with care teams, with potential carers, one person also doing all the training and upskilling for carers and getting people ready, and also being out in the community to raise awareness and build trust... You might end that year with five placements. Whereas if there's a longer-term investment, and we accept that the first six to nine months are about setting up that infrastructure, you're at maybe 10-15 placements in year one and then 75 in year three. In some places we now have 300+ placements. But unless you have a longer-term partnership that accepts some upfront investment, that doesn't happen.”

Valued people-powered approaches working 'upstream'

Across the country, beacons of innovation have appeared as local authorities, the NHS and Integrated Care Systems experiment with different ways to address the complex challenges communities face. These initiatives have been working to move attention and resources 'upstream' of service delivery, focusing on creating the economic, social and community conditions that enable citizens to live healthier, happier lives.

Simply put, public services are seeking to design approaches that solve problems before they happen, preventing people feeling lonely, for example, or working to promote healthier approaches to end of life care. Public services who have adopted these ways of working and understand the need to address the social determinants of health have often been fertile ground for people-powered innovations. This means that pioneering public services are frequently the ones also pulling in pioneering outside innovations.

The decisions made by public services directly affect the fabric of the places and nature of the communities in which we live. Those that have a vision for change, for early intervention, and for what they want to grow inside and outside of public services, are helping coordinate people-powered health innovation.

IN PRACTICE

The Reader is building a reading revolution, bringing people together and books to life to make warmer, healthier, stronger communities. 1,668 people are involved with one of 115 new shared reading groups in the North West (with many more outside of this area). 91 per cent of group members say the reading sessions make them feel better, and 84 per cent say they've made new friends in their group.

In Liverpool City Region, The Reader partners with the Liverpool City Region Combined Authority, Knowsley Council, Liverpool City Council and Wirral Council Council, and community groups to support social connection and enable people to live well. Partners in public services recognise the value of working upstream, earlier than the point of crisis, weaving together a social fabric that enables people a safety net before they are even aware they need it.

While work for acute need is still a public service priority, for people experiencing mental health crisis for example, the partnership of civil society, public services and The Reader aims to weave together everyday support from literature, routine, and social connections, equipping everyone with tools for resilience and wellbeing.

5. Where next?

How policymakers, funders and local public sector leaders can support more people-powered health and care innovations to scale

Scaling is frequently written about in simplistic, linear terms which bear little resemblance to the realities and experiences of social innovations. The success of the 16 innovations within this paper relied on a wider understanding of scaling. As such, there is no simple roadmap or top ten things to consider, and no linear path for other innovators to follow. But there is still much work to be done to provide the right 'enabling conditions' to support people-powered health and care innovations to scale their impact. Deep systems-change to create the new normal takes time, well beyond short-term project cycles, and resources and energy that go well beyond money. Only through active field building and taking patient, long-term but urgent systems-shaping approaches have some of the best examples been able to 'scale up', 'scale deep', 'scale out' and scale the conditions for success.

Whilst there are not simple solutions, through discussions with innovators, policy-makers, researchers and other practitioners we have repeatedly heard recurring themes of what will drive forward the shifts required to help enable people and community-centred health and care innovation to scale.

Patient, long-term funding

Many of the innovations we have worked with shared how long-term grant funding enabled them to be more strategic, building for scale differently with long-term purpose at the core. Innovations that originated in civil society also shared that having funding that is focused on the end goal, and less tied to outputs and delivery, is critical. For a long time, we have also thought there needs to be greater connection between funders, so that innovations can journey across them in their scaling journey. There needs to be more funds available that see this long term systemic shift as core. Approaches such as the Funders Collaborative could work to help better connect and align funders to enable change, and more long-term initiatives like the National Lottery's Growing Great Ideas Fund are needed to help fuel the change.

Place-based experimentation and investment in local leadership

Many of the innovations recognised that their work was only one part of the jigsaw. Yet it was rare that their work was being weaved together or integrated well to create the scale of change required. It also remains relatively rare that places learn, copy and adapt approaches from elsewhere to pick up the best innovation. Where this is happening, local public sector leaders are investing their time and money to create scale for multiple approaches, holding the risk and providing local leadership. There is a need for more financial and wider support for experimentation to build the different elements of people-powered health and care approaches together. Whilst there are many elements of the jigsaw, we need to learn much more about how to bring this together to create a more integrated and full working system. This also needs to include experimentation around decommissioning, and being able to move resources and attention upstream of issues.

Field building

To be able to scale the impact of people-powered approaches requires us to think less of large-scale structures and processes for scale and more about creating an environment that weaves together approaches that help us lead healthier, happier lives. The work of building and mainstreaming these approaches cannot be done by one actor or organisation alone. We need to get better at growing the field, rather than focusing on individual innovations. This means that individual innovations, as we have highlighted, will need to work in interconnected ways in the coming years with each other, with local public sector leaders, and others. Funders and commissioners need to design for, commission, and fund the collaborative behaviours and action that is needed to make this real. We hope more people will share insights about how best to do this, remaining open to new approaches, whilst also taking a long-term view of how to support a field to work together that will enable the scale of impact required.

6. Useful resources

System change

Leadbeater, C. & Jennie Winhall, J. (2020) 'Building Better Systems: A Green Paper on System Innovation', The Rockwool Foundation. This paper is for all those who want to achieve greater social impact by acting on and investing in deliberate system change.

Conway, R., Masters, J. and Jake Thorold, J. (2017) 'From Design Thinking to Systems Change: How to invest in social innovation for change', The RSA.

Social Care Institute for Excellence, (2020) 'Scaling innovation in social care. Rapid pragmatic evidence review: summary report' A rapid pragmatic literature review of publications since 2015 to provide a baseline understanding of the evidence on scaling innovation in adult social care.

School for Social Entrepreneurs Scaling Resources

Social Innovation Exchange. Web resources on scaling.

Riddell, D. and Moore, M. (2015) 'Scaling Out, Scaling Up, Scaling Deep: Advancing Systemic Social Innovationand the Learning Processes to Support it', W. McConnell Family Foundation and Tamarack Institute. This report, from the US, distills important lessons from a decade of practice in accelerating impact and scaling social innovations, including the strategies used to achieve success.

Spring Impact (2018) 'Social Impact Replication Toolkit'. The Social Replication Toolkit aims to help social purpose organisations practically take forward their scaling ambitions.

Deacon, C. (2016) 'What does it take to go big? Insights on scaling social innovation', Nesta. This report shares lessons and practical insights from the 52 projects supported by the Centre for Social Action Innovation Fund on what it takes to scale a social innovation.

Murray, R., Caulier-Grice, J. and Mulgan, G. (2010) 'The open book of social innovation', Young Foundation and Nesta

Nesta and Collaborate (2020) 'New Operating Models Handbook: An emerging practice for the future of local government', Nesta. A practitioner's guide to new ways of working that enable upstream innovation in local government.

Nesta and Collaborate (2020) 'From the Margins to the Mainstream', Nesta

People-powered approach to health and care

Khan, H. et al (2016) 'Health as a social movement: the Power of People in Movements', Nesta. This report illuminates the power of people in movements to improve health, and proposes the need for new models of engagement between institutions and social movements.

Redding, D. (2016) 'New approaches to value in health and care', Nesta. This report makes a series of calls to action to ensure that the approach to understanding, capturing, measuring and assessing value in health and care takes full account of value as it is experienced by people and communities.

Jopling, K. (2020) 'Online Peer Support Learning resources', National Voices.

'Social Care Futures'. #SocialCareFuture is a growing movement of people with a shared commitment to bringing about major positive change in what is currently called "social care."

Nesta, Shared Lives Plus and PPL (2018) 'Growing Innovative Models of Health, Care and Support For Adults', Social Care Institute for Excellence.

Redding, D. et al (2016) 'Realising the value: Ten key actions to put people and communities at the heart of health and wellbeing', Nesta

People Powered Results, Nesta

Realising the Value, Nesta

Evidence and learning

Deacon, D. et al (2020) 'Evaluating Social Innovation to Create Lasting Change: supporting social innovators to build an evidence base for people powered approaches', Nesta

PPL (2016) 'Impact and cost: Economic modelling tool for commissioners', Nesta

Old, R. and Bibby, W. (2020) 'The Value of People Power', Nesta

Cornwell, C., Khan, H. and Mulgan, G. (2019) 'The Nightingale: Time to get serious about addressing the social, behavioural and environmental influences on health', Nesta. This paper proposes a new centre of innovation and research excellence to improve the social, behavioural and environmental determinants of health.

Footnotes

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