Four themes were identified in the analysis and are presented in the following sections: (a) the role of evidence, (b) the role of partnerships, (c) the influence of champions and other human-based resources, and (d) the impact of contextual factors both organisational and external. All of these played a role, alone or in combination, to facilitate or block implementation or diffusion of the innovation.
(In order to protect the participants' anonymity, as they are drawn from a narrow range of award years, after each quote below, the innovation is identified by the extent to which it is related to the healthcare provision-see Table 1 for the relevant categorisation).
A. The role of evidence
Evidence was considered to play a crucial role. This was visible at multiple time points in the initiation, implementation and diffusion of service innovations. Specifically, there was a focus on quantitative evidence and this was seen to operate in three main ways: (a) as a proof of effectiveness, (b) as a means of diffusion and (c) as a precondition for the initiation of the innovation.
A1. Evidence as a proof of effectiveness
"Hard" evidence, in the form of quantitative data, was perceived as the 'gold standard' demonstration of effectiveness, constituting an optimal and credible base for assessing an innovation. It equipped innovators to attest to the usefulness and success of their initiatives, and to persuade prospective adopters that they were valuable. A participant characteristically commented:
"So our outcomes are important to us, because they give us sort of a language by which we can sort of articulate the success of it." (Innovation less related to the healthcare provision)
Even when the innovators considered that "soft" aspects of the impact were valuable and significant for the demonstration of usefulness, they also attempted to corroborate this with numerical evidence. The latter represented the indisputable metric needed to buttress accounts of "soft outcomes".
"All the guys that work for me work for nothing, and the job satisfaction of seeing these guys change and...build confidence...is just absolutely amazing, and I think, if nothing else, if people want to call it soft outcomes-I mean, we have got figures of how we've improved stuff, you know...I can give you some statistics on that, on how we've improved stuff in 2009." (Innovation directly related to the healthcare provision)
Lack of quantitative evidence was seen as a notable shortcoming not only for the sustainability and diffusion of the innovation but also for its initiation. This perception was particularly pronounced where there were other barriers and when the initiative was peripherally linked to the core business of the NHS. In such cases, quantitative evidence that would link the innovation to health-related outcomes was imperative.
"One of the things which we need to expand is the health impact of schemes like this (social inclusion schemes), whilst we have a lot of anecdotal evidence we need to gather empirical evidence to demonstrate the long term benefits. In an increasingly challenging fiscal climate, supporting evidence may encourage organisations to make the investment in this type of development." (Innovation less related to the healthcare provision)
Within certain professional groups, almost notably clinicians, "hard" evidence which would be obtained from scientific methods was construed as the necessary prerequisite for the demonstration of the innovation impact, without which any persuasive effort was doomed to failure. Anecdotal or experiential testimonies were unable to exert any significant influence; scientific data were seen as the only basis for a process of persuasion, and on which prospective adopters could make informed decisions.
"For some reason, with doctors, if you haven't got some data, and maybe a p-value, then it's really hard to convince them that something works. What we've found it is, if we just give it to people and tell them it's a good idea, they don't believe us; whereas, if we give it to people and we show them our chart, where we can show that, when we use the checklist, we have a massive change, and suddenly we've got a p-value, that seems to win hearts and minds." (Innovation directly related to the healthcare provision)
A2. Evidence as a means of diffusion
"Hard" evidence was also a sound means of dissemination, both intra-organisationally and inter-organisationally. Encouraging health outcomes based on empirical data led organisations, in some instances, to propose the adoption of innovation to other departments. Moreover, the availability of evidence enabled innovators to neutralise resistance and opposition.
"...So instead of taking an aggressive approach to that, we backed it up with data...So we simply just sent the audit data round, which picked up a few people." (Innovation directly related to the healthcare provision)
Similarly, evidence was seen to help innovators obtain human and financial resources needed to expand geographically and inter-organisationally.
"...and then we actually audited the results of their intervention...and actually evidenced that the team were having an effect on patients' wellbeing, and that led to the team being enhanced staff-wise, and the service then rolling out city-wide." (Innovation directly related to the healthcare provision)
A3. Evidence as a precondition
Quantitative data were often seen as a base and precondition for the initiation of the innovation, indicating the need for change or the scope for benefit. Pre-existing evidence, which was available before the initiation of the innovation, was used to argue, justify and bolster the case for the developing initiative and it clarified innovators' incentives and intentions, particularly when resistance was anticipated. In this way, uncertainty was reduced and the stakeholders involved could estimate the potential risks and benefits.
"I personally was surprised that there wasn't more opposition really to closure than that, but I think people were genuinely, staff included, genuinely convinced by the evidence supporting why this was the right move and what it would mean." (Innovation directly related to the healthcare provision)
B. The role of partnerships
Inter-organisational connections, either formalised as partnerships or loosely linked, constituted an integral part in the process of developing, establishing and diffusing the innovations. In some instances, the partnerships were seen to be part of the essence of the innovation itself.
Existing working relationships between partners' organisations were often identified as the starting point of the innovation and the driving force for its development. Trust and mutual support were vital prerequisites for cooperation, since they ensured that the decisions and commitments made would be adhered to by all parties. The importance of trust was amplified when there was high uncertainty around what would follow.
"But I think why it worked for us was that we had a combination of a good working relationship in an environment where the decisions could be made by those people, so you already had some trust, you already had confidence that partners were going to pull their weight...I mean what the PCT [Primary Care Trust] didn't know was whether people would come and use their offer, but what they did know was that if they gave the city council in our area the money, we'd do with it what we said we'd do with it." (Innovation less related to the healthcare provision)
The building of partnerships was a goal of innovators in their attempt to initiate and establish their services, and the lack of them was often assumed to be a reason for failure of previous initiatives, even when these might be well supported financially. The quote below illustrates this point.
"Then, as we were looking around, we realised we hadn't really got any formal links with other services...and actually, whilst we'd got a good level of resource going into the [name of previous service], we weren't getting the impact that we wanted. So, that's where it started from." (Innovation directly related to the healthcare provision)
Having built supportive partnerships, the innovation gained more chances of sustainability in the long term, since partners represented a securing mechanism, warranting and endorsing the continuation.
Dissemination of service innovations was also seen to be contingent upon partnerships. Partners who had an interest in the novelty were perceived as significant in promoting and publicising the message beyond organisational boundaries.
"...and we've got some very good relationships with voluntary organisations anyway, but to just obviously build on that, do more promotions out in the community, working with organisations in obviously promoting what we're doing and how that could fit into the outside world." (Innovation directly related to the healthcare provision)
Importantly, partnerships were sometimes seen as one of the beneficial side-effects that enabled people to construct a common communication framework and a mutually shared agenda, potentially useful for future interactions and collaborations. Interestingly, in some instances the emergent partnerships themselves were identified as a novel characteristic of the service, usually when the collaborations were believed to be exceptional and rare in the field of healthcare.
"It is the process and, you know, great credit to the PCTs across [city name] to agree to work together. That isn't the same in lots of other areas. And so the structures that were put in place and the way that they worked closely with the clinicians and the wider stakeholder group certainly was innovative." (Innovation directly related to the healthcare provision)
Finally, and in retrospect, success was perceived to have been unlikely without the a priori consensus of the involved partners. Proactive engagement and dialogue were vital because organisations had the opportunity to agree on the principal elements of the initiative, and in turn the perceived risks were minimised, the undertaking was legitimised and the partners were committed to support the initiative and to follow the rules.
"...I think, you know, because we had great stakeholder engagement, and we'd started off with a big consensus event where we'd agreed some basic principles that we would abide by, then I think everybody felt comfortable." (Innovation directly related to the healthcare provision)
Proactive engagement with partners was also seen as an effective strategy against future resistance and able to mitigate potential obstructions, particularly when the innovation was perceived to be radical and to diverge significantly from the existing norms.
"So we knew that we'd have to come up with something completely different, so we engaged key stakeholders at the outset... because we involved them at the beginning we didn't receive any opposition." (Innovation directly related to the healthcare provision)
C. People-based resources
People within and outside the organisations were perceived as particularly significant, either in facilitating or inhibiting the innovation journey.
Most interviewees highlighted the importance of champions, who could be employees in various organisational positions, people in the local community or the users of the innovation. Importantly, the innovators themselves, in being passionate about and committed to their initiatives, ultimately became champions.
The role of top and senior management was critical, since the financial support of the initiative, and thus its sustainability and success, was often contingent upon their decisions. Public espousal of the core ideas of an innovation was also represented as a key resource, able to transfer new knowledge necessary for the advancement of the initiative. The interviewee below, commenting on the significance of champions, said:
"It is important. We're fortunate, we're led from the top, our Chief Executive and our Chairman are very passionate, as are our Trust Board, about sustainability. We've also got an environmental awareness campaign that we started again in the New Year that's just gone. We've now got 147, I think it is, environmental champions across the Trust, that are driving it forward, and we're recruiting all the time. These are obviously voluntary posts, but the passion and the commitment out there is absolutely fantastic. So I don't think it would stop. I think it would take it to new levels, because people are bringing in things that we've never even thought of." (Innovation less related to the healthcare provision)
The users of the novel services could also constitute powerful champions, as they were able to circulate their experience to the local community, thus promulgating the new service and counteracting possible resistances.
"The students themselves who have come through the Academy have demonstrated behaviours which are exemplary and they have been the greatest advocates for the Academy,-the reputation of the Academy has allowed it to grow, we do still have people who are anti the Academy, which is reflective of working with excluded groups, but we have far more supporters." (Innovation less related to the healthcare provision)
Employees were seen as a vital channel for intra-organisational and inter-organisational diffusion, since they can persuade their colleagues informally or influence decisions directly, especially when they occupy key positions. They were considered as powerful advocates when they experienced beneficial results in their daily working routines and regarded the innovation as advantageous. By contrast, employees affected negatively can put up barriers that require effort to surmount through proactive engagement and timely information provision.
"...the way that we did that was to just start off with very small pilots in non-acute areas, and develop a process which was so much better for the nursing staff that they were, you know, they were so delighted to have it that they would, you know, they would work with us and become advocates for us when we went to new clinical areas." (Innovation directly related to the healthcare provision)
Barriers to the implementation and diffusion of innovations were perceived to arise when the innovators and the decision-makers belonged to different professional groups. Different educational backgrounds, organisational roles, and diverse worldviews resulted in different priorities, which could delay or obstruct the spread of innovation. In such cases, innovators had to devote much effort to persuading decision makers of the usefulness of the initiative.
"...sometimes the people who are in charge of the budgets are not necessarily very familiar with clinical priorities. So they might be somebody who's actually an accountant, who's responsible for helping the PCT decide which disease areas and which services to put their money in. So you have to...be prepared to almost educate people about why what you're doing is important." (Innovation directly related to the healthcare provision)
D. Contextual factors
The context, both intra-organisational and extra-organisational, was also perceived to decisively influence the life-cycle of the healthcare innovations.
D1. Intra-organisational context
three basic subthemes were identified, relating to: (a) organisational receptiveness, (b) available resources, and (c) organisational capability to promote the innovation.
a. Organisational receptiveness
A series of long-term changes often preceded implementation of the service innovation, especially when the latter was large-scale and system-wide. These changes were believed to prepare the organisation structurally and functionally to receive the novelty smoothly, especially when the impending initiative was complex and multifaceted. In this case, the process of implementation and spread was constructed as an incremental change, embedded in an already changing system.
"...we'd been developing our pathway for stroke and aspects of it, year on year, since 2000, and I think it was that foundation that truly enabled us to respond in the way that we did and deliver that [innovation]." (Innovation directly related to the healthcare provision)
Organisational culture was also perceived to be a critical factor. Specifically, the openness of the organisation to trial new ideas and carry the associated risks was seen as significant, particularly when the change was not triggered by external factors, such as policy initiatives, or an obvious and urgent organisational need.
"...there was an environment of being prepared to take a risk, with the right kind of conditions to support that." (Innovation less related to the healthcare provision)
Equally important for diffusion was the fit between the innovation and the organisational ethos. When innovators' values were perceived to be congruent with prevailing organisational norms and beliefs, the diffusion was facilitated, since the novelty affirmed the cultural organisational orientation. By contrast, when the innovation collided with basic organisational principles, resistance emerged and dissemination was impeded.
"You know, it's just changing-it's a big culture change, and it does meet with controversy and it does meet with people who still feel that prisoners shouldn't have any rights at all, and so you are constantly coming up against that." (Innovation directly related to the healthcare provision)
b. Available resources
Sufficient human and financial resources were of paramount importance not only for the proper implementation of service innovations but also for their diffusion to other organisations, sectors and fields of practice. Shortage of resources, or fear of this, could block innovators' efforts and led to stagnation. An interviewee, employing the metaphor of "paralysis", commented:
"It's very clear what we need to do in stroke, and sometimes, just the paralysis is just that the money isn't there to develop early supported discharge." (Innovation directly related to the healthcare provision)
c. Organisational capability to promote the innovation
Innovators' own capability to promote their initiatives within and beyond their organisation was considered to facilitate diffusion. Specifically, awards, media attention and the possibility of academic publications were viewed as a powerful means of communicating the innovation to the wider publics.
"When we got that far, and, crucially publicised what we'd been doing-enter awards, produced journal publications-which was very helpful to us. You know, having the picture of the process on the front page of the premier international transfusion journal, things like this.., trying to develop some momentum behind it." (Innovation directly related to the healthcare provision)
Winning awards was experienced as a crucial social recognition in three main ways: firstly, awards were perceived as an external and unbiased validation of the innovation, against which it was difficult for doubters to argue. Secondly, awards were seen to raise the profile of organisation and its reputation of being innovative, which in turn helped it to build further networks and inter-organisational collaborations. It also identified the organisation as an early adopter. Thirdly, innovators regarded the awards as an effective means of promoting an agenda, which in turn could attract further resources.
"...if you do have a good profile nationally, regionally, things come to you. You know, you are invited to participate in things, to be early adopters and, that's for the benefit of the people that we serve really, so it's not just about the glory-it's about being at the table..." (Innovation directly related to the healthcare provision)
Active promotion of the innovation with other organisations was presented as essential and innovators believed that they should communicate and publicise on an on-going basis. In this way an extrovert organisational culture is cultivated. This sharing-behaviour enabled innovators to identify pitfalls and advise prospective adopters of the most promising ways of implementation.
"You know, that's one of the big ethos behind kind of the networks really is, it's around sharing. It's not about keeping it to yourself. It is definitely around sharing good practice, sharing what's learnt, and also, hopefully things that went wrong for us, sharing that as well and saying this is how...don't do that, don't go down off that road because we tried that and it didn't work, as much as it is about saying this route worked really well." (Innovation directly related to the healthcare provision)
Innovators recognised that diffusion would involve adaptation to the new context. "Re-invention"  rather than replication was seen as an imperative for prospective adopters. In the context of complex organisational settings, interviewees stressed that to "survive" and be successful was only possible if necessary adaptations and adjustments were made.
"And also everybody, to some extent, has to evolve these things for their own circumstances, don't they?....It's not a one-size fits all." (Innovation directly related to the healthcare provision)
D2. Extra-organisational influences
Three main external influences were identified in innovators' accounts: (a) economic, (b) political, and (c) ideological.
a. Current economic climate
The constrained economic climate was often cited as inhibiting initiatives which were expensive and did not save costs directly. Such innovations were unlikely to attract funding and sustained financial support, since they were seen to oppose the measures needed in challenging economic conditions.
"I think we did it at exactly the right time, because I think, now, it's quite a difficult time in terms of obviously, the economic climate. It's really difficult in terms of funding that's available, and actually, there needed to have been some pump-priming upfront to be able to deliver this." (Innovation directly related to the healthcare provision)
b. Political influences
Politics was constructed both as a positive and a negative force in diffusion efforts. In terms of benefit, the presence of regulatory bodies that would shape practices around specific innovations was considered to facilitate certain initiatives. Conversely, it was more problematic where there was a more fragmented landscape of accountability and no clear responsible body to align stakeholders' activities.
"The problem is, there is actually no national body, as I said again, responsible for food. If you ring the Department of Health and say "Who's responsible for food in the NHS?" you'll get a complete blank." (Innovation less related to the healthcare provision)
Additionally, when the innovation was believed to entail political risks or ran against the dominant political forces within the local context, the diffusion met severe challenges.
c. Ideological influences
The last critical factor for success was the perceived fit of the innovation with the broader ideological context, both within and outside the healthcare sector. When an innovation was viewed to reflect dominant ideological beliefs and to be consistent with the "spirit of the times", initiatives were more likely to become established. This was especially so for those innovations which were peripherally linked to the core function of the NHS. In this case, innovators had to resort to ideological resources external to the domain of healthcare, such as environmentalism, in order to endorse the value of their initiatives.
"I was going to say this is a really good period of time to be doing these things because there is a general awareness, there are all sorts of things that the Trust has to do in saving energy. People think it's a good idea. The community thinks it's a good idea. It costs you if you don't." (Innovation less related to the healthcare provision)