Responding to change by changing
Tim Hobbs | CEO | @tim_hobbs_lab
Let us know what you think via @DartingtonSDL and @FNPNationalUnit
This is a story about evolution. It considers what evidence-based programmes and the green lizards of Florida have in common. It’s about what we at the Dartington Service Design Lab think is the next frontier in the generation of evidence designed to evolve, and improve, practice. Our thinking has been shaped by our ambitious programme of partnership working with the Family Nurse Partnership (FNP) National Unit.
The evolution of green lizards
The native green lizards of Florida lived happily in shrubs and the lower branches of trees. That was until an unruly and invasive species of brown lizard moved into town. Faced with dwindling resources, a changing environment and increased competition, the green lizards faced a choice. Adapt or die. And adapt they did. Within just 20 generations they had evolved bigger and stickier toepads. This allowed them to scale the higher, smoother and previously unassailable branches of the trees. The green lizards now thrive in these higher realms, away from the reach of those pesky invaders.
Threats faced by evidence-based programmes
In some ways evidence-based prevention and early intervention services face similar threats to the green lizards. The pool of available resources to sustain them is dwindling. The world around them is changing, and there is increasing competition for public or philanthropic funding. Commissioners and evaluators are also aware of a ‘replication crisis’ – positive results from rigorous evaluations conducted in one place at one time are often not reproduced when the services are implemented and evaluated in a different place and time.
Family Nurse Partnership
This pattern been the experience of the Family Nurse Partnership (FNP) – a public health home-visiting parenting programme for first-time young mothers. It was introduced to England in 2007, and at its peak delivered in 132 out of 152 local authorities. It is the first evidence-based early intervention programme for families to be taken to this scale by the UK government.
Yet like many other public services, FNP has faced significant change and challenge: funding cuts, an increasing emphasis from commissioners on person-centred care, and challenging results from a randomised controlled trial in 2016.
The need to ADAPT
Like the green lizards of Florida, FNP had to make a choice. When the world changes around you, adapt. So ADAPT it did…
The FNP National Unit – part of the Tavistock and Portman NHS Trust – partnered with the Dartington Service Design Lab to co-design and implement an ambitious programme that we call ‘rapid-cycle adaptation and testing’. We named it FNP ADAPT (Accelerated Design and Programme Testing).
Rapid Cycle Adaptation and Testing
ADAPT harnesses the strength of research and the pragmatism of improvement approaches to adapt, test and learn about the FNP programme, while respecting its strong evidence base. We work collaboratively with nurses and clients to design adaptations that we think will enable FNP to better meet the needs of families – and then we test to see if we were right.
To date, the ADAPT team from the Lab and the FNP National Unit has supported 10 delivery sites (and more sites this coming year) to develop and test two types of adaptation:
Clinical changes: these adapt the FNP programme to help it achieve a specific outcome (for example, quitting smoking or addressing neglect).
System changes: these aim to increase efficiency, improve outcomes, and allow nurses to personalise FNP (for example, spending less time with clients with less serious needs and more time with clients with more serious needs).
The Rapid Cycle Adaptation and Testing method has five main stages: (i) forming a co-production team of practitioners, users, scientists and commissioners; (ii) designing adaptations (considering user perspectives, evidence, logic and ‘dark logic’ models); (iii) implementing and testing of adaptations using ‘minimally sufficient’ quantitative and qualitative data; (iv) ‘tweaking’ these adaptation based on what we learn through testing cycles; and (v) deciding whether to develop these prototype adaptations into ‘business as usual’ elements of the programme, test further, or abandon them.
So what have we learnt so far?
This is an ambitious programme. FNP are pushing at the boundaries of how to deliver an evidence-based service in changing contexts, and together we are learning a lot along the way. Here a few things we’ve concluded so far:
It is possible to design, implement and test adaptations to a well-developed and structured evidence-based programme, like FNP. So far we’ve designed, implemented and tested six clinical adaptations and four system adaptations. What’s absolutely crucial is the deep involvement of users and practitioners – we couldn’t have done any of this without the enthusiastic support of mothers and nurses, who generously gave us so much of their time, and insight.
Translating adaptations into well-established ways of working is hard in practice. We can design and make changes centrally, with local leads, nurses and clients, but our data suggests that their subsequent real-world adoption by front-line practitioners is variable. There is a change management element required to this work, which we had probably underestimated. This is something we’ll be focusing a lot of our attention on over the next year.
The word ‘rapid’ is a relative term! It took the green lizards in Florida a mere 20 generations to adapt (which in evolutionary terms is lightening fast, yet translated to human lifecycles would be about 540 years). When I talk to user-experience (UX) designers working in tech, or product designers, their cycles of adaptation and testing often take hours, days or weeks if they are pushing it. Yet they’re often dealing in metrics such as ‘likes’, web traffic, or sales. With FNP we are focused on designing changes to nurse home-visiting practice that aims to affect complex, often intergenerational patterns of parenting or children’s health and development (such as breastfeeding, speech development, or neglect). This is seriously hard work, and it takes time to know if it’s working. So our cycles of test and change are much longer – weeks, months, sometimes years? But at least not 540 years.
So what next?
With the FNP National Unit, we’re applying the principles of rapid cycle adaptation and testing to ourselves. We’ll continue to refine our approach, and over the coming months start to see whether the work we are doing is making a demonstrable impact on child and family outcomes.
We are also exploring opportunities to connect with others doing similar work, such as the Harvard Center on the Developing Child and their Frontiers of Innovation approach. We hope to create an international learning network with others doing similar work – if that’s you, get in touch!
If you want to find out more about our work and learning to date, take a look at our interim report, which is published today.