North East and North Cumbria is one of 42 integrated care systems (ICSs) in England, set up in 2022 to bring together partners from across a geographical area to improve health outcomes, reduce health inequalities and prevent ill-health.
Inspired by Cincinnati Childrens, North East and North Cumbria ICS adopted an ambition to be the ‘best at getting better’ by continuously improving the way people in our system are supported for better health and health and care. At the heart of this approach is ‘Boost’, our learning and improvement community that brings people from across the system to inquire, learn, share and take action for improvement together. Currently, there are nearly 7,000 people who are members of this community.
Right from the setup of the ICS, we wanted to create a theory of change (ToC) for the learning and improvement community, setting out why and how it would contribute towards our system improvement goals. Analysis of high performing systems shows how strongly connected networks create a capacity to facilitate knowledge exchange for innovation and improvement across a system. We view relationships and relatedness as primary enablers of system improvement, and regard the leadership role across the ICS as that of system convening, helping to connect people and build relationships, so people can more easily learn, share knowledge and take action together, driven by shared goals for improvement.
The NENC learning and improvement community builds on existing strengths, capabilities and relationships within the ICS area, but we wanted the community to be something additional and amplifying, towards the achievement of goals. So, co-creating a ToC for the community with community members was a way of enabling everyone to be on the same page and to move forward together, with shared purpose.
Theories of change are often created for change initiatives in the voluntary sector and for academic research projects. This is particularly the case where commissioners and funding bodies ask for a ToC as part of a funding proposal. Theories of change are much less common for large complex change interventions that are initiated by the NHS. We hope that, in future, ToC will become a more commonplace way to plan for change in the formal health and care system as well.
Here is the ToC we have developed for the NENC ICS learning and improvement community:
In this blog, we seek to explain:
A theory of change is an explicit process of thinking through and documenting:
The ToC fills in what has been described as the ‘missing middle’ between what a change initiative does (its activities or interventions) and how these lead to desired goals being achieved.
Through the development of the ToC, we are better able to understand the direct connection between change activities and the achievement of our long-term goals. This facilitates better planning, in that activities are linked to a detailed understanding of how change actually happens. It also leads to better evaluation, as it is possible for us to measure progress towards the achievement of longer-term goals that go beyond the identification of the specific outputs of our change interventions.
There is no single definition or methodology for a theory of change. There are however, some core principles that are consistent through most of the available frameworks. The ToC should be:
The use of the term ‘theory of change’ is increasing. At the same time, the use of other related terms such as ‘log frame’, ‘logic model’ and ‘programme theory’ are declining:
Tracking the use of terms over time (Source: NPC)
The shift from the use of ‘logic model’ to ‘theory of change’ may be because leaders are increasingly developing models for initiatives that are complex, ambiguous and big picture. Logic models are linear, progressing step by step, typically through from inputs to activities to outcomes. In a logic model, an effect never precedes a cause. By contrast, a ToC is usually more comprehensive and dynamic, considering the complexities and interdependencies within and across the system. A logic model describes what you expect to happen but does not address why it will happen. The purpose of a ToC is to identify why your activities and interventions will create the outcomes it will. Both logic models and ToCs have an important role. However, for a complex change situation like the learning and improvement community (where we need to hypothesise and test our approach because we cannot to certain about cause and effect due to the multiplicity of interacting factors), a ToC is a better fit.
We researched and took advice from those who are highly experienced at creating ToCs in other sectors, particularly the voluntary and community sectors. Change leaders in the formal health and care sector can learn greatly from their expertise. NPC stressed the importance of focusing on the process of developing the ToC as much as the outcome.
By focusing on the process of developing the ToC (who to involve and how) we were able to get a lot of people engaged and invested which helped the learning and improvement community; we got more challenge which led to a better ToC outcome, and it made us focus on what was really important to stakeholders; ‘have to do’s’, not just ‘nice to do’s’. It felt like we were modelling ‘best at being better’.
So, the building of our ToC was a collaborative and iterative process. A first version was created by a group of cross sector partners from across the ICS. It was further developed at a collaborative workshop and then tested with more members of the learning and improvement community. The people who took part in the process included people with lived experience, clinicians, leaders and improvement activists from the NHS and local government, voluntary and community organisations, NHS England and academic researchers.
This is what our stakeholders said:
The ToC approach means we are seeking to collectively explain ‘why’ these activities and interventions will lead to the outcomes we seek. Therefore, we started the ToC with ‘We believe’ – a statement of what we collectively hold to be true. Then we moved to ‘Therefore’ ‘And’; setting out how taking a learning approach to our biggest challenges and how a thriving learning and improvement community will create the conditions to activate the changes we want to see (‘Then’). ‘This means’ learning and experimentation become the way that people across North East and North Cumbria do their daily work ‘and’, improvement will be driven by lived experience. Consequently (‘As a result’) the actions of the community will contribute to the achievement of the health and health and care goals of the ICS.
Whilst we were able to set out our ToC on a single page, we were also aware that there were multiple components to it. We wanted to our ToC to be usable and accessible to our large and growing community, who have different starting points and needs. So, we also created a summary version:
The summary Theory of Change for North East and North Cumbria Learning and improvement Community
The process of creating our ToC has made us reflect much more deeply about how we think change will occur. It has helped us collectively to set out the complex connections leading to impact. It is guiding the actions we are taking as a learning and improvement community and guiding our assessment of progress and outcomes.
We know that our ToC journey and the frameworks we have developed are influencing others, beyond our integrated care system. For instance, NHS England has recently published its ToC for NHS Impact, the single, shared approach for improvement in the NHS:
The Theory of Change for NHS Impact
Annie Laverty
Suzanne Hamilton
Helen Bevan
Kathryn Grayling
