Adoption as the critical determinant of successful organisational change

Adoption is where many transformation programmes quietly succeed or fail. A change may be strategically sound, well sponsored, and formally launched, yet still fail to deliver meaningful value if it is not used consistently in practice. In healthcare, this is a familiar pattern: a new pathway is introduced but applied unevenly, a system goes live but old workarounds remain, or teams complete training yet routine behaviours change only partly. The result is that organisations can appear to have implemented change without fully adopting it. Adoption is therefore the point at which intended change becomes operationally real. It is where value is either realised or lost. 

In practice, adoption is often misunderstood because organisations confuse launch, use, and embedding. Launch means the intervention exists. Use means some people are engaging with it. Embedding means it has become part of routine delivery. Those are not the same thing. A programme may be live across an organisation and still not be normalised in daily work. That is why adoption needs to be understood not just as a delivery milestone, but as an organisational and system process shaped by relevance, legitimacy, fit with workflow, and the realities of local work. Greenhalgh’s review of innovation in service organisations emphasises that uptake depends not only on the innovation itself, but also on adopter concerns, communication and influence, organisational readiness, and the wider context. The Normalisation Theory Process (NPT) adds a further practical point: new practices become durable only when people can make sense of them, engage with them, enact them, and continue to appraise them in routine work. 

A practical way to think about adoption is to ask four questions.

1. Who exactly needs to do something differently?

Too many programmes describe the intervention but not the behaviours required from those expected to use it. Without that clarity, change remains abstract. Teams may support the objective while being uncertain about what they themselves are meant to do differently. This is one reason adoption often looks stronger in programme documents than in live settings. The King’s Fund review of innovation adoption in the NHS makes a similar point: moving from a proven idea to sustained uptake requires more than evidence that an intervention works. It requires local translation, implementation support, and the ability to adapt the innovation into existing services. 

2. Does the change fit the way work is actually done?

This is where adoption often rises or falls. The ChatHealth case shows this clearly. It began because school nurses in Leicestershire wanted a safer and easier way for children and young people to access support using communication channels they were already comfortable with. Adoption was driven by more than the idea itself: a project lead was secured, a project board chaired by a senior director oversaw the work, the application was designed with the school nursing team, and the pilot was implemented across services covering 65,000 children and young people.

The outcome was immediate and practical. School nurses received around 100 additional requests for support each month, including more first-time users and more adolescent boys, who had previously been less likely to access face-to-face support. Later spread was then supported by NHS England and East Midlands AHSN funding, which helped maintain a small team to market and implement the service more widely.

The practical lesson is straightforward: adoption improved because the intervention addressed a clear access problem, was designed around frontline workflow, and was backed by hands-on implementation capacity. 

3. Is the value visible and the route to use made practical?

Adoption is stronger when the benefit is concrete, timely, and close to day-to-day work. But visible value alone is not enough. The Florence telehealth case illustrates this well. The King’s Fund reports that AHSN support accelerated uptake by providing condition-specific protocols, practical toolkits, and support for clinical champions promoting the service to peers, contributing to an additional 1,000 patients using Florence within the first nine months of the programme.

Yet the same case study also shows the limits of early momentum: even seven years in, wider adoption across primary care, community, and hospital services remained at an early stage and still relied on active clinical sponsorship.

The point is clear: adoption does not accelerate because people are trained. It accelerates when the value is visible, implementation is made practical, and credible people actively carry the change into routine use.

4. What support exists after launch?

One of the clearest lessons from NHS innovation case studies is that adoption rarely happens through passive dissemination alone. The King’s Fund review describes the importance of “boots on the ground”: senior clinicians and programme teams spending time with organisations, helping them implement new models, supporting adaptation, and evaluating performance over time. The ESCAPE-pain case shows this in practice. The programme had a strong evidence base and was designed as a low-cost, group-based model using existing staff and facilities, but it did not spread simply because the evidence existed. After early pilots, adoption accelerated when the Health Innovation Network backed it as a spread priority, supported marketing and implementation, helped synthesise the evidence for commissioners and managers, established early champion sites, and persuaded local systems to trial it.

Over four years, 10 of the 12 CCGs in South London adopted the programme, and it later spread further through collaboration with other AHSNs. NHS England then reported 36 ESCAPE-pain programmes across six AHSNs, with analysis estimating a £5.20 return for every £1 invested.

Wider adoption was further strengthened by adapting delivery into community and leisure settings through accredited training for exercise professionals. The practical point is that adoption was driven not just by evidence of benefit, but by active implementation support, champion sites, and adaptation that made the model usable in more settings. 

Why adoption varies

These cases also show why adoption varies across settings. Healthcare organisations are complex systems, and uptake is shaped by local leadership, relationships, capacity, competing priorities, and organisational history. Greenhalgh and Papoutsi argue that spread and scale in healthcare do not follow a simple logic of replication; they also depend on ecological and social processes. In practical terms, leaders should expect variation. The question is not only whether an intervention is evidence-based, but what needs to be adapted, supported, or reinforced locally for adoption to become routine. 

What leaders should do differently

For leaders, the implication is straightforward: adoption should be designed for, not assumed. That means:

• defining what adoption looks like in practice

• identifying who needs to change behaviour

• testing fit with workflow

• making the value visible

• putting support in place beyond launch

It also means measuring adoption directly. Alongside outcome measures such as waiting times, productivity, quality, or financial impact, organisations should track uptake, consistency of use, penetration across teams, and evidence that the new model has become part of routine work. Without that distinction, it is difficult to know whether disappointing results reflect a weak intervention, weak adoption, or both. 

Conclusion

Ultimately, adoption is the critical determinant of successful organisational change because it is the point at which intention either becomes routine practice or fails to do so. Transformation should not be judged only by what was announced, funded, or launched. It should be judged by what became used, integrated, and sustained in the reality of service delivery. In healthcare, that is the difference between change that is visible on paper and change that is real. 

References 

[1] Collins B. Adoption and spread of innovation in the NHS. London: The King’s Fund; 2018.

[2] Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly. 2004.

[3] Murray E, Treweek S, Pope C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Medicine. 2010;8:63.  

[4] Greenhalgh T, Papoutsi C. Spreading and scaling up innovation and improvement. BMJ. 2019.

[5] The King’s Fund. Secure text messaging with school nursing teams. Case study article. London: The King’s Fund; 2018.  

[6] The King’s Fund. Florence: telehealth for long-term conditions. Case study article. London: The King’s Fund; 2018.  

[7] The King’s Fund. ESCAPE-pain programme for hip and knee pain. Case study article. London: The King’s Fund; 2018.  

[8] NHS England. Increasing the impact of Academic Health Science Networks. Board paper PB.24.05.2018/06; 24 May 2018.