Recognise the barriers to your improvement


It’s often quoted that 70% of change programmes fail in the NHS but it’s less clear why and what the solutions may be.

The Health Foundation has recently published a new evidence scan which offers some insight, summarising the key barriers which hamper improvement in projects and programmes.

Relevant to small and large scale change programmes, the scan is a quick and useful read for anyone involved in planning or implementing improvement initiatives.


The evidence scan summarises the leading themes from 73 studies relating specifically to the NHS and further 100 studies from international settings. The studies were identified from a search of 12 databases.  As well as reviewing the literature, the scan also includes lessons from the evaluations of 14 Health Foundation projects. The scan helpfully summarises key messages in quick reference tables.

Key barriers to improvement

The barriers identified are organised by:

  • the nature of change initiatives, including the strength of the evidence base, fit within existing context and complexity of the changes involved;
  • the individuals involved, including skills, attitudes, clarity of roles, resources and prioritisation;
  • organisational factors, including engagement, leadership, focus, information and timing;
  • and system factors, including stability, policy context, fragmentation, incentives and relationships.

There are a number of examples from studies which add some insight. Barriers are also categorised by the stage of the change or improvement programme at which they become evident: design, delivery or dissemination.

Some barriers run throughout programmes, from design to dissemination: management skills; lack of time allocated; insufficient use of data and information; lack of financial resources; and the impact of policy, regulation and NHS culture.

There is an emphasis on system-wide issues, particularly relevant as we move towards more integrated and collaborative models of care. There is also an acknowledgement of context – the author of the scan has deliberately avoided prioritising barriers as the impact will depend on local factors and configurations.

Organisational culture is key, including the skills and attitudes of those involved

Organisational culture is key, including the skills and attitudes of those involved

No excuses

Importantly, the scan recognises the risk that the barriers listed are used as excuses for poor implementation.

By openly stating potential barriers, the scan should help change managers identify relevant barriers and develop mitigating strategies, just as they do for risk management.

By recognising the potential barriers to improvement, the scan helps commissioners identify and manage barriers - but it should not be seen as a list of possible excuses should the improvement fail!

By recognising the potential barriers to improvement, the scan helps commissioners identify and manage barriers – but it should not be seen as a list of possible excuses should the improvement fail!

Critical success factors

The Health Foundation have also published an analysis report, Constructive comfort: accelerating change in the NHS, which uses the evidence scan as a key source.  The report provides more of a national focus and will be an interesting reading for change managers and improvement leads.


There are probably going to be few surprises in the list of barriers – commissioners involved in large change programmes will be familiar, sometimes painfully, with many of those listed.

However, the concise summary of barriers, organised by the level where and time when they may occur, could provide a useful framework for programme/improvement teams to instigate discussions about barriers in relation to local contexts.

Not all of the barriers will be within a commissioner’s control, particularly those relating to stability and organisational structures of the NHS.

However, there are some actions which can be taken to address known barriers – here are some questions which commissioners may wish to consider:

  • Is there a shared vision for the change across all stakeholders?
  • Have the relevant specialist and professional groups been involved in design?
  • How are the risks of trying something new being mitigated?
  • What skills and experience do our staff have and need?
  • How realistic are the expectations of how quickly change can be achieved?
  • How are we embedding this change into normal practice?
  • How are we encouraging an improvement mindset in our organisation, so that it is seen as part of day to day practice?
  • How are we keeping up to date with new evidence and innovations?
  • How well equipped are we to use information and data effectively?
  • How are we communicating this change to our teams?
breaking through barrier

By recognising barriers relevant to their own context, commissioners can develop strategies to mitigate their impact.


De Silva D (2015) What’s getting in the way? Barriers to improvement in the NHS. Health Foundation.

De Brún C. Report highlights challenges facing CCGs as they take on new co-commissioning responsibilities. The Commissioning Elf, 5 Feb 2015.

De Brún C. An integrated leadership approach needed to improve care. The Commissioning Elf, 11 Mar 2015.

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Alison Turner

I'm Head of the Evidence Analysis team within the Strategy Unit at NHS Midlands and Lancashire Commissioning Support Unit. I'm interested in how knowledge management can support value based healthcare and evidence based decision making. I've previously worked in a range of different healthcare settings, including acute care, commissioning, health services research and medical education. More recently, I worked at NHS Evidence and NHS Institute for Innovation and Improvement.

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