Exploration of ‘Affiliation’ Models for Scaling Complex Interventions in Healthcare

Abstract

A significant challenge in healthcare is scaling up successful interventions. Multiple theoretical scaling frameworks have been proposed, however published evidence of their application is lacking. Healthcare may benefit from experience generated in social science; affiliation models focus on formalising partnerships between groups, creating networks with clear governance structures. These models may address barriers reported with traditional dissemination which affect implementation timescale, adoption, reach, fidelity and sustainability of interventions, ultimately leading to inequity of effect.
This work uses a complex intervention; PROMPT (Practical Obstetric Multiprofessional Training), to investigate two affiliation scaling models; one based on the Institute for Healthcare Improvement’s framework for going to full scale (PROMPT Wales) and the second on Social Franchising methodology. PROMPT is a training package for maternity staff to improve team performance, with published evidence of improving clinical outcomes, team efficiency, culture and reducing hospital litigation costs. It has been spread widely both in the UK and internationally, however prior work identified barriers with disseminating PROMPT, and outcome improvements have not always been replicated.

Our mixed method programme of studies included a systematic review to appraise current scaling methodology in healthcare, and evaluation of the affiliation projects in the form of process measures, surveys and qualitative analysis. The systematic review identified 10 common scaling steps which were utilised in the affiliation projects. Both projects enabled successful scaling of PROMPT with good intervention fidelity. Heterogenicity of implementation between sites was reduced in comparison to previous PROMPT dissemination projects. Furthermore, PROMPT Wales demonstrated improvements in safety culture following scaling. Qualitative evaluation of Social Franchising identified the key mechanisms through which this methodology enhances scaling. This work enriches the scaling literature for complex health interventions, and I call for other healthcare scaling projects to publish their methodology in order to refine and develop knowledge in this essential implementation field.

Date of Award	17 Mar 2026
Original language	English
Awarding Institution	University of Bristol
Supervisor	Christy Burden (Supervisor), Timothy J Draycott (Supervisor), Erik Lenguerrand (Supervisor) & Carolyn Tarrant (Supervisor)