From Pilot to Practice: Can Impact Scale?

There’s no shortage of pilots in the NHS.

Every year, hundreds of small-scale innovations are funded, trialled, evaluated and then quietly shelved. Not because they didn’t work. But because what worked in the pilot didn’t make it through to practice.

We know that scaling is hard. What we don’t talk about enough is why. And more importantly, what we can do differently from the outset.

If we want to take good ideas from pilot to practice in a way that sustains impact, we need to design with scale in mind from the start – not treat it as a final hurdle to overcome.

Because scaling healthcare innovation isn’t just about wider adoption. It’s about ensuring the intended benefits survive the journey.

Why Scale Fails

There are a few reasons healthcare innovation doesn’t scale easily:

Context dependency: What works in one trust or locality may not transfer neatly to another.

Resource constraints: A pilot may have access to dedicated funding, staffing, or support that disappears at scale.

Change fatigue: Staff often experience a relentless cycle of pilots without follow-through, leading to disengagement.

Inflexible systems: Commissioning, procurement, and governance processes rarely flex to support innovation embedding.

Lack of scale readiness: The host system is rarely assessed for its capacity to absorb or adapt to the innovation.

Less evidence for new ideas: In a system that values proof concept and clear benefits, the lack of evidence and evaluation can stop an idea from scaling.

NIMBYISM: Everyone loves the idea of innovation making things easier, but the effort and disruption can prompt a not in my backyard reaction from areas already under significant pressure.

But underneath all of this is a deeper truth: we often design for proof, not permanence.

Pilots Are Not Mini-Versions of Scale

It’s a mistake to assume that a successful pilot can simply be replicated, multiplied, or rolled out with fidelity. Scale is not about copying. It’s about adapting.

Pilots are typically small, supported, and opt-in. They often involve hand-picked teams and favourable conditions.

Scaling means embedding something in the everyday reality of a much more complex, stretched, and variable system. It means encountering resistance, variation, legacy systems, and competing priorities.

So, the question becomes: if we know the conditions of the pilot are unrepeatable at scale, what are we really testing?

Designing for Scale from Day One

If we want scale to be more than an aspiration, we have to build it into the DNA of the innovation process.

That means asking different questions early on:

Who will need to adopt this, adapt it, and sustain it over time?

What behaviours, workflows, or decisions will this change?

What pressures or policies might support or constrain uptake?

How will we track not just activity, but meaningful outcomes?

These are not afterthoughts. They are design questions. And if they’re not answered early, we risk building elegant solutions that collapse under operational weight.

Can We Also Design for Impact at Scale?

It’s one thing to scale an idea. It’s another to scale impact.

The NHS has seen plenty of innovation that spreads quickly but dilutes over time – losing sight of its original intention or delivering outputs without the outcomes.

Take, for example, a digital triage tool developed to improve patient experience. In a pilot site, it may lead to faster access, reduced complaints, and better staff morale. At scale, it may become a compliance exercise – deployed widely, but with no noticeable shift in patient experience.

So, what went wrong?

Too often, the measures of success change as innovations move from test to rollout. What was once an experience-led or relational intervention becomes a performance metric. The how of delivery shifts, and the why gets lost.

This is where impact design becomes critical.

Impact-by-Design: A New Framing

At Future Care Capital, we’ve been exploring the idea of impact-by-design. It’s a simple premise: don’t just design the innovation – design the conditions for the impact it’s intended to deliver.

This includes:

Clear articulation of intended outcomes, not just activities

Guardrails to protect purpose as adaptations are made

Shared ownership of impact across stakeholders, not just delivery teams

Feedback loops that track not just scale, but depth and effectiveness

Evaluation frameworks that reflect real-world complexity and variation

When these are built into the scale plan from day one, the innovation has a better chance of surviving the transition from pilot to practice without becoming hollow.

Embedding Impact in the Scaling Process

Designing for impact means thinking differently about every stage of the scaling journey.

1.Early Engagement

Too often, pilots are designed in isolation. Bringing in potential scale sites – commissioners, ICS leads, clinicians, patients – early in the design process allows the innovation to reflect the diversity of real-world settings.

2. Adaptive Implementation

Scaling should not mean standardisation for its own sake. Instead, we should enable controlled variation – allowing local teams to adapt the model while staying true to the core purpose.

Think of it like a recipe: the ingredients can shift, but the dish should still taste like itself.

3.Shared Learning Infrastructure

Impact doesn’t just scale through good planning – it scales through good learning. That means creating infrastructure for feedback, iteration, and knowledge exchange between sites.

When organisations can learn from each other in real time, the innovation evolves without drifting.

4.Aligned Incentives

Finally, we need to ask: does the wider system reward or penalise this innovation? If teams are judged solely on efficiency or short-term targets, relational or preventative innovations will struggle to survive – even if they deliver long-term impact.

Commissioning, regulation, and workforce planning all shape what’s possible at scale. Designing for impact means working with – not against – those levers.

What We’re Learning in Practice

We work with organisations across health and care to evaluate innovation not just on its promise, but on its potential to scale well.

We’ve seen that when scaling is baked in from the start:

The innovation is more likely to be resilient to local variation

The impact is more likely to stay connected to its purpose

The system is more prepared to receive and adapt to it

We’ve also seen that designing for scale isn’t about moving faster. It’s about moving smarter – and doing the slow, sometimes political work of building alignment and shared purpose across organisations.

Scale is a System, Not a Step

If we want healthcare innovation to move from pilot to practice with its impact intact, we need to stop treating scale as a final step.

Scaling is not the end of innovation. It is its second beginning – and it requires just as much creativity, rigour, and collaboration as the first.

When we design for scale, and design for impact, we give innovation a better chance to stick. To adapt without drifting. To grow without thinning. To matter, not just to the pilot team – but to the people it was built to serve.