Background Various theories provide guidance on implementing, sustaining and evaluating innovations within healthcare. There has been less attention given, however, to personal theories drawn from practice and the expertise of managers and front-line staff is a largely untapped resource. In this paper, we share learning from experienced improvement organisations to provide a conceptual level explanation of the conditions necessary to facilitate and sustain improvement at scale.
Methods Staff (n=42) from three leading change organisations in the UK, spanning health, education and social care, took part in three consultation meetings with the aim of sharing knowledge about sustaining large-scale change. This included one government organisation, one National Health Service Board and one large charity organisation. Using a participatory grounded theory approach, the workshops resulted in a co-created theory.
Results The theory of Motivating Change describes the psychosocial-structural conditions for large-scale, sustained change from the perspectives of front-line staff. The theory posits that change is more likely to be sustained at scale if there is synergy between staff’s perceived need and desire for improvement, and the extrinsic motivators for change. Witnessing effective change is motivating for staff and positive outcomes provide a convincing argument for the need to sustain improvement activity. As such, evidence of change becomes evidence for change. This is only possible when there is a flow of trust within organisations that capitalises on positive peer pressure and suppresses infectious negativity. When these conditions are in place, organisations can generate self-proliferating improvement.
Conclusions The theory of Motivating Change has been co-created with staff and offers a useful explanation and guide for others involved in change work that capitalises on front-line expertise.
- quality improvement
- human factors
- quality improvement methodologies
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Initiating and sustaining effective change in healthcare is a continuing challenge, with even the most successful improvements often being difficult to sustain or replicate in other contexts.1 Key figures in improvement science have emphasised the importance of learning from the psychological, social and structural processes influencing the implementation and maintenance of practice innovations.2 3 They have called for researchers to look into the ‘black box’ of quality improvement to learn lessons from both successes and failures.4 Yet, a systematic review of 72 published studies of the impact of quality improvement collaboratives noted a marked absence of data about the conditions under which effective interventions were spread and sustained.4 Typically, improvement studies have been time-limited and small-scale, without rigorous evaluation of long-term outcomes5–8 or careful consideration of the scope and scale of change, the preparation prior to implementation, and the time, expertise and funding invested.9 10 Recognising the need for explicit guidance on implementing, sustaining and evaluating change at scale, various theories and frameworks have been developed to help guide this process,11 particularly in healthcare where there exist several notable examples: such as, the Institute for Healthcare Improvement (IHI) Framework for Spread.12 However, there is no ‘magic bullet’ for ensuring that the benefits of quality improvement initiatives endure6 and key scholars have called for improvement scientists to draw on a range of cross-disciplinary knowledge in the pursuit of sustaining large-scale change.13
In addition to available theory, there is also considerable merit in listening to people who can share their lived expertise in successful sustained change5 or offer personal insights about the improvement evaporation effect, where new innovations are not maintained.14 There are various organisations actively operationalising large-scale improvement initiatives across the UK. Staff and managers within these organisations have their own personal theories of sustaining large-scale improvements, known in reflective practice discourse as re-theorising and reformulating, where professionals develop their own personal theories of practice drawn from experience.15 With a few exceptions,5 16 there has been little qualitative exploration of the personal experiences and expertise of managers and front-line staff, meaning that they are a largely untapped resource within the improvement science field. Ultimately, if we want to glimpse into the ‘black box’, it makes sense to speak to the people operating inside it and to value their experiential knowledge alongside theoretically and empirically derived academic frameworks.
Context of the paper
This paper presents the output of knowledge mobilisation activity as part of the work of the Scottish Improvement Science Collaborating Centre (SISCC). The SISCC is a Scotland-wide collaboration—involving universities, National Health Service (NHS) boards and partners in health, social care and the third sector—that aims to strengthen the research evidence base for how large-scale, sustained change can be achieved and replicated in different contexts. SISCC works to a collaborative model, in which researchers work as equal partners with people who are directly involved in delivering improvement activity. The work presented in this paper originated in meetings between SISCC researchers and their partners to elicit advice about designing a programme of large-scale improvement research. The consultation activity was initially a precursor in planning the SISCC research programme, but on realising the conceptual generality of the advice received, the researchers and partners agreed on the need to publish and share the lessons learnt more widely.
Three full day consultation meetings were held with three different organisations during 2016 (table 1). The meetings involved a range of staff members from senior executives to front-line practitioners (42 attendees in total, with 12, 15 and 15 attendees at each meeting, respectively). The consultation process was informed by classic grounded theory—a research method for generating theory directly from empirical experience.17 Grounded theory aims to develop practice-relevant theory directly from people with extensive experience, however, it typically continues to exist within a traditional research paradigm where researchers have ownership over the resulting theory. Instead, the work presented in this paper used a participatory approach, in which the process and the resulting theoretical product were co-created and co-owned in the context of knowledge mobilisation.
Each of the three full-day consultation meetings involved three rounds of progressively focused small group discussions in which participants were asked to reflect on the core activities involved in setting up, rolling out and sustaining improvements. At the start of the day we asked participants to work in groups to create their own personal theory of ‘what works’ when implementing and sustaining individual initiatives. We then asked groups to compare their different theories and to collectively identify similarities and differences in their understandings about ‘what works’ when sustaining different initiatives and contexts. Finally, groups engaged in discussion to critically compare their own theory about ‘what works’ in sustaining large-scale change with existing improvement models, theories and frameworks. By focussing first on the familiar, participants were able to consolidate their own personal theories, before progressing to a conceptual level discussion of general lessons for implementing large-scale sustainable change across different contexts.
Discussions were recorded on flip charts and additional notes were taken by three researchers. These were analysed by the first author using classic grounded theory processes in order to consolidate all of the data into one overarching theory.17 This involved the process of open coding to identify all possibilities in the data until a core category (motivating change) was identified. Thereafter, selective coding expounded the core category and related categories. This was followed by theoretical coding and memo-sorting to clarify the relationship between all components and arrive at an integrated theory. In these final stages of analysis, we agreed a unifying structure for the theory, which we organised according to psychosocial-structural conditions (described later). Theory development was discussed with a second researcher to enhance conceptual thinking and, in accordance with classic grounded theory,17 extant literature was consulted only after the theory was consolidated to support, extend and contextualise the new theory in the discussion section of this paper.
Following data analysis and consolidation of a first draft theory based on data from the consultation events, the partnership organisations provided the researchers with feedback according to grounded theory credibility criteria outlined by Glaser and Strauss .17 Specifically, all three organisations responded positively to the final write-up of the theory, confirming: fit (the theory captures the workshop data and the social realities of their work); work (the theory offers a useful explanation); relevance (the theory has contextual relevance); and modifiability (there is potential for the theory to be transferred conceptually to different contexts). They also suggested refinements of the theory and these amendments were made iteratively until all authors were content that the theory presented a single voice that amalgamated the collective expertise of the three organisations.
Patients were not directly involved in the design of this study. The focus of this project was accessing staff expertise; however, a future next step would be to seek patient and public input to develop the theory further and fully elucidate the key role they play in implementing, sustaining and evaluating large-scale change initiatives.
A note on presentation and the structure of the theory
Unlike a traditional presentation of descriptive qualitative findings which might offer comparison of the participating organisations, this paper presents a single-voiced, co-created theory. The theoretical product is not a direct summary or replication of the data from the consultation meetings, but a conceptual amalgamation of the organisations’ differing experiences and expertise. In keeping with classic grounded theory, the findings are written in the present tense using quotations sparingly and only as necessary to elucidate concepts. This is because theory should be organised around concepts—abstract of people, places and times—that are derived from data, rather than the data itself.17 The theory that follows is therefore not presented as an undisputed fact, but as a plausible and modifiable hypothesis about the key elements for creating sustainable large-scale improvement derived from the collective expertise of participants in the partner organisations. It represents a shared understanding agreed between all participants to present a simple, well-defined and well-integrated explanation.
As described earlier, the theory of Motivating Change is organised around the psychosocial-structural conditions for large-scale sustained improvement. By ‘conditions’, we are referring to the circumstances and factors that have an influence on or determine the outcome of improvement work. In the theory, these are grouped under three sets of conditions: psychological, social and structural. We define psychological conditions as relating to the human mind and to how people within organisations think and feel about improvement. Sustained improvement is similarly influenced by social conditions, which we define as the relationships between individuals within organisations and the wider organisational culture. Finally, structural conditions relate to the systems, resources, management structures and physical environments that constitute organisations.
The theory of MotivatingChange
The central premise of the theory of Motivating Change is that organisations must create the right psychosocial-structural conditions for successful, large-scale sustained change. This means that there must be individual motivation to act (psychological conditions), collective support for action (social conditions), and structures that create capacity, capability and opportunity for action (structural conditions). A main concern for large-scale change organisations is embedding improvement that lasts. Rather than just implementing and sustaining one change—for example, a single initiative or specific project—the goal is to create long-term improvement cultures where positive attitudes towards improvement are generated and sustained. When staff within organisations are actively seeking, enacting and maintaining improvement work, improvement becomes self-proliferating. The theory of Motivating Change posits that this is the lynchpin of successful, sustained change. Seeing evidence of successful change inspires front-line staff to seek out opportunities for improvement in the future and, in turn, effects a fundamental transformation in the intrinsic motivators shaping their attitudes and behaviours. When motivation spreads from one individual to another, there can be a collective cultural shift to a workforce with a desire and ability to see and act on improvement opportunities. And all of this can only be achieved in the presence of supportive structural conditions.
We now describe each of the psychosocial-structural conditions for sustained change at scale. We expand on the importance of these conditions and how they are created and sustained. We also provide case examples from each of the participating organisations; one example to illustrate each of the psychosocial-structural conditions.
The psychological conditions for sustained large-scale change: internalised motivation
Individual motivation for change is an important psychological condition that influences whether organisations achieve self-proliferating improvement. The different intrinsic and extrinsic motivations for change are summarised in table 2.
To harness individual motivation as a driving force for change, organisations can capitalise on the intrinsic motivations of staff and service users who are already committed to improvement. Inevitably, however, there will be varying degrees of motivation for change within any organisation and, often, change is instigated by external drivers. In this case, the extent to which externally motivated change aligns with staff’s intrinsic values will determine how much perceived worth they attach to any given improvement activity. When government or organisational perceptions of a problem and solution differ significantly from the values of those delivering and using a service, it is less likely to motivate change. We define this as a ‘policy-practice paradox’, whereby competing internal and external priorities may prohibit progress towards improvement. For example, government-defined targets that are not considered relevant or necessary in localised areas can undermine motivation for change and turn staff and service users into passive resisters, rather than proactive change agents.
To reconcile this paradox, the theory of Motivating Change suggests that organisations must work to narrow the gap between the external drivers of change and the intrinsic motivators of staff at a local level. For this to happen, there must be (A) Convincing evidence that change is needed. (B) A continual process of turning evidence of change into evidence for change. In this way, organisations can support staff and service users to internalise the extrinsic motivators for change.
Provide evidence for change (show that change is needed)
For individuals who do not see the need for improvement, extrinsic motivators—such as research evidence or service user feedback—can be powerful in changing their minds. However, this is only effective when the external drivers for change align with individuals’ intrinsic values. Certain extrinsic motivators are easier to reconcile with intrinsic motivations, for instance, a bigger purpose that advocates change as the ‘right thing to do’ feeds directly into the intrinsic motivations underpinning the work of many front-line staff. Similarly, service user voice is a powerful motivator for practitioners who intrinsically value person-centred care. As such, organisations must consider appealing to these intrinsic motivations when they select and use evidence as a rationale for change.
Turn evidence of change into evidence for change (show that change is working)
Seeing evidence that change is working is motivating. Positive outcomes provide a convincing argument for the need to sustain improvement activity. We conceptualise this as evidence of change becoming evidence for change; where external evidence becomes internalised as motivation for improvement. For this to happen, organisations must show that change is working in a way that appeals to different stakeholders in the change process. Data that work to convince front-line staff (eg, service user feedback) may not necessarily convince policy makers. Therefore, astute data collection and sharing data in a way that engages different audiences is key to turning evidence of change into evidence for change. Conversely, when no outcome data are collected or shared at all, this is highly demotivating, as the cycle of turning evidence of change into evidence for change is disrupted, since there is no reinforcement of change having a positive effect.
Table 3 provides a practical example from Unicef UK to illustrate how to motivate change by creating the right psychological conditions.
The social conditions for sustained large-scale change: a flow of trust
A critical social condition for sustained change at scale is trust. There must be trust between front-line staff, leaders and stakeholders who share a desire for change and a belief that the proposed improvements will be effective. In this way, motivation for change spreads through a flow of trust within an organisation. Although they are important, the internalised motivations of one individual cannot drive whole-scale sustained improvement alone. Rather, motivation for change needs to be collectively internalised, turning an external vision of change into a shared commitment across an organisation. The concepts of sustainability and spread commonly referred to in the improvement field therefore should relate to a particular innovation, and to spreading and sustaining motivation. Only in the right social conditions can motivations for change be internalised and enacted, enabled through a flow of trust that is influenced by: leadership, positive peer pressure, infectious negativity and constructive resistance.
Leaders establish a flow of trust through recognition and reward; turning evidence of change and into evidence for change. Effective leaders create positive energy from negative results by sharing learning to motivate the pursuit of improvement. By understanding what motivates individuals already committed to improvement, leaders can build these motivations in others and model these attributes. Leaders are, themselves, evidence of change; seeing front-line staff move on to become improvement leaders spreads capability, and spreads motivation through positive peer pressure.
Positive peer pressure
Positive peer pressure is a healthy competitiveness whereby the outward display of intrinsic motivation for change in one individual, becomes an extrinsic motivator for another. It enables evidence of change in one area to become evidence for change in another. Individuals (whether staff or service users) with existing strong intrinsic motivation can spread this through their relationships with others around them. People involved in successful improvement projects may be relocated to help operationalise improvements in other areas, both to spread capacity and exemplify motivated attitudes towards change. Front-line staff may be more willing to listen to a service user or a peer than to a manager or external organisation. For positive peer pressure to help scale up sustainable change, however, it must be founded on willingness to share best practice rather than a perverse desire to compete for resources and reward.
Counter to positive peer pressure, negativity can spread within an organisation, undermining intrinsic motivations for change. People may be resistant to change for various reasons and, if these go unacknowledged, can result in an apathy that hinders improvement. Infectious negativity may be more likely to occur when there is little attempt in the change process to narrow the gap between the extrinsic drivers of change and individuals’ intrinsic values and local priorities. Infectious negativity can also spread when changes are not easy to measure or when the results are not as promising as hoped. When there is no convincing data that change is working, it is difficult to see evidence of change turn into evidence for change, fuelling apathy. In these circumstances, the presence of infectious negativity should prompt leaders to stop, reassess and seek ways of harnessing opposing views constructively (as described next). Of course, leaders are not immune from infectious negativity themselves, which may compromise their ability to model positive motivations.
As opposed to unchecked infectious negativity, harnessing constructive resistance is important in designing, implementing and sustaining changes that are feasible and meaningful in practice. Listening to opposing views can help to improve the change intervention and enable critically minded staff to feel appreciated rather than disenfranchised. Moreover, providing individuals with the opportunity to voice and work through concerns about a change can be an important part of the psychological process of adjusting to that change.
Table 4 provides a practical example from Healthcare Improvement Scotland to illustrate how to motivate change by creating the right social conditions.
The structural conditions for sustained large-scale change
Internalising the motivation for change and spreading motivation through a flow of trust is contingent on specific structural conditions. These structures relate to the physical environment, finance, incentives, time and methodology.
Visual cueing in the physical environment (eg, achievement boards), which overtly displays evidence of improvement, fuels positive peer pressure and supports turning evidence of change into evidence for change.
Financial resource is often under the control of policy and organisational budgets rather than local areas. However, when financial savings from improvement activity are used directly to sustain the effort or to fund a future project in the same area, this is more motivating than seeing the resource redirected elsewhere in the system. This amplifies the potential for evidence of change to become evidence for change.
Incentives such as accreditation or awards feed into positive peer pressure. However, where there is disconnect between the incentive (for instance, reaching a government-defined target) and the values and perceived need for change at a local level, these are unlikely to motivate change. Incentives may also have a perverse effect, where teams only ‘up their game’ at assessment time. This is more likely when the incentive does not appeal to staff’s intrinsic motivation, that is, when there is a policy-practice paradox.
Time relates both to the time for improvement (setting aside dedicated time and freeing up time in the schedules of busy practitioners) and the timing of improvement (ensuring the structural conditions are in place before initiating change). Although this can be carefully planned, there will always be an element of opportunism.
An agreed process of change—whether locally designed or drawing on existing models such as the lean approach18 or the IHI Model of Improvement19—can scaffold the improvement process. Consistent use of methodology can build and consolidate a flow of trust by promoting a shared language and vision. However, if the rigidity of the methodology does not allow staff to feel sufficiently autonomous and self-motivated, or service users to feel listened to and valued, it can also have a negative effect on sustained motivation.
Table 5 provides a practical example from NHS Highland to illustrate how to motivate change by creating the right structural conditions.
The key propositions of the theory of Motivating Change (box 1) provide hypotheses for future research and can help in planning and monitoring large-scale change.
: Propositions of the theory of Motivating Change
Turning evidence of change into evidence for change, within the context of a flow of trust and supporting structures, internalises extrinsic motivators and creates the right psychosocial-structural conditions for large-scale sustained change, transforming individuals and organisations into self-proliferating improvers.
Sustained change at scale requires organisations to be self-improving.
Self-proliferating improvement is dependent on a combination of psychosocial-structural factors: the individual motivation to act, a collective motivation for action, and structures that create the capacity and opportunity for motivations to be enacted.
The closer the alignment between extrinsic and intrinsic motivators for change, the more likely it is that change will be implemented and sustained.
Turning evidence of change into evidence for change helps staff to internalise extrinsic motivators and redresses any potential policy-practice paradox.
Developing and sustaining collective motivation for action is dependent on a flow of trust across the organisation that is mediated by leadership and positive peer pressure.
Leadership requires both the technical skills of leading improvement, and the relational skills required to create a positive flow of trust and facilitate the internalisation of extrinsic motivators.
In a culture of positive peer pressure, the outward display of intrinsic motivation for change in one individual becomes an extrinsic motivator for another.
Infectious negativity, catalysed by an unredressed policy-practice paradox, undermines the sustainability of improvement.
Harnessing constructive resistance helps to design, implement and sustain changes that are relevant, feasible and meaningful in practice.
Internalising the motivation for change and spreading motivation through a flow of trust is contingent upon specific structural conditions (physical environment, finance, incentives, time, methodology) that either facilitate or hinder successful improvement work.
To support the application of the theory of Motivating Change in planning and evaluating future large-scale, sustainable change projects we have operationalised these concepts into a practical framework (table 6). The framework could be used to plan the implementation and scale-up of a change or could be used retrospectively to reflect on the conditions responsible for either the success or failure of the change. There are prompt questions to facilitate the application of each concept in the theory.
Motivating Change describes the psychosocial-structural conditions for sustained, large-scale change. It contributes to an international landscape of existing models for implementing and sustaining innovations—for example, Normalisation Process Theory20 and the NHS Sustainability Model21—by confirming the importance of context, collective action, cognitive participation, leadership, attitudes and organisational fit. However, by emphasising the centrality of motivation and describing the conditions for sustained change, rather than the process through which this is achieved, the theory of Motivating Change makes some additional useful contributions. Indeed, a systematic review of quality improvement models concluded that the specific model of improvement used is less important in determining successful sustained change than the conditions under which it is implemented.11 By highlighting the importance of personal motivations, Motivating Change challenges predominant discourses which privilege structural processes and workforce characteristics over individual and local contexts. Ultimately, when people are conceptualised as ‘human factors’, there is a risk that they are perceived simply as barriers or facilitators to the change process rather than as active agents. This can result in overly prescriptive, process-driven approaches that disengage rather than include staff and service users.22 Thus, Motivating Change contends that people should not be conceptualised as mere incidental factors along the way, but as the very key to establishing lasting improvement.
According to Self-Determination Theory,23 intrinsic motivation requires individuals to experience feelings of: autonomy (being able to act according to our values); competence (confidence that we can act in the way we want); and relatedness (connected to others through our actions and choices). For change to be self-determined, individuals must feel able to actualise these three senses regardless of whether the original driver for change is external or not.23 The theory of Motivating Change describes how extrinsic motivators become internalised in the context of quality improvement and identifies opportunities for enabling individuals to experience all three senses even when change is externally driven, for example: enabling autonomy by appealing to intrinsic motivations; building competence through turning evidence of change into evidence for change; and fostering relatedness in a flow of trust which spreads and sustains motivation. Presenting evidence for change in a way that is perceived to be valid by those implementing it—as similarly described in Graham’s knowledge to action model24—increases the likelihood that they will act on it with feelings of autonomy as opposed to obligation. Greenhalgh et al3 referred to this as relative advantage, whereby people who perceive tangible advantages for themselves or their work are more likely to embrace extrinsic motivators as their own. The more tailored the knowledge and reasoning provided to staff, the more convincing it is as evidence for change and the more likely they are to internalise it as an extrinsic motivator.
Motivating Change lends strength to the call for improvement scientists to take heed of motivational theory in understanding ownership and self-determination in the change process.25 Given that most change in healthcare will likely be externally driven rather than intrinsically derived, it is particularly important to understand the means through which competing motivators can be reconciled. Moreover, it is important to understand how motivation for change is garnered and sustained at an individual level, and at a collective level where there can be sufficient momentum to sustain change.13 Rogers’26 concept of diffusion features heavily in improvement science as a way to explain the communication of knowledge across an organisation. Motivating Change demonstrates, however, that it is not simply knowledge that diffuses throughout organisations, but motivations as well. Through a flow of trust, leaders and peers, by externalising their positive motivations for improvement, can convince the collective and generate a shared vision. Conversely, infectious negativity can suppress or hinder motivation for change. While monitoring knowledge use is common—for example, Graham et al’s24 knowledge to action model suggests monitoring knowledge use during the sustaining phase in order to identify strategies for maximising sustained practice—there appears to have been no attempt at monitoring individual and collective motivation while implementing and sustaining change. This paper suggests that, in recognising motivation as socially contagious, greater attention should be given to the spread and sustainability of motivations for new innovations, not just the innovations themselves.
The theory of Motivating Change was co-created by three improvement organisations who may not be representative of others engaged in large-scale improvement. Although the organisations recognised the importance of service users in the change process and included this in the theory, their voices did not contribute directly to the theory development and future work could extend to better understanding service users’ role. However, it should be noted that, from the perspective of classic grounded theory, the aim of this work was not to generate objective facts, but to develop conceptually general lessons about sustained, large-scale change. Theory is intended to be modified17 and this paper provides a foundation for future work where it can be verified and modified to strengthen its usefulness and scope.
Motivating Change conceptualises the psychosocial-structural conditions for large-scale, sustained change. By narrowing the gap between extrinsic and intrinsic motivators, and equipping staff with the capacity and opportunity to act on these motivations, it is possible to create self-improving organisations with a systems structure that welcomes change as a means to improvement. The theory adds to and extends the existing evidence base on how to create large-scale sustained change and promotes the shared expertise of those individuals already actively doing improvement work on the ground. Importantly, in highlighting motivational processes as central to the change process, rather than simply one aspect, this paper calls for greater humanising of the improvement process and demonstrates the value in listening to individuals and organisations with successful track records in lasting improvement. It also provides a practical and usable resource in the Motivating Change Framework to facilitate the implementation and evaluation of future large-scale, sustained change.
The authors thank all the staff represented by the named key authors from the three organisations (Unicef UK, NHS Highland and Healthcare Improvement Scotland) for their time and willingness to co-create theory, and their feedback on drafts of the paper. The authors also thank Karen Ritchie for her comments and Gillian Clark and Fiona Szeller for invaluable administrative support in arranging consultation meetings and facilitating ongoing communication between partner organisations. The authors also thank the team in NHS East Lancashire for sharing their experiences of achieving the BFI Gold Award to help illustrate the concepts within the theory.
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Contributors JPB designed the project, led and facilitated the knowledge mobilisation activity, analysed the workshop notes, prepared the complete first draft of the paper and redrafted in response to team input. MJR contributed to design, workshop facilitation, data analysis, commented on drafts and coordinated communication with the partner organisations. MT contributed to workshop facilitation, commented on drafts and contributed to the final writing of the manuscript. NG contributed to workshop facilitation and commented on drafts. SA, CS and RG facilitated partnership working with their organisations, contributed to theory development, commented on drafts and agreed on the final manuscript on behalf of participating members in their organisations.
Funding This work is supported by core funding from the Scottish Improvement Science Collaborating Centre, which is jointly funded by the Scottish Funding Council, Health Foundation, Chief Scientist Office, and NHS Education Scotland. The funding bodies had no role in the design or interpretation of this study or in writing the manuscript.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No additional data are available.